Reflux and Heartburn

Prof SK Lam

In China and East Asia, stomach pain is the key symptom

As a symptom, heartburn is common in western communities, occurring in one in three of some populations.  20 years ago, heartburn was unheard of among Chinese; there was no equivalent in the Chinese language.  In recent years, as Chinese westernize, reflux symptoms occur commonly, probably around one in 5 or 6 individuals living in cities.

However, while heartburn may be present, the complaint is often an epigastric or retrosternal chest pain or discomfort, occurring often after meals, and sometimes sleep-awakening at night.  The problem usually occurs in middle age.

For those presenting with chest pain, the best investigation is a CT coronary angiogram, which nowadays takes about 5 minutes.

If symptoms are in the epigastrium and if CT coronary angiogram is negative, an endoscopy (esophago-gastro-duodenoscopy, OGD) should be performed firstly to confirm the diagnosis and importantly to do a 4-quadrant biopsy of the gastro-esophageal junction.

The idea is to exclude intestinal metaplasia or Barrett’s esophagus, which is a pre-cancerous condition.  This is needed because reflux may be silent in half of the patients presenting with Barrett’s.

Once Barrett’s is established, the pathology of this innermost of the 5 layers of the lower esophagus can be shown up using chromoendoscopy, usually with methylene blue.  The persistently stained area(s) can be removed by e.g. Endoscopic Mucosal Resection.  After this the surrounding normal mucosa will grow to close the hole with normal epithelium.  EMR can be safely performed nowadays and in a daycare setting.  Prof SK Lam has invented a endoscopic procedure that in theory reduces the risk of perforation or bleeding to close to zero; the method is being considered agencies for granting of patents.

Subsequently, maintenance treatments with proton pump inhibitors and improvement in life-style can prevent the reflux eosophagitis and the consequent Barrett’s from coming back.