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Reflux and Heartburn

The chief symptom in Chinses & East Asians is epigastric pain. Barrett’s, which is often silent must be excluded. If present it can be successfully treated by endosocpic mucosal resection.

Close up of doctor's hand at computer typing
Prof SK Lam

Placeholder ImageIn 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.

How to prevent cancer: esophagus, stomach, colon

The key is to treat the precancerous conditions before cancer develops.  These conditions include:

  1. Reflux esophagitis with intestinal metaplasia or Barrett’s esophagus.

    Barrett’s esophagus is diagnosed by endoscopy and biopsy.  It cannot be successfully treated with medications.   Barrett’s esophagus can nowadays be treated by chromoendoscopy to show up the lesion, followed by endoscopic mucosal resection of the lesion.  Thereafter, Barrett’s esophagus can be prevented from coming back by reducing the acid secretion of the stomach, using medications.  Acid reduction in this situation is analogous to reducing blood pressure in patients with hypertension to prevent complications.

  2. Helicobacter pylori, a stomach germ that can cause stomach cancer.

    This bacteria can be detected, for example, by a simple breath test.  It is now known that Helicobacter pylori needs to be got rid of at a relatively young age, before the stomach develops intestinal metaplasia, which may lead to cancer.  Like, Barratt’s esophagus, intestinal metaplasia of the stomach cannot be cured with medications, but can be treated by endoscopic mucosal resection, following chromoendoscopy.

  3. Colonic adenoma

    Colonic adenoma is a benign polyp, which frequently occurs in patients with a family history of colon cancer, and in people with a relatively advanced age.  Polyps may develop into colon cancer after an average of 15 years.  They can be detected and removed by simple procedures called polypectomy during colonoscopy; removing them could, therefore, prevent colon cancer.  Polyps may escape detection by examination of stools using fecal occult blood tests, which, however, may detect early colon cancer.  It has been suggested that people over the age of 50, particularly those with a family history of colon cancer, should have a colonoscopy examination and have their polyps removed if detected.