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Heartburn, Barrett’s, Hiatal Hernia and Esophageal Cancer

Dr. Indraneek Chakrabarty discusses how Heartburn, Hiatal Hernia, Barrett's Esophagus and Esophageal Cancer are related, and the treatment options available.
Heartburn, Barrett’s, Hiatal Hernia and Esophageal Cancer
Featured Speaker:
Indraneel Chakrabarty, MD
Raised in Hemet, Indraneel Chakrabarty received his BS, Biochemistry from
UCR in 1998, his MA in Medical Sciences from Boston University School of
Medicine (BUSM) in 2000, his MD from BUSM in 2004, and his fellowship in
Gastroenterology and Interventional Endoscopy in 2011 from Lahey Clinic. He
was on staff as a Hospitalist and Teaching Associate at Massachusetts General
Hospital (MGH) at Harvard Medical School. Dr. Chakrabarty is board certifi ed in
Internal Medicine and Gastroenterology

Melanie Cole, MS (Host): Welcome. Today we’re talking about GURD, Barrett’s esophagus, hiatal hernia, and esophageal cancer. This is a big show. My guest is Dr. Indraneel Chakrabarty. He's a gastroenterologist and interventional endoscopist and a member of the medical staff and Temecula Valley Hospital. Dr. Chakrabarty, as I said, this is a big topic. A lot of cover. Let’s start with GURD. Tell us a little bit about the prevalence of GURD and how it relates to Barrett’s esophagus, hiatal hernia, and esophageal cancer.

Indraneel Chakrabarty MD (Guest): Yes. GURD is a big epidemic in the United States, mostly because of people gaining weight, obesity, not eating correctly, all of the fast food. All these things basically cause the valve, the junction of the esophageal sphincter, to loosen. As it loosens, acid can come back up easily and cause reflux. As acid content has a pH of 1, it’s very caustic. Your stomach makes a pH of 1 to help destroy bacteria as it’s first line of defense against food. When the acid is in a place where’s it’s not controlled, such as an esophagus, then you get various symptoms, including heartburn which is the most common. People get atypical symptoms too, which is food getting stuck. They may get a sensation of a lump in the throat. They may lay down at night and the acid goes down their airway, they start coughing. They can even eventually end up with asthma from it. They may even lose their voice and get hoarseness. Or some people just have severe chest pain where they feel like they're having a heart attack and it’s actually reflux. Other people may feel like food is getting stuck in their throat and then they're seeking help for it.

In the long run, this can cause damage to the esophagus. That damage is caused by the acid destroying the cells in the lining of the esophagus. So now you’ve got cells are dying and regenerating as you get exposed to the acid. Eventually that causes more increased DNA replication. That DNA replication can cause mutations as you're representing in a caustic environment. Eventually that leads to precancerous conditions call Barrett’s esophagus.

Host: So then tell me how we can find out about these things. We have endoscopy, obviously. Do you think that like colonoscopy there should be considered a well visit, sort of a preventive screening? Does it work the same way, Dr. Chakrabarty, where we can look to see Barrett’s? I just, myself, had an endoscopy to check for Barrett’s because I talk for a living, but do you think that we should have this as a screening tool to kind of put all these things together?

Dr. Chakrabarty: Yes. There are recommendations for who should be screened and who do not need screening. Typically if you’ve had reflux symptoms for greater than five years, you should definitely be screened for Barrett’s esophagus. Especially if you're over the age of 50 and you're having reflux symptoms or heartburn symptoms, you should get an endoscopy done. Some people have silent reflux. They don’t realize it, and that’s why at the age of 50 there’s a little less threshold.

Host: So then less talk about how these go together and the treatment options that could prevent it. So if someone knows that they have GURD, heartburn, reflux. Can the treatments that they might try, whether they are proton pump inhibitors or H2 receptor blockers or antacid, whatever they—can that then help to prevent Barrett’s?

Dr. Chakrabarty: The thought is when you block the acid and you have good, strong acid control, there should be less damage in the lining of the esophagus. That should help control or prevent you from getting Barrett’s if you don’t have it. If you already have Barrett’s that has taken hold, the suppression of the acid will help prevent it from progressing. Now, there’s different degrees of Barrett’s. There’s Barrett’s without dysplasia, there’s Barrett’s with intermittent dysplasia, and then there’s high grade dysplasia. Dysplasia’s just markers for how far along the Barrett’s is before it become esophageal cancer. So we see the biopsies to see, under the microscope, if you have no dysplasia or high grade or intermediate. They all have different risks. If you have no dysplasia, your risk is pretty low. It’s 2.9% over 10 years. If you have high-grade dysplasia, it’s 10% per year, which is significantly more for esophageal cancer. There’s new modalities now to get rid of the Barrett’s. So if you have high grade dysplasia, then we recommend getting an ablation done—burning the tissue down to the stem cells and it regenerates your tissue and normalizes the lining.

Host: So while we know that Barrett’s itself is a risk for esophageal cancer, GURD, if treated, maybe not so much so. Where does hiatal hernia fit into this? Tell the listeners what that is.

Dr. Chakrabarty: Yeah. So hiatal hernia is a loosened valve, usually because of the diaphragm basically separates your chest and abdomen. There’s a hole in the middle where the esophagus goes through and connects to the stomach right at that junction of the diaphragm. Combined the diaphragm on the outside works with the sphincter on the inside to kind of support and keep that valve tight. Now, as people get older, if they gain weight, the diaphragm gets stretched and that hole gets wider. Now it’s not supporting as much from the outside. The stomach slides inside a little bit and you basically have a valve that’s loose and acid can come up real easy. Patients will especially feel this when they bend over, or they lay flat. They may feel things coming up into their chest more frequently.

The other causes for hiatal hernia can be genetic. Some people just, their valves widen up and loosen up. Others are because their numerous pregnancies. As babies push up onto the stomach into the diaphragm area, it stretches the valve there. Those are the most common reasons for hiatal hernia. The hiatal hernia allows you to get increased exposure from acid and often can lead to people to get Barrett’s esophagus because they’ve been having reflex for a long time.

Host: So what would you like listeners to know about these conditions and when you feel it’s important to see a gastroenterologist to look and explore treatment options?

Dr. Chakrabarty: So if you’re someone who’s had reflux symptoms more than once or twice and it’s going on for a long time, definitely go seek help. See your primary care doctor, or if you have access to a gastroenterologist, see your gastroenterologist. You definitely want to make sure it’s under control. If it starts happening more than five years, then you definitely need an endoscopy to rule out Barrett’s esophagus. If you're over the age of 50 and you have symptoms or reflux, you should just get checked out anyways to make sure you're not Barrett’s. Because it is a preventable disease now now that we have ablation techniques to get rid of the Barrett’s and prevent esophageal cancer.

If you have a hiatal hernia, depending on the size there’s different modalities to fix the hernia as well. Then also get you off medications. These medications are overall fairly safe, but the proton pump inhibitors—medicines like protonic, Nexium, Prilosec, Dexilant, you’ve probably heard of these. They’re really strong antacids. The main side effect with them is they block your ability to absorb calcium well. Especially in women we worry about osteoporosis or getting bone fractures from weakened bones or lack of calcium absorption. Many people will decide to do a hiatal hernia repair, especially if they have signs of osteoporosis because getting a hip fracture can honestly be very debilitating. This is more of an issue in our patients who are over the age of 50 to 60 as far as osteoporosis goes. Younger patients they do very well with these medications.

Host: So as we’re looking at these treatment options, are some of them then they make it so that you don’t have to take medication afterwards.

Dr. Chakrabarty: Correct. So if you get a hiatal hernia repair, typically most people can get off their medications. If you’re still on the medications, then the hiatal hernia repair probably was not successful.

Host: What about some of the treatment options? You mentioned a little bit about for Barrett’s and for even GURD. There are some options out there now for interventional procedures. Just give us a quick summary of that and what they would do for somebody.

Dr. Chakrabarty: There are some treatment modalities for GURD. The main therapy is obviously the medication, antacid. The medicine such as Zantac and famotidine. There are the H2 class blockers. They're not as strong typically, but if they work then that’s great. They work. Typically they don’t work as well, and we have to put them on these proton pump inhibitors. If you do have a hiatal hernia, there are different sizes of hiatal hernias. If you have one centimeter or two centimeters, there is a new modality called a Linx procedure, which is a band of magnets they can put around the esophagus and the sphincter there. That helps tighten the valve without needing a major surgery, which is a little different. It’s called a laparoscopic Nissen fundoplication where they take part of the stomach and wrap it. That’s a more involved surgery usually reserved for larger hernias that are bigger than two centimeters up to like ten centimeters.

Those work pretty well. The Linx procedure, which is the magnets, is really nice because it’s removable and it’s all now MRI compatible and scan. If you go to the airport, it’s all compatible with that kind of equipment. The laparoscopic Nissen fundoplication works very well for large hernias, but there is a 25% chance of it becoming undone and your reflux coming back after two/three years.

Host: So interesting and so many people suffer from these. Dr. Chakrabarty, wrap it up for us. What would you like the listeners to know about GURD, the prevalence of it, and then the associated Barrett’s, hiatal hernia, and/or esophageal cancer? How can we prevent this from happening?

Dr. Chakrabarty: So GURD effects at least one in three Americans. Esophageal cancer is one of the fastest growing cancers because of this GURD issue. It used to be ranked like 15th. Now I believe it’s ranked number 11 in the country. It’s rapidly rising because many people don’t realize that chronic GURD can lead to esophageal cancer. If you're taking Tums all the time or Maalox or over the counter medication and have not sought professional attention to your reflux symptoms, I suggest that you go and get checked out for proper evaluation. It can be completely prevented now with these new techniques and an endoscopy.

Host: So interesting. Thank you so much, doctor, for joining us today and sharing your incredibly expertise in this area. Thank you, again. That wraps up another episode of TVH Healthchat with Temecula Valley Hospital. Head on over to our website at for more information and to get connected with one of our providers. If you found this podcast informative, please share on your social media and be sure to check out all the other fascinating podcasts in our library. Physicians are independent practitioners who are not employees or agents of Temecula Valley Hospital. The hospital shall not be liable for actions or treatments provided by physicians. Until next time, this is Melanie Cole.