For patients suffering from heartburn, a burning throat, difficulty swallowing, or asthma related to reflux, some of life’s most basic needs and simple pleasures – like eating, breathing, and sleeping – may be anything but pleasurable or simple.
These are all warning signs of esophageal disorders and can be a precursor of something more serious – esophageal cancer. Even for those who are cancer-free, esophageal disease may cause people to experience chest pain, hoarseness, vomiting, sleeplessness, and more.
Fortunately, help for all of these symptoms is readily available.
Houman Rezaizadeh, M.D., director of the Esophageal Disease Center at UConn Health’s Department of Gastroenterology and Hepatology, says when a patient has an issue related to esophageal health, the center’s multidisciplinary team of physicians collaborate to diagnose and begin treating that person’s condition as quickly as possible. The center, located in Farmington, houses medical professionals and support staff in everything from gastroenterology, medical and surgical oncology, thoracic surgery, and ear, nose and throat to radiology, speech and swallowing therapy, and pathology – all under one roof.
“We meet quarterly to review cases, but we all have each other’s numbers. We are in touch constantly, and a lot of us are within the same office space, so we’re right next to each other.”
And while patients at other healthcare facilities may have to wait up to four months for an initial appointment and assessment – and another three to four months for a procedure – UConn’s Esophageal Disease Center has put into place an expedited system of direct referrals that significantly reduces wait times to just weeks, and ensures that patients receive the best possible care.
Improving a poor quality of life
Dr. Rezaizadeh says that patients with esophageal and gastrointestinal (GI) issues often experience a poor quality of life. Because of pain or dysfunction, they may have trouble sleeping and may wake up feeling exhausted. They might be unable to swallow easily, or may have asthma and other breathing issues brought on by allergies. Chest and abdominal pain is also common. They might be scared to eat certain foods – or they may be unable to pinpoint their food triggers and suffer needlessly from heartburn or cramps.
“Our big concern is that people either end up buying over-the-counter antacids for their reflux, or are repeatedly prescribed antacids by their primary care doctor,” he says. “And so you have these patients who have had reflux for 10 or 20 years. They’ve just been self-medicating. And what they don’t realize is that they’re at increased risk of developing Barrett’s esophagus and esophageal adenocarcinoma – they end up getting esophageal cancer because nobody ever decided to look or do an endoscopy. These patients need to be screened.”
Barrett’s esophagus is a condition in which the lining of the lower esophagus – the tube connecting the mouth to the stomach – is damaged by acid reflux, becoming thicker and inflamed. While patients with gastroesophageal reflux disease (GERD) often have heartburn or regurgitation of food due to the deterioration of a valve between the esophagus and stomach, those who go on to develop Barrett’s may also experience difficulty swallowing food and, less commonly, non-cardiac chest pain.
Left untreated, Barrett’s can lead to esophageal adenocarcinoma, a type of esophageal cancer. Five-year survival rates for esophageal adenocarcinoma range from 5% to 47% — depending on whether the cancer is localized when it’s diagnosed, or has already spread to other parts of the body – so early detection is critical. It’s important to have regular checkups if you have these symptoms. Dr. Rezaizadeh says while most other cancers are on the decline in the United States, the incidence of esophageal adenocarcinoma is “dramatically rising.”
The good news? He notes that if precancerous cells are discovered early, through screening, they can be treated to prevent esophageal adenocarcinoma.
“Ten years ago, when people had Barrett’s esophagus, they would often wait until they got the subsequent cancer and then we would send them to surgery,” he says. “But now we test them in the earlier phases of that disease and we do what’s called ‘radio frequency ablation.’ We burn the lesions and actually return the esophagus to normal, which prevents these patients from getting cancer. That’s a major advance.”
He says a new technology coming up in the next couple of years will allow for an easy method of screening in a primary care physician’s office. The “Cytosponge” is a small capsule – essentially, a little pill – attached to a long string. The patient swallows the capsule, which then dissolves and “opens into a little ball resembling a sponge. The primary care provider will pull out the capsule quickly and it scrapes the inside of the esophagus.” The procedure is painless but allows a pathologist to examine those cells and find any evidence of Barrett’s or esophageal adenocarcinoma at an early stage – before they can develop into something more serious. Tested in clinical studies, the device was found to be accurate, safe, and acceptable to patients.
Seeking new therapies for EoE
New treatment approaches are also on the horizon for a condition called eosinophilic esophagitis. EoE is an allergic swallowing disorder that doesn’t respond to the usual reflux therapies. Because it a newer entity, not much is known about it, and symptoms can vary from one patient to the next.
Young children can experience eating problems and fail to gain weight. Older children and adults may have abdominal or chest pain, reflux, insomnia, and malnutrition. Food may sometimes get stuck in the throat. Symptoms may disappear for a while, then return, and can show up days or weeks after patients eat a food they’re allergic to. This makes it more difficult to treat than many other esophageal conditions.
EoE is diagnosed through an upper endoscopy and biopsy of the esophagus.
Dr. Rezaizadeh says he has seen numerous patients who have had this condition for years. “Many patients have tried everything and are not improving. I work closely with them to try to figure out what their food allergies and food triggers are, to try to get them back to normal life and normal eating habits.”
He says most EoE patients end up on an elimination diet to identify the foods that trigger their symptoms. “The large majority of EOE patients in the western world are allergic to foods that fall into six food groups, and so we work with them to try to figure out what their triggers are. If they avoid those foods, their EOE can become a non-issue.”
Dr. Rezaizadeh says while there is currently no FDA-approved treatment for EoE, “there are multiple treatments on the horizon. They’re just going through Phase 2 and 3 trials right now.” Clinicians at UConn’s Esophageal Disease Center are starting to enroll these patients in clinical trials, to help them find relief and, potentially, a cure.
Healing hernias and dysphagia
Sometimes, a patient is diagnosed with a paraesophageal hernia – an opening in the diaphragm that can allow the lower part of the esophagus, the stomach, or other abdominal organs to move up into the chest, where they don’t belong. The patient may have mild symptoms – such as indigestion, nausea, or difficulty swallowing – or more obvious signs that something is wrong, like vomiting, or sudden and severe chest or stomach pain.
“If a patient has really severe heartburn or other significant symptoms, I collaborate with our surgical team to determine what kind of surgery is going to be best for that patient. We work together to tailor treatment options for them,” Dr. Rezaizadeh says.
He also sees many patients with a medical condition called dysphagia – difficulty swallowing, with food getting stuck in the throat/esophagus. “It’s a major reason that people come to see us, actually. That could be related to reflux. It could be related to a narrowing in the esophagus, or motility disorder. It could be related to EoE, caused by food allergies. It could be related to esophageal cancer. So that’s why all of those patients need an adequate workup.”
Other symptoms that he and his medical team would consider “alarming” include persistent reflux that’s not improving with acid-suppression medications; dramatic, unintentional weight loss; and vomiting blood. These signs are especially worrisome in patients over the age of 50, he says, so patients should not hesitate to reach out to their doctor.
However, patients of any age can experience esophageal symptoms. Esophagitis – inflammation or irritation of the esophagus – can be caused by acid reflux, side effects of certain medications, and bacterial or viral infections. Barrett’s esophagus typically affects older males. Reflux is very common, and “kind of covers the gamut of patient populations,” while esophageal adenocarcinoma “is basically seen in all western populations, so it’s across the board.”
Dr. Rezaizadeh says for patients with bothersome reflux, “we really work with them to get them to a point where they’re improved and they’re happy and able to not worry about their reflux, and not worry about their Barrett’s.”
Patients can also do a lot to help themselves. For instance, one of the biggest triggers in esophageal inflammation is eating very late at night, which can also cause significant reflux. “So you want to avoid eating three to four hours before bedtime,” he says. And while studies haven’t identified specific foods that are associated with reflux, “I tell patients that if you find a specific food bothers you and gives you indigestion or reflux, avoid that.” He adds that one study has shown that soda or carbonated beverages can increase reflux in women.
Patients would also be wise to limit alcohol consumption and avoid smoking, since these are associated with esophageal squamous cell carcinoma, a second type of esophageal cancer. Squamous cell carcinoma develops in the cells lining the upper and middle part of the esophagus. Adenocarcinoma – which is related to long-standing reflux, obesity, history of smoking, male gender, age over 50, and people with family history of either Barrett’s Esophagus or esophageal cancer – usually affects the lower part of the esophagus.
A call to serve
Dr. Rezaizadeh, who received his medical degree from the University of Medicine and Dentistry of New Jersey (now Rutgers), served his residency in Internal Medicine at University of Rochester Medical Center, and was a Fellow in Gastroenterology at UConn School of Medicine, says he has always found the GI field interesting. His interaction with patients during his training only reinforced his commitment to the field.
“I love the diverse patient population that we take care of, young and old. We also have people with acute problems, where they have a problem for a short period of time, and we have people with chronic problems, an issue that’s lifelong,” he says. “To be able to help them – like somebody who has had trouble swallowing or can’t eat, or constantly has reflux and indigestion and isn’t able to live a normal lifestyle because of that – is really rewarding. I love that.”
Carol Latter is Seasons Magazines editor and a freelance writer living in Simsbury.
Photography courtesy of UConn Health