DON’T FORGET THE ESOPHAGUS
One of the most common questions I am asked is “What happens if long-term reflux goes untreated?” the answer is that serious and life-threatening complications are possible, and the likelihood is increasing. As a matter of fact, even with daily proton-pump inhibitor treatment (such as Prilosec, Nexium, “purple pills”), deadly complications such as esophageal cancer can still occur.
The prevalence of esophageal and throat cancer is on the rise. In fact, cancer of the esophagus—known to be caused by esophageal reflux—is the fastest growing cancer in the United States, up a whopping 850 percent since the 1970s.
If you have long-standing reflux (esophageal or airway reflux), you should have a throat and esophageal examination. Believe it or not, this may mean seeing two different doctors because not all ENT doctors (otolaryngologists) perform esophagoscopy, and very few GIs perform laryngoscopy or throat examinations.
Your best choice for obtaining a comprehensive examination is an ENT doctor who performs transnasal esophagoscopy (TNE).
I have been performing these examinations (throat and esophagus) at the same time for many years. In reviewing my chronic cough cases, I was surprised to find that 64 percent had esophageal disease.1 the findings were esophagitis 48 percent, hiatal hernia 18 percent, candida (fungal) esophagitis 8 percent, Barrett’s esophagus (esophageal precancer) 8 percent, and one had esophageal varices.
My chronic cough study group may or may not accurately represent the general population because the average duration of chronic cough symptoms in my patients was ten years.1 Nevertheless, the data strongly suggest that patients with silent airway reflux, essentially all refluxers, undergo throat and esophageal examinations. However, the idea that you can only be checked for cancer in a special facility and under anesthesia is archaic.
Since early detection is vital to improve esophageal cancer survival, routine esophageal screening using transnasal esophagoscopy (TNE) is recommended for people with both airway and esophageal reflux. TNE is by far the safest and most cost-effective as the first esophageal examination method.
TNE is performed with the patient seated comfortably in a chair using an ultrathin endoscope that is introduced though the nose and then easily advanced all the way down into the stomach. TNE exam is comfortable, the examination images are superior, and accurately obtained biopsies may be performed when needed.
Esophagogastroduodenoscopy (EGD) performed by the gastroenterologist is the wrong type of esophageal examination for patients with reflux. Since EGD is done with the patient sedated, the esophagus is collapsed, and once the first cup-forceps biopsy is taken, there is blood in the field. Thus, errors in diagnosis may result from errors in tissue sampling. The finding of columnar (stomach) lining in a biopsy obtained during EGD does not translate to a diagnosis of Barrett’s esophagus. And Barrett’s esophagus is not a diagnosis that people want to have since it is a known precursor to esophageal cancer. In the past, people with Barrett’s were told that they had a one percent per year chance of getting cancer. Today, We believe that the risk is much less than that and that Barrett’s can be healed with a long-term low-acid, low-fat diet.
Here’s an interesting and important case example:
A patient from Seattle came to see me. She had been enrolled in the Seattle Barrett’s Program, having been positively diagnosed (by biopsy) with Barrett’s esophagus. After she read my book, Dropping Acid: The Reflux Diet Cookbook & Cure, she put herself on my strict reflux diet for a full year.
So after a year on the induction reflux diet, she came to see me and asked that I perform TNE. I did, and her Barrett’s was gone. Paradigm shift: Barrett’s esophagus reversed with low-acid diet and alkaline water!
In the last few years, I have seen a trend in the overdiagnosis of Barrett’s esophagus in patients undergoing EGD. Less than half of the patients who came to me having already received a diagnosis of Barrett’s esophagus from EGD actually had it. Since TNE is performed with the patient awake and swallowing normally, it is easier to see the normal anatomic landmarks so that more accurate biopsies can be obtained.
In summary, the diagnosis of airway reflux is not made by endoscopy (TNE or otherwise), but by clinical diagnosis, laryngeal findings, and by airway reflux testing. However, once the diagnosis of airway reflux is made, an esophageal examination (TNE) is indicated to rule out significant esophageal disease.