March 10, 2000

New center set to diagnose, douse heartburn

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Dean John Chapman was king of the Coneheads at this year’s Cadaver Ball, where eccentric entertainment of the “Saturday Night Live” variety was the theme. Through songs, skits and dance, medical students spoofed a wide variety of subjects and themes. (photo by Mayhew Koellein)

New center set to diagnose, douse heartburn

Sufferers of gastroesophageal reflux disease (GERD) can now get one-stop diagnosis and treatment at Vanderbilt University Medical Center's newly formed Heartburn Center.

The new center gives patients the opportunity to be seen during one visit by both gastroenterologists and surgeons who frequently treat the disease.

Studies indicate that every day about 7 percent of the U.S. population experiences heartburn or exhibits other symptoms of GERD, and about 20 percent have at least weekly heartburn. Other symptoms of the disease can include vomiting, difficulty swallowing, and chronic coughing or wheezing.

“It’s a big problem. We estimate that there are about 150,000 people in the middle Tennessee area that have daily GERD symptoms requiring continuous medical therapy,” said. Dr. Michael D. Holzman, assistant professor of Surgery.

The good news is that the vast majority of people with heartburn and reflux problems can be easily treated, said Dr. Glenn M. Eisen, associate professor of Medicine in Gastroenterology.

"The problem is that very few people consider it a disease, but rather a nuisance and just live with it.”

The Heartburn Center offers a multidisciplinary approach to diagnosis and treatment.

“Obviously the vast majority of patients won’t need surgery,” Holzman said. “It takes a team approach to decipher who needs which treatment, and we provide every service.”

Eisen said that once someone is diagnosed with reflux, or typical heartburn, there is a step-care approach to treatment. For people who have infrequent heartburn about once a week, particularly after a big meal or alcohol consumption, the treatments usually include lifestyle modifications. These can include avoiding eating for at least several hours before bedtime, elevating the head of the bed for those who have symptoms while lying down, and avoiding foods known to cause stomach irritation or interference with the muscle action of the bottom of the esophagus.

“Lifestyle modifications don’t always work that well because patients generally don’t like to do them,” Eisen said. “It’s hard to get people to lead a monastic lifestyle because of occasional heartburn. They usually prefer medication therapy.”

Eisen says the simplest therapy for occasional heartburn is antacids. “The liquid form is usually better because it also coats the esophagus,” he said. “Antacids work the fastest but have very limited buffering ability.”

Patients with recurring symptoms need stronger therapy.

“The therapies we have for patients with more severe symptoms are H2 blockers, and another class of medications known as proton pump inhibitors,” Eisen said.

“The H2 blockers are available over-the-counter at half the dose of the prescription strength and they work for patients with occasional reflux, but are less effective for patients with recurrent symptoms,” he said.

Proton pump inhibitors are now the standard treatment for patients who experience regular heartburn or reflux symptoms. These medications are very effective in eliminating heartburn symptoms in about 90 percent of patients, Eisen said.

Eisen recommends an endoscopy for patients with chronic heartburn or reflux, especially those who have experienced alarm symptoms such as difficulty swallowing, vomiting blood, severe abdominal pain, or unexplained weight loss.

“These symptoms can permanently damage the esophagus. Also, there is a premalignant condition that is strongly associated with chronic reflux, called Barrett’s esophagus, which is a change in the lining of the bottom of the esophagus because of chronic acid damage,” Eisen said. “Barrett’s is associated with how long and how frequently the patient has had symptoms. Patients with a long history of reflux should be screened because this is a precancerous condition. They can then be enrolled in a surveillance program if necessary.”

For those patients whose disease cannot be successfully managed by medication, surgery presents an option.

“There are very few patients that don’t respond to the medication," Holzman said. "Population based studies indicate that about 1 percent of patients that have chronic heartburn may benefit from surgical intervention.”

Holzman describes the procedure, called Laparoscopic Nissen Fundoplication, or simply laparoscopic anti-reflux surgery, as one that requires experience on the part of the surgeon.

“It’s a difficult operation. What we do is make small incisions and laparoscopically take the uppermost part of the stomach and wrap it around the lower part of the esophagus to augment the esophageal sphincter," he said. “It creates an active mechanism. When your stomach is empty the wrap is loose, as your stomach gets full the wrap gets tighter.”

“Where the experience and judgment come in is that if the wrap isn’t tight enough the patient doesn’t get any benefit, and if it’s too tight the patient may not be able to swallow well.”

Holzman said success rates for the procedure are in the range of 90-95 percent. Vanderbilt surgeons have performed between 350-400 laparoscopic anti-reflux surgeries thus far. Patients receiving the laparoscopic procedure require an average of a one-day hospital stay.

For more information about GERD and the Heartburn Center call 615-322-4880 or visit their website at