When your ACID REFLUX could be a sign of something more sinister

BRIAN WILLIAMS has had 15 endoscopies over 15 years and has no doubt he owes his life to the procedure. In an endoscopy, a long, thin, flexible tube with a light and tiny highdefinition camera at one end is passed into the body. Images — and often cell samples — are taken during the procedure, which is carried out under sedation or, if the endoscope is passed via the throat, as in Brian’s case, with a local anaesthetic spray (and sometimes a light sedative).

Endoscopies are mainly used to diagnose the causes of heartburn, nausea, vomiting and chest pain, and to look for signs of inflammation, ulcers and tumours in the oesophagus and stomach. This is one of the most commonly performed NHS tests, carried out on 54,000 patients a month.

At Brian’s first endoscopy 15 years ago, the test revealed he had Barrett’s oesophagus — a pre-cancerous condition affecting around two in every 100 people in the UK, where cells in the lining of the gullet change as a result of acid and bile from persistent heartburn.

While most patients won’t go on to develop cancer, around one in 20 men and one in 33 women with the condition do, but often it is detected late, when there is no cure.

‘I’d always had heartburn after eating certain foods, such as onions, curry and spicy foods, or eating late at night, but it was more of an annoyance than a major problem and went away if I took Gaviscon,’ says Brian, 69, from Farnham, Surrey. ‘It was quite a shock to know I had Barrett’s.’

He was put on proton-pump inhibitor medication, which reduces acid production, and had endoscopies every two years to monitor the condition. The drug treatment greatly reduced his heartburn.

But five years ago, an endoscopy at St Thomas’s Hospital, London, revealed more significant abnormalities in the oesophageal cells — he was one of the unlucky ones. His Barrett’s oesophagus had worsened and he required urgent treatment as there was a 60 per cent chance of him developing oesophageal cancer in the next five years.

UNTIL recently, the usual treatment involved major surgery to remove most of the oesophagus and pull up the stomach to make a new one. There’s at least a two-day stay in intensive care afterwards with chest drains and feeding tubes (around a third of patients have difficulty eating after the procedure). This approach is still used in many hospitals in the UK.

However, Brian, a retired research scientist, was referred to Dr Jason Dunn, a consultant gastroenterologist at Guy’s and St Thomas’s NHS Foundation Trust in London, who performed a new, 40-minute minimally invasive treatment, which is carried out under sedation.

The technique involves inserting an endoscope and tiny tools down the throat to cut away the affected lining, and is currently used in about 40 UK hospitals.

Two months after his surgery, the remaining affected area of Brian’s oesophagus was treated with radiofrequency ablation — high doses of radiowaves which destroy the lining, allowing a healthy lining to grow back.

The treatment was a success and Brian now returns to hospital every 12 months for a check-up endoscopy.

However, for his younger brother Colin, a mechanical engineer who had similar heartburn problems, it was sadly a very different story.

Despite heartburn symptoms and difficulty swallowing, he didn’t bother seeing a doctor. After years of reflux problems, Colin finally went for tests three years ago after his difficulty swallowing became particularly bad. He was found to have advanced oesophageal cancer.

It was, by then, too late to treat it and he died two years ago aged 66.

‘If I hadn’t gone for regular endoscopies and screening, that would have been me, too,’ says Brian. ‘It is so important to get help as early as possible.’

The UK has the highest rate of oesophageal cancer in the EU, possibly because we have a genetic susceptibility to the condition.

Yet, according to research last year by Public Health England, many people are unaware of the link between acid reflux and the disease — even though around 10 per cent of people with heartburn will have Barrett’s. The research revealed that almost two-thirds of people don’t know that heartburn could be a sign of cancer.

Another problem is that many patients with ongoing acid reflux don’t go to their GP for help — instead managing the condition with over-the-counter remedies — and, even when they do, they may not be referred for an endoscopy.

‘Patients often have few or no symptoms, so often present late when they may already have advanced oesophageal cancer and can’t be offered a chance of a cure,’ says Dr Dunn.

‘The challenge is identifying patients with Barrett’s oesophagus early, and intervening in those at the highest risk before they develop cancer.’

In an attempt to improve Britain’s dismal record on this form of cancer, Public Health England launched a campaign last year to raise awareness of the link between heartburn and oesophageal cancer and encourage patients to go to their doctor if they have symptoms most days for three weeks or more.

In a separate move, the National Institute for Health and Care Excellence (NICE) urged GPs to send patients with a wider range of possible cancer symptoms (such as abdominal pain and unexplained weight loss) for tests to try to ensure they are diagnosed as early as possible.

However, while these campaigns seem to have been successful to some extent — and have seen some endoscopy units with double the number of patients being referred — it is stretching services to breaking point as units struggle to keep up with demand.

PATIENTS are also waiting longer than the six-week target for an endoscopy. Latest figures from NHS England show that, while numbers on waiting lists are falling, 3.6 per cent of patients were still having to wait six weeks or more for an endoscopy via the throat (the national target is less than 1 per cent).

The problem is even worse for other endoscopy tests, such as one for the bowel called a flexible sigmoidoscopy, which reduced deaths from bowel cancer by 40 per cent when it was given as part of a national screening programme. Normally there should be only a two-week wait for it.

Outside of this, figures show 4.3 per cent of patients were waiting for more than six weeks to have the procedure.

‘The idea is to get patients to a specialist quicker so that we can pick up the cancers in the early stage, or at a pre-cancerous stage, to improve the outcome,’ says Dr Andrew Veitch, a consultant gastroenterologist at The Royal Wolverhampton NHS Trust.

‘However, there is a major problem with capacity in endoscopy, with the immediate problem being a shortage of trained doctors and nurses to deliver the rapid increases in demand for the services.

‘Over the past ten years, the UK has led the way in improving standards of endoscopy and efficiency in running services, and other countries now look to the UK to help improve their services.

‘However, factors including our ageing population mean there is a 10 per cent increase in demand for endoscopies every year.

‘We support initiatives to increase early cancer detection, though campaigns to bring greater awareness of symptoms put further pressure on the service. Many services are routinely running six days a week, in some cases seven days a week. We are very keen to get patients in early and do the work, but it is challenging with the manpower and facilities that we have.

‘It is not sustainable — we need to work as efficiently as possible, but we also need more people.’

The problem stems from the fact that it takes at least a year to train a doctor or specialist nurse to carry out these procedures.

‘The Department of Health gives us six months’ warning that it is going to carry out an awareness campaign, but it takes a good year to train more staff,’ says Dr Veitch.

‘So even if we were to start training people immediately, there is going to be an inevitable time lag before we have enough staff with the skills to start performing these tests.’

Currently, there are around 3,500 doctors and nurses trained to carry out endoscopies in England, but hundreds more are needed.

Nevertheless, Dr Dunn urges anyone with persistent acid reflux or a family history of Barrett’s or oesophageal cancer to go to their GP as they may need an endoscopy.

‘If you have acid reflux for more than three weeks, you should consult your doctor — particularly if you are over 55,’ he says.

‘Treatment of Barrett’s oesophagus is now very effective, so it’s important to seek medical help early if you have these symptoms.’