Five Questions With: Dr. Guy Nicastri

"There are between 16 and 20 million people being treated for chronic GERD symptoms in the U.S. "

Dr. Guy Nicastri is a board-certified surgeon and an expert on gastroesophageal reflux disease (GERD), colloquially known as heartburn. Nicastri is affiliated with Lifespan’s Rhode Island Hospital, The Miriam Hospital, and Newport Hospital and will give a community lecture on March 25 at Newport Hospital entitled “Heartburn: you don’t have to live with it.”

PBN: What causes gastroesophageal reflux disease, or chronic heartburn?
NICASTRI:
In normal digestion, a muscular valve in the lower esophagus opens to allow food into the stomach and subsequently closes to prevent food and acidic stomach juices from returning to the esophagus. Gastroesophageal reflux disease occurs when the valve is weak or relaxes inappropriately. The backwash (reflux) irritates the esophagus lining and causes GERD. Heartburn is the most common symptom. The severity depends on the degree of valve dysfunction and amount and type of reflux. Although no cause is known, certain conditions increase the risk of GERD. These range from obesity and hiatal hernia to smoking, diabetes, and certain medications and tissue disorders, such as scleroderma.

PBN: What is the typical age of onset, and what age group is particularly hard hit by chronic heartburn?
NICASTRI
: Gastroesophageal reflux disease occurs in all age groups, including children. Since symptoms can occur in any age group and since the disease slowly progress over time, severe GERD symptoms are commonly found in middle- and older-age adults.

PBN: Has the percentage of people diagnosed with GERD gone up or down in the past couple of decades?
NICASTRI:
There are between 16 and 20 million people being treated for chronic GERD symptoms in the U.S. No good data exists for the true incidence of GERD, but there is good data on secondary measurements, such as hospitalizations for severe, chronic GERD. Hospitalizations for severe esophagitis, esophageal strictures, Barrett’s esophagitis (a precancerous change in the lower esophageal lining caused by chronic reflux), and esophageal cancer have increased severalfold over the past three decades. In 2014, more than 16,000 new U.S. esophageal cancer cases were diagnosed, making this among the fastest-growing cancers, according to the National Cancer Institute. Most of this increase has been in cancer of the lower esophagus and is believed to directly result from chronic reflux.

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PBN: Once someone is on medication for the problem, is it difficult to get off the medications?
NICASTRI
: Since medications are designed to neutralize acid reflux, they are effective in alleviating the major symptom of GERD: heartburn. They also help treat lower esophagus irritation. However, the true problem of GERD is a malfunctioning valve. Once medication is stopped, heartburn symptoms often recur, necessitating resumption of medication. Reflux still occurs, it just can’t be felt. Over time, some heartburn sufferers become medication resistant, often needing to increase dosages and frequencies or switch antacids. Others begin to experience non-acid reflux symptoms. These include regurgitation, particularly at night, chronic sore throat and coughing, and voice hoarseness. Many heartburn medications are now sold over the counter and it is difficult to know if and when medications are stopped.

PBN: How has treatment changed in the past 10 years?
NICASTRI:
In recent decades, chronic GERD treatments have centered around acid neutralization. Medications have been developed and most have been effective. Since they do not treat the malfunctioning valve, however, reflux still occurs. Because we now recognize long-term complications of chronic medication use (ranging from osteoporosis to increased colon infection risk), the emergence of non-acid reflux symptoms (ranging from regurgitation to voice hoarseness) and concern over increasing Barrett’s esophagitis and esophageal cancer rates, newer strategies focus on fixing the valve in the lower esophagus. Some require surgery, such as hiatal hernia operations to restore a functioning esophagus. These are mostly performed laparoscopically and patients often go home shortly after. Others can be performed endoscopically, requiring no incisions. Newer procedures are usually a more permanent fix and stop chronic use of antacid medications. Newport Hospital’s Esophageal Lab and Heartburn Center can help coordinate an evaluation and treatment options.

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