Heartburn, Smoking and Barrett’s Esophagus

Heartburn, Smoking and Barrett’s Esophagus

Mike from Houston sent us a question this past week: “I was diagnosed with Barrett’s esophagus in 2010. I stopped smoking and have lost around 40 pounds. I was started on Nexium 40 mg daily. I have had regular upper endoscopies since 2010 and they have consistently showed a regressing Barrett’s segment. My last scope was last week, and it showed a small residual patch of Barrett’s esophagus measuring less than 1 by 1 cm. Is it possible for Barrett’s to get better with time?

Dear Mike,

Obesity, and smoking in the setting of acid reflux are major risk factors for Barrett’s esophagus. Studies have shown that Barrett’s mucosa does regress back to normal after reliably stopping acid reflux following Nissen fundoplication. This is particularly true for short segment Barrett’s esophagus. Weight loss is associated with decreased acid reflux and decreased inflammation. In combination with smoking cessation, weight loss may prevent Barrett’s esophagus progression to cancer and promote Barrett’s esophagus regression. At Houston heartburn and reflux center, 90% of acid reflux patients who are cigarette smokers have evidence of Barrett’s esophagus on upper endoscopy. The incidence of Barrett’s esophagus in non-smokers at Houston heartburn and reflux center is around 10%. Cigarette smoking greatly exacerbates esophageal injury in GERD patients and smoking cessation is highly advised.

Heartburn medications like proton pump inhibitors, on the other hand, don’t stop reflux and simply mask symptoms. There is no evidence to suggest that proton pump inhibitors cause Barrett mucosa to regress to normal. The evidence is controversial on the effect of heartburn medications like proton pump inhibitors on the progression of Barrett’s esophagus to cancer. A number of GERD patients presenting to Houston heartburn and reflux center show progression of acid reflux despite years of PPI treatment including development of Barrett’s esophagus. One concern with chronic acid suppression secondary to PPI use is the increased bile salt accumulation in esophageal squamous cells. This leads to cellular damage, increased incidence of Barrett’s esophagus and increased progression to cancer.

In summary, weight loss and smoking cessation cannot be overemphasized in acid reflux patients. Obesity and smoking are major risk factors for Barrett’s esophagus development in GERD patients. Smoking cessation and weight loss decrease inflammation and reflux. Nissen fundoplication is superior to heartburn medications in reliably stopping reflux and preventing the progression of Barrett’s esophagus to cancer.