Feeling the burn - Macleans.ca

Feeling the burn

Afflicting millions— even babies—chronic reflux is becoming the epidemic of our times

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Feeling the burn

When Cooper Olsen was four weeks old, he started to projectile vomit. Soon, he was crying through every feeding: “He’d arch his back, throw his head back and scream,” says his mom, Julie, who lives in the affluent L.A. bedroom community of Valencia. “Then he’d gulp from the bottle and cry.” It went on like this—gulp, scream, gulp, scream, gulp, scream—“over and over again,” says Julie, who works in the L.A. office of a New York-based consulting firm. After one horrible night, “over three hours of constant, bone-chilling screaming,” she and her husband, Bob, a pilot with a large U.S. airline, took Cooper to the hospital; by then, he’d stopped gaining weight. There, a doctor diagnosed him with gastroesophageal reflux disease, commonly known as “GERD.” Since he started taking Prevacid, Cooper’s become a different baby.

Yes, chronic reflux, that almost quintessentially Auntie May disease, is now hitting North Americans at every age. Indeed, the uptick of diagnoses in kids and babies is “really scary,” says Seattle physician Tom Vaughan, an expert on acid reflux and professor at the University of Washington. Two decades ago, it was almost unheard of. Now the use of proton pump inhibitors (PPIs), the strongest acid-blocking drugs, for infants like Cooper—who might once have been dismissed as “colicky”—has soared by 750 per cent in the U.S. in the past decade; a range of reflux drugs have been approved for use in kids under age 11. This year, a lime-flavoured, “kid’s-strength” version of the GERD prescription drug Nexium will hit the market. “More and more kids are being treated with PPIs and getting anti-reflux surgery,” says Dr. Douglas Corley of Kaiser Permanente Hospital in Oakland, Calif. “And no one has any idea what the long-term effects are.”

Unfortunately, ignoring the symptoms—which for kids can include coughing and tummy aches—has its perils too, notes Gail Attara, executive director of the Canadian Society of Intestinal Research. Six years ago, at age nine, her son was diagnosed with acid reflux. “He didn’t feel the effects of reflux,” says Attara—“or he wasn’t expressing it.” She took him to the doctor because she couldn’t figure out why he had such terrible breath: “He’d never had a cavity. He ate well, and was healthy in every other way. Somehow, his esophageal sphincter was open,” she explains, “and it was letting [stomach acids and] those odours up.” After being on acid suppressant medication for one day, she says, his breath was “as sweet as when he was a baby.”

The numbers among children mirror a wider trend; researchers say GERD, which only appeared in medical literature in the 1930s, may be on its way to becoming the epidemic of our times. Almost everyone has heartburn now and again, often after pigging out at Thanksgiving or Christmas. But chronic reflux—caused when digestive acids routinely splash the upper chest or throat—affects close to six million Canadians at a cost of $670 million to the health care system every year. Drugs to combat it are among the most-prescribed pills in North America, neck and neck with those used to treat high blood pressure, cholesterol and asthma. And the incidence of reflux is increasing by five per cent a year, according to a 2007 study in the journal Clinical Gastroenterology and Hepatology. The rest of the world, meanwhile, is following our lead: Europe is roughly 10 years behind North America in the incidence of GERD; Asia is 10 years behind them, says Dr. Ernst Kuipers, chair of the department of gastroenterology at Erasmus University in the Netherlands. “It’s the downside of development,” says Kuipers.

One issue that researchers, led by microbiologist Martin Blaser of New York University, have narrowed in on is the eradication of Helicobacter pylori, a once-common bacteria known to cause ulcers and stomach cancers. It turns out H. pylori—which has been virtually eliminated from industrialized countries—may have been protecting the body from GERD; it did this by slowing or decreasing the production of acid, particularly with age, says Kuipers. “As rates of H. pylori go down, GERD rates go up,” he says. “We think that relationship is causal.”

The increase in obesity is speculated to be another cause, says Corley. Certainly people are bigger and fatter than 20 years ago, says Corley, who published a paper in the American Journal of Gastroenterology two years ago, linking obesity and GERD. “But that’s not the whole story,” he says. People who are heavier tend to eat more fat, which slows stomach emptying. “It takes longer for the stomach to begin the digestive process and shove contents out into the duodenum.”

But that doesn’t mean those who run, eat their greens and avoid Taco Bell are immune, says Attara. In fact, she says, “one in three patients don’t consult with a physician at all because they think it’s due to their physical condition,” she says, when it may not be. On average, most wait two years before seeing a physician, which allows for the gradual worsening of symptoms. Painful heartburn and a queasy stomach are the most common. But some sufferers have difficulty swallowing, or experience a hunger-like pain, sense of fullness, gas or bloating. A chronic cough or sore throat, or a bitter taste in the mouth, can accompany the condition. And some show no symptoms at all. “They’re the most worrisome,” says Morgan. “They’ll get complications—bleeding or stricturing—without even knowing they have a problem.”

Reflux was once believed to be a benign or trivial condition, says Dr. David Morgan, a physician and professor of gastroenterology at McMaster University. Not so. “It’s not ‘just a little heartburn,’ but a quality-of-life issue, particularly for those who get nocturnal symptoms,” he says. “They’re waking up because of reflux. They’re chronically tired. They miss work, or have trouble concentrating.” And they require pills, which can run a dollar or two a day. Indeed, a recent Canadian study of 6,000 GERD patients showed the quality of life of individuals with reflux disease is lower than those who suffer from diabetes and arthritis.

Worse, left untreated, digestive acid can corrode the lining of the esophagus and cause a condition called Barrett’s esophagus, which can lead to cancer. It’s no coincidence, suggests Attara, that in Canada and the U.S., adenocarcinoma of the esophagus is the single fastest-growing form of cancer: its incidence has jumped more than 400 per cent in the last 30 years, in lockstep with the incidence of GERD. One link is the body’s own resilience and ability to cope: as the esophagus adapts to inflammation and injury, it sometimes develops a new, acid-resistant lining; it looks and functions more like the small bowel, Morgan explains. This causes heartburn symptoms to disappear, masking more dangerous conditions, including cancer. (White men older than 55 are at highest risk.) Because the body can adapt to hide it, cancer is often detected at a late stage. At that point, the prognosis is grim: only 14 per cent survive five years after diagnosis. (Though it’s on the rise, esophageal cancer is still relatively rare, representing fewer than one per cent of new cancer cases in Canada.)

A survey by the American Gastroenterological Association Institute this spring found that nearly 40 per cent of those who take the strongest medication for GERD continue to experience symptoms regularly. For the worst sufferers among them, there may be an alternative: a minimally invasive surgery in which the upper part of the stomach is wrapped around the lower esophagus to recreate the weakened valve; symptoms improve, though few are completely cured. But for babies like Cooper, there’s good news. They tend to outgrow the condition as their digestive systems mature. By the time they’re a year old, most will be asymptomatic, and few will go on to develop the chronic condition as children or adults. Last week, Bob and Julie bought an “acid reflux pillow”; the wedge-shaped pillow keeps Cooper, now aged four months, propped up at a steep angle. For the first time in his life, he slept through the night.