Acid Reflux Disease Medication

Q: Hiatus hernias can be dangerous, but only really in the long term (eg it increases your risk of stomach cancer, but that takes years to develop). There's every chance that if you leave it or treat it with ranitidine it will not be a problem for you. The definitive test for a hiatus hernia would be something like a barium swallow (you lie on your back and swallow some barium, then roll around while they chase the barium with an X-ray machine). A hiatus hernia would be initially treated with an anti-reflux medication. Surgery is the only thing that will 'cure' it. Can anyone give me some more information about this please?

A:Esophageal cancer can be squamous cell carcinoma, or adenocarcinoma. Adenocarcinoma of the esophagus starts in Barrett's esophagus, where the lining has undergone metaplastic change from chronic acid reflux. The most common type of esophageal cancer through history has been squamous cell cancer since the esophagus is entirely lined with squamous mucosa, but the incidence of squamous cell cancer of the esophagus is actually decreasing while adenocarcinoma of the esophagus is rapidly increasing in incidence. The theory for this, not proven by randomized, prospective study, is that the use of effective anti-acid medication beginning 30 years ago (H2 receptor antagonists such as Tagamet) and now PPIs will effectively remove acid from the stomach, upsetting the acid-base relationship and now allowing alkaline bile salts to come out of solution in the stomach. Since these meds have not addressed the reflux mechanism, that patient is now refluxing bile salts, which are more damaging to the esophagus than acid. However, it's the acid that causes the symptoms, so the patient feels better even though he is accelerating the development of Barrett's esophagus. If you graph out the increasing use of H2 blockers and now PPIs over the last 30 years, and compare it to the graph of the incidence of adenocarcinoma of the esophagus over that same period, you will find that the graphs are identical. Not exactly a smoking gun, however the comparison is compelling, and it reminds me exactly of the way that the link between tobacco and lung cancer became evident. This info was related to me in a conversation with Tom DeMeester and a slide with that graph on it comes up in almost every talk he gives. It is therefore becoming increasingly suspected that the use of anti-acid medication DOES NOT decrease the incidence of esophageal cancer, but in fact may actually increase

it. The treatment you outline is completely appropriate. The only thing I would add is that the esophagectomy can be done laparoscopically, something that will speed recovery and decrease complications. Having done the procedure that way several times, I would highly recommend that approach. Yes, the size of the tumor is a very important prognostic factor, and since the size is discernalbe preoperatively, that clinical staging guides the preop chemo-radiation along with CT and PET scan. However, the actual prognosis and additional post-op treatment will be far better understood after the operation when the tumor and surrounding tissue and lymph nodes can be definitely examined.