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BRITISH BROADCASTING CORPORATION
RADIO SCIENCE UNIT
CASE NOTES 3. - Indigestion
RADIO 4
THURSDAY 28/12/04 2100-2130
PRESENTER:
MARK PORTER
REPORTER: LESLEY HILTON
CONTRIBUTORS:
BRENDAN DELANEY
ALYN MORICE
PETER FAIRCLOUGH
PRODUCER:
PAUL MCGRATH
NOT CHECKED AS BROADCAST
PORTER
Hello, if you're feeling a bit dyspeptic after the excesses of Christmas then today's programme is just what the doctor ordered, because it's all about indigestion or heartburn or dyspepsia. Call it what you will it's an extremely common and often very distressing problem and never more so than at this time of year. Four out of ten people will have suffered from dyspepsia at least once in the last 12 months, the vast majority of them never go near a doctor, preferring to self-medicate with over-the-counter remedies. And in a typical year we spend over a £100 million on such remedies. But are we spending our money wisely? And when should dyspepsia prompt a visit to the doctor rather than the pharmacist?
Case Notes reporter Lesley Hilton finds out that children can suffer too and talks to a surgeon who is pioneering a new operation that could provide a lifelong cure for adults as well as children. And if you suffer from a persistent nagging cough, particularly when you talk, laugh or after you've eaten a meal, then it's probably due to a problem with your gullet, rather than your chest, and there could be a surprisingly simple solution. I'll be meeting one of the world's leading authorities on acid reflux cough and finding out why his clinic in Hull has become so popular.
CLIP
People come from all over the country actually, from the north of Scotland to Cornwall they come and see us. So it's a symptom which drives people to desperation that they'll even come to Hull.
PORTER
My guest today is Brendan Delaney, professor of primary care at the University of Birmingham and he joins us from our studio in Edinburgh.
Brendan, perhaps we should start by clearing up the confusion that surrounds the terminology. What do we mean by dyspepsia and is it the same as indigestion and heartburn?
DELANEY
Well it really depends who you talk to. Specialists have been very keen to split out gastroesophageal reflux disease, that is symptoms of heartburn and acid reflex, so a burning feeling coming up into the centre of the chest from the stomach from dyspepsia, which is more of pain in the centre of the stomach, just below the rib cage. Unfortunately, splitting them up in general practice doesn't really work very well because the individual symptoms aren't particularly predictive of any kind of underlying disorder and you really need to have had a look down with an endoscope before you can really make sense of the individual symptoms that the patient has.
PORTER
And the patients are coming to see the doctor because they've got a problem - it doesn't really matter which type it is I suppose. What are the main causes of dyspepsia - perhaps we can break them up in that way?
DELANEY
Well unfortunately the commonest cause is no cause found ...
PORTER
So often the case in medicine.
DELANEY
Yes exactly. Or functional dyspepsia or functional reflux disease, depending on whether they've got predominant heartburn or upper gastric pain. If there is a cause found then at the moment the most common is oesophagitis or inflammation of the gullet, part of gastroesophageal reflux disease and less than 10% of patients will have a peptic ulcer, either in the duodenum or the stomach. And then finally, on the very end, the rare causes, overall about 1% of patients, will turn out to have a malignancy either of the stomach or the oesophagus.
PORTER
So when you're talking about this functional dyspepsia are we talking about an acid related problem - is it too much acid?
DELANEY
Well in some patients yes, we know that because if we suppress their acid production they get better in an empirical way but a few patients, who unfortunately don't respond to acid suppression, can be quite a headache to manage and we really don't know what causes their symptoms.
PORTER
So this is a sort of irritable bowel affecting the upper part of the bowel really?
DELANEY
Yes or it could indeed be the lower part of the bowel because of course it wraps around the stomach over the top anatomically, so localising pain could be quite difficult if someone's got upper abdominal bloating.
PORTER
What about the role of overindulgence - I mean people in the last few weeks or certainly in the last few days have been overindulging and dyspepsia, indigestion, certainly in general practice seems to be much more common when people have been overdoing it?
DELANEY
I think particularly with reflux disease if you've got heartburn then if you fill your stomach up late at night with greasy food which is going to be slow to empty then you lie down flat you're asking to get your heartburn. But you've got to have a predisposition to it to start with and we can't just blame indigestion on lifestyle, there's an underlying problem.
PORTER
What about pregnancy because heartburn is very common in pregnancy isn't it?
DELANEY
Yes and I think almost all pregnant women will get heartburn at some stage during their pregnancy. It's caused by relaxation of the lower end of the gullet and obviously the increasing swelling of their abdomen.
PORTER
When should sufferers seek help? We said that obviously most people self-medicate, are there any sort of flags that should cause concern that should make them see the doctor rather than the pharmacist?
DELANEY
Yes, the important thing to bear in mind, of course, even if you have one of these red flags you're unlikely to have cancer but you should still consult with your doctor and that predominantly is - or the most important is dysphagia. Now that's a sensation of food sticking on swallowing, it's not just a sensation of discomfit but an actual physical sensation that the food sticks. People who have unexplained weight loss in association with dyspepsia or are diagnosed as being anaemic and could perhaps have a bleeding stomach ulcer as the cause. And they're all red flag symptoms and should lead both to a consultation with a GP and reasonably rapid referral for an endoscopy.
PORTER
And of course if you mention those to a pharmacist he or she should direct you direct to your GP.
We'll leave it there for the moment Brendan. Of course the definitive first line investigation for working out what's causing dyspepsia is an endoscopy, looking around the gullet, stomach and first part of the intestine, that's the duodenum, with a fibre optic endoscope. We caught up with Mary Ogden, as she had an endoscopy performed by gastroenterologist Peter Fairclough at the Royal London Hospital in Whitechapel. Mary had been having trouble swallowing.
OGDEN
I was at a party and I couldn't get the food down. I'd eaten a lovely piece of roast beef and it stuck just about there. And I felt very hot and sweaty and embarrassed. And I had to leave the room and bring it up. That was it. Sometimes, you know, you sort of have a little reflux but it hasn't been bad, particularly at night - you go to bed and you lie down and you suddenly feel a bit burny there and I'd reach out and get a Rennie and that was it.
ACTUALITY - ENDOSCOPY
FAIRCLOUGH
Fine, just pop up and have a seat on the edge of the bed. Open wide, that's good. Fine, swallow. And you remember that this will make the back of the mouth numb. Not nice tasting is it.
OGDEN
Well not bad, I've had worse.
FAIRCLOUGH
It's not Dom Perignon though. Lie up on the bed for me. Turn on your left shoulder and hip and face me. Now I want you to hold this little piece of plastic between your teeth. That's it. And lean over and hold on to the edge of the bed with that hand. Okay are you ready? Now I'll tell you what I'm doing. Just passing the telescope over the tongue and through the back of the mouth and we're coming down, in a second, to the swallowing mechanism and going through now, just give a little swallow for me Mary, that's it, well done, very good. Okay? So we're in the gullet now. Try and relax, just get your breath. That's it, well done. And we're just passing down the instrument, down the gullet now into the stomach now. You'll feel a little bit windy because I'm putting gas in the stomach - are you okay there? Good, good. I'm coming to the bottom end of the stomach now. Okay, sorry about that. It's going out of the stomach into the duodenum and that looks normal, bottom end of the stomach looks fine and just bringing out the telescope now, a little at a time, having a look as I go. And I'll just suck some of the gas out of your stomach, so you won't be too burpy. Okay, you've got a hiatus hernia and a little bit of narrowing going out of the stomach, out of the gullet into the stomach. And that's still healing up I think with the new treatment you've been having. Okay some biopsy forceps please. Just going to take some little samples in here. Are you okay there? Good. Right this doesn't hurt, I'm just going to take a little sample. Open please. Close. Okay, open again. Close. Okay jolly good. Now the reason for taking these samples is that the lining of your gullet has been damaged by the acid and we just need to see exactly how much damage there is and whether we need to give you any different kind of treatment for it. Alright. So I'm going to take the endoscope out now, it's come out through the back of the mouth - well done. That's it, all finished.
OGDEN
Well it's uncomfortable, it is not painful but it is uncomfortable. But they're so lovely and they look after you so well and I wasn't waiting around long. They told me exactly what they were doing but they didn't tell me that the noises would be so loud - but they're used to it you see. But they did today, they told me it was gas - that they put gas into the stomach to hold it out and so now I don't feel quite so embarrassed.
PORTER
Mary Ogden and Dr Peter Fairclough.
You're listening to Case Notes, I'm Dr Mark Porter and I'm talking about dyspepsia with my guest Professor Brendan Delaney.
Brendan, Mary there had a hiatus hernia, now that's quite a common finding in endoscopy isn't it, perhaps you could explain.
DELANEY
Well basically it means that the upper part of the stomach is pulled up slightly into the chest, so it lies above the hiatus or the gap within the diaphragm - the muscle that separates the abdomen from the chest. And it's associated with heartburn symptoms but isn't in itself an alarming diagnosis and as you said it's very common.
PORTER
And that's because the valve that's on the stomach is no longer properly competent, it's allowing the stomach contents to come back up into the relatively delicate gullet yeah?
DELANEY
Precisely.
PORTER
We haven't mentioned helicobacter pylori yet, H. pylori - a discovery that really turned the world of gastroenterology on its head.
DELANEY
Yes indeed. I think there were great hopes that eradication of H. Pylori would eradicate dyspepsia. Unfortunately, for the majority of patients who have functional dyspepsia this isn't the case. For example, if you have a duodenal ulcer and you have helicobacter pylori then that ulcer will keep on coming back year after year and getting rid of your helicobacter pylori will pretty much stop that. If you have functional dyspepsia there's a small group of about 9% of patients who might benefit from H. pylori eradication which makes it worth doing but the vast majority won't.
PORTER
So while helicobacter pylori causes most ulcers it doesn't cause most cases of indigestion, which was what was hoped originally wasn't it - that you could cure someone forever from their indigestion by giving them a week's course of antibiotics.
DELANEY
That's right, indeed. There still is an argument that it might be a reasonable first line strategy to do with patients who come up with dyspepsia - let's test for H. Pylori and treat it and see if it makes them better and in fact we're doing quite a large trial across the country, funded by the Medical Research Council, for that at the moment.
PORTER
How many people carry H. Pylori - middle aged adults for instance?
DELANEY
It runs along at about 10% minus your age. So a 40 year old would have around a 30% chance of having it. However, it's heavily related to social class - higher socioeconomic groups it's pretty rare, and if you were born in the third world or grew up in poverty than you're pretty much likely to have it - about 90%.
PORTER
How important is diet and lifestyle - does drinking too much, eating too much rich food and being overweight and perhaps smoking - affect your chances of suffering from dyspepsia?
DELANEY
A bit, there are some weak associations between being overweight, smoking and having a high alcohol intake. But what evidence there is that looks at whether actually reducing weight or stopping smoking makes much difference is very inconclusive.
PORTER
Now on prescription we basically can't offer anything much different than you can buy over-the-counter, you can buy the strongest group of drugs - the proton pump inhibitors - omeprazole - across the counter now, so why would people come to the doctor, what more can you get from the doctor in terms of medicines to relieve your symptoms?
DELANEY
Well I think for a start the over-the-counter licence for proton pump inhibitors is quite limited, it's no more than a couple of weeks of treatment and that's on the advice of a pharmacist. So if you're going to enter a long term usage then a consultation with a GP who can check for any alarm symptoms, give you some advice about your symptoms and advise you how to take the medication and of course it's much cheaper on prescription is quite sensible.
PORTER
Is there a downside to suppressing stomach acid production long term?
DELANEY
Well this was raised when proton pump inhibitors were first produced but there's been long experience of the drugs now - about 10 years - and the answer is in essence no.
PORTER
Well dyspepsia isn't only a problem in adults, children can suffer too, and sometimes severely enough to warrant surgery as Lesley Hilton discovered when she met David Beadle.
ACTUALITY - DAVID BEADLE SHOPPING
Would you prefer the Spelt or the Spelt and Sunflower or the Spelt and Rye.
I'll have the Spelt please.
Spelt - okay we'll do that then. Right is there anything else you ...
Well we need some live yoghurt, we're getting low ...
HILTON
David Beadle is 17, he's had acid reflux for a couple of years and it makes his life a misery at times.
BEADLE
I started getting burning in the bottom of my throat, almost as though one was vomiting, it was very strong kind of burning. And there was a pause not long ago where it wasn't so bad but since then it's been getting worse and worse and if I don't have the drugs - I have zoton and nexium sometimes - when I don't have those drugs it's much worse I get than it normally is when I have the drugs and I have a bit of regurgitation, I have a lot when I don't have them and I burn in the bottom of my throat and I get some heartburn as well. Especially if I have perhaps a lot of liquid and solid together - maybe if I have cereal in the morning.
HILTON
Such an acute form of acid reflux in a child or young person is uncommon, children don't usually have the same diet and lifestyle habits as adults. Dr Mike Thomson is a consultant paediatric gastroenterologist at the Sheffield Children's Hospital.
THOMSON
The disease of reflux - acid from the stomach coming up into the swallowing tube - is not exactly the same as the adult disease but it has some similarities. For instance alcohol and tobacco are clearly not issues generally speaking in paediatrics but there are certain situations that these similarities occur in, for instance, the child will have the tight area at the top of the stomach, which is a valve, which may not be competent and that's the main problem.
HILTON
Despite drastically changing his diet and trying complementary therapies like acupuncture and homeopathy David has lost over two stone in weight in the last year and a half. He's now on the waiting list to have a fundoplication operation through keyhole surgery. This has been the only treatment for serious cases for some years and involves wrapping the upper part of the stomach around the lower part of the oesophagus. It's a relatively major procedure, which is irreversible, and carries the possibility of problems afterwards, such as the inability to burp or vomit and problems with swallowing. David's mother, Sally, is very worried about the risks involved.
SALLY BEADLE
The fundoplication operation means that they'd make five holes in him as a keyhole surgery operation and there's a risk anyway of making five holes in somebody that something could be damaged on the way. I know there's a very high success rate but as the surgeon said there's a 1% chance of the stomach or the oesophagus being punctured, of course that is only 1% but if you're that 1% then it's a 100% for you, so there's a worry that he might not be able to burp or vomit after, which some people would say would be a blessing but imagine actually if you had a stomach bug and you couldn't be sick, I think it would be pretty bad.
ACTUALITY - HOSPITAL WARD
Hello James how are you?
Fine.
How's your tummy?
It has hurt a little bit before.
It's only been a couple of weeks, I'm very pleased with the way you're coping with this, well done, you're very grown up, very brave.
HILTON
Six-year-old James Watts has had acid reflux since birth. As a baby he had severe projectile vomiting and couldn't eat solid foods. Doctors thought it was a form of food phobia and he's only recently been properly diagnosed. His mother Justine says the condition has had a serious effect on his quality of life.
JUSTINE
To look at physically he just never really looked like a particularly healthy child - he's always been tall for his age, but very skinny and very pale. And basically not as much energy as a child of his age would normally have. But more than anything it's the constant tummy aches and feeling of sickness that he's had for as long as we can remember.
HILTON
But in Sheffield Mike Thomson has developed a far less invasive technique that's fully reversible.
ACTUALITY - OPERATION
And we just separate [indistinct word] from the tissue, go back into the stomach and close the chamber and hopefully when we pull the scope this loop that Andy is holding will pass down into the oesophagus. So this means we've made a successful second suture. We now ...
HILTON
James Watts has just had this new procedure. Mike Thomson describes how it's done.
THOMSON
A little sewing machine is put on the end of an endoscope, which is passed - when the child is asleep under a short light general anaesthetic - down into the swallowing tube of the oesophagus. And it's passed down to just below where the oesophagus enters the stomach and six stitches - three pairs of two - are made and these three pairs are tied together creating a little bit like a purse string effect, if you like. But there is no operation as such, no incisions in the abdomen and this is undoable if need be and is not necessarily a permanent fixture.
HILTON
Mike Thomson says this type of endoscopic fundoplication has proved highly effective in the 30 children aged between 6 and 16 treated over the past year. Twenty five of them are now off medication completely. James was the youngest child to be treated, so how does his mother feel about him having a procedure which is still in its infancy?
JUSTINE
I don't think that technology would advance very much unless people are prepared to undergo something that is not as tried and tested as a lot of the older procedures. But certainly the alternative we were given, which is an open operation, I don't think that James, as an individual, would have coped with either emotionally or physically and there's no choice, as far as we were concerned as parents this was the route we wanted to go.
PORTER
James Watts's mother Justine talking to Lesley Hilton.
Brendan, I think most people would be surprised that dyspepsia symptoms can be severe enough to warrant surgery but in pronounced cases they really can affect your quality of life can't they.
DELANEY
Indeed, evidence shows that for severe patients it can be as bad an impact on quality of life as having heart disease or angina.
PORTER
Do you think that laparoscopic fundoplication is going to be something we're going to be offering more of?
DELANEY
Basically no, I think the difficulty with all surgical procedures is as we've heard here in the example of 30 cases in the hands of an expert with very selected numbers of patients it appears to do well, you move it out into the general population and less selected patients, more general surgeons, it doesn't do as well and it doesn't get uptake.
PORTER
Well so far we've only looked at the more obvious consequences of dyspepsia but gastric juices in the wrong place can cause more than heartburn. Professor Alyn Morice from the University of Hull is a world authority on long term cough associated with back-flow of stomach juices into the gullet, so-called acid reflux cough - a common and often missed cause of persistent and troublesome cough. I started off by asking him who's most likely to be affected?
MORICE
It seems that women have a heightened cough reflex and this is one of the reasons why they tend to come. And it tends to be a condition which comes on as you get older, perhaps because you've put on a bit more weight.
PORTER
But how many people do you think across the country are suffering from it?
MORICE
Well there was a large survey done by the European Respiratory Society and they reckon about 1 in 10 people have a chronic cough.
PORTER
And what proportion of those people with chronic cough do you think have got acid reflux cough?
MORICE
The majority I would say. There's one or two who have asthma as well but usually the asthma is sorted out when they go and see the doctor because the doctor immediately assumes that the cough is due to asthma and so they almost invariably have had asthma treatment and when they come and see me the first thing I do is stop all the asthma treatment and usually nothing happens.
PORTER
Conventional wisdom has it that the key symptom of reflux is heartburn - the acid coming out of the stomach burns the relatively delicate lining of the unprotected gullet. But in these people they can just have cough can't they.
MORICE
That's right, only about half of the patients with reflux cough actually have the heartburn and often the doctor says it can't be reflux because they don't have the heartburn but it's not true. Isolated cough can be the only symptom of reflux.
PORTER
And are there any characteristic telltale signs that the patient or the doctor should look out for that would point towards an acid related cough rather than perhaps asthma or some other common cause?
MORICE
Recently I've gone away from doing tests because I think that the history, as we call it, what the patient tells you, is the characteristic feature. So that the cough tends to go away at night because the valve tightens up at night, then the patient wakes up and unlike an asthmatic who wakes up coughing the patient will often wake without a cough but it's when they get out of bed or move over in bed and that's the valve opening to allow for the gas that's accumulated in the stomach overnight to be released, then they get a cough. Sometimes with dry food and that's a reflex from the back of the throat going down to open the valve and particularly cough after food as well, so about 5 to 10 minutes after eating people start coughing. When you eat you swallow air and the body naturally opens the valve to allow that air out after you've finished eating and that causes the reflux at the same time. Other symptoms are hoarseness of the voice, when you're talking or on the telephone, laughing is another one and that's because the diaphragm normally holds the valve closed and when you're using your diaphragm to make the words that allows the reflux to whip past.
PORTER
And what about treatment?
MORICE
The conventional treatment for heartburn is drugs which block acid and they do work but for some reason, I don't really understand, they take longer to work and they're not quite as successful because whilst heartburn you need to burn the gullet, as you've said, with reflux cough if it's reflux going up to your vocal cords and landing on your voice box although it doesn't really matter if it's too - acid at all really, it'll make you cough. So there's other things that we have to give which deal with the movement of the gullet, they tend to be sort of second line treatment if the acid treatment doesn't work or antacid treatment.
PORTER
So using antacid treatments - and we use drugs like the proton pump inhibitors or PPIs as they're known - drugs like Esomeprazole and Lansoprazole, very commonly prescribed drugs - they may not have an immediate effect, indeed they may not get rid of the cough altogether.
MORICE
Correct and also most doctors tend to give them once a day, whereas in fact they only last in the body for about an hour and a half, so whilst once a day will block sufficient acid to prevent heartburn, in reflux cough, where you're trying to block all of the acid, you need to give them twice a day. And indeed we've gone over to giving them twice a day and another type of tablet - ranitidine - at night to block all of the acid. I mean I saw a lady last Thursday in my cough clinic and she'd had a cough for 66 years and the poor lady was doubly incontinent with it and we made her better with baclofen, which works on the movement of the gullet.
PORTER
And how quickly did her symptoms clear?
MORICE
It took her about two weeks for her to get better but the key was to understand the origin of the cough to provide the specific therapy. When we can't get people better with that, we've just done a study looking at low doses of morphine and that seems very effective in people who have intractable reflux cough.
PORTER
Professor Alyn Morice who's written a definitive guide to coughs and their treatment which can be accessed for free via the internet, well worth reading. Check out our website: bcc.co.uk/radio4 for details.
Brendan, perhaps we should finish by reiterating advice for the vast majority of people who self-medicate with dyspepsia remedies from their pharmacist. If you had to go for an over-the-counter remedy which one would you go for?
DELANEY
I think there are two things: if you want instant relief from waking up in the middle of the night with symptoms then an antacid or an alginate will give you that instant relief.
PORTER
Those are the white medicines aren't they and the liquids - so tablets and liquids. When would you use a PPI - the omeprazole - because they're very expensive aren't they, you can only buy a few as well?
DELANEY
Yes, so if you're waking up on consecutive nights or you've got symptoms during the day you want something you can take for a few days at a time or perhaps in anticipation of an event which might cause you heartburn in the middle of the night.
PORTER
And when should your indigestion or heartburn - perhaps for New Year's Eve is what you're saying there - and when should your indigestion or heartburn ring alarm bells and warrant an appointment perhaps with the GP instead of the pharmacist?
DELANEY
Well back in the summer the National Institute of Clinical Excellence, the NHS body that issues guidance to doctors, produced new guidance on this area and in essence it's patients of any age with unexplained weight loss with dyspepsia or dysphagia - the sticking, as we've described earlier - then specifically in older patients, say over the age of 55, if they've got recurrent symptoms not settling down on initial acid suppression and particularly people who've got a family history of stomach cancer or have had an endoscopy in the past which has shown something called Barrett's Oesophagus.
PORTER
Of course the vast majority of people who do need to see their doctor it's about optimising treatment rather than finding anything sinister.
DELANEY
Yes absolutely and in fact NICE said optimal treatment would be on demand patients' self-managed use of proton pump inhibitor rather than taking it continuously.
PORTER
And the NHS would like that presumably as well because we spend something like - well nearly half a billion pounds don't we on indigestion remedies and proton pump inhibitors take a large slice of that.
DELANEY
Yes and particularly if you've got a functional heartburn you can probably get away with taking your medication only on a third of the time.
PORTER
Well Professor Brendan Delaney that's all we have time for, thank you very much.
And next week's programme is about respiratory problems, including chronic obstructive pulmonary disease - COPD - an often forgotten condition that can have serious implications for the one in six people over 40 who develop it. And on a slightly different note - could playing the recorder help your child's asthma?
ENDS
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