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FRIDAY, Oct. 30, 2009 ( — World Trade Center workers who were at Ground Zero for months after September 11, 2001, continue to have higher-than-normal rates of heartburn and acid reflux even years later. And the more mental health problems they have—such as depression or posttraumatic stress disorder (PTSD)—the greater their risk of ongoing gastroesophageal reflux disease, or GERD, according to a new study.

The findings suggest that mental stress and depression can be a factor in GERD, which is characterized by persistent heartburn, says study coauthor Benjamin Luft, MD, a professor at the State University of New York at Stony Brook. And several factors may be playing a role in people who worked at Ground Zero.

“It was a very complex exposure,” he says. “You had a combination of both physical exposure and it also had a very potent impact on their mental health as well. Certainly a large percentage of patients had a variety of mental health problems.”

About 1 in 5, or 20%, of people in the general population has GERD. About 58% of the 9/11 workers reported heartburn and other gastrointestinal problems shortly after the events of 2001, and 42% had mental health problems such as depression or PTSD.

When the researchers followed up with 697 workers in 2005 and 2006, 42% still had GERD symptoms. There was also a link between persistent problems and mental health distress. Overall, 72% of those workers who had multiple mental health problems had heartburn and other GERD symptoms, and those with GERD were two to three times as likely to have depression or PTSD than those who were heartburn-free.

“This was really a very clear example of how mental health and physical disease can impact one another,” says Dr. Luft.

The researchers did not expect to find that so many people had problems that had persisted for so many years. “There is somewhat of a surprise that people continue to be symptomatic,” Dr. Luft says. “That we have such a high percentage of patients that continue to have GI disturbance and mental health distress, it was really something of great concern.”

The study was presented recently at the American College of Gastroenterology meeting in San Diego. The heartburn symptoms were unrelated to smoking or obesity, two factors known to increase the risk of GERD. Next Page: Toxic dust a factor too

[ pagebreak ]The symptoms are likely due to a combination of factors, including exposure to environmental toxins, according to Dr. Luft. The workers not only inhaled toxic dust, but they also most likely swallowed it.

“The material had two characteristics—one, it contained a lot of different chemicals and potential toxins, but the other thing about it was the dust itself was extremely caustic,” says Dr. Luft. “The pH was very high. The feeling was that with such a high pH, it could almost cause something analogous to a chemical burn.”

Although most people think the inhaled dust might affect the nose, throat, and lungs, “it also could impact your upper digestive tract as well,” he says.

The researchers did not look at what kinds of GERD treatments the workers were using and whether one type was better than another. GERD can be treated with antacids, histamine-2 blockers, and proton pump inhibitors; in very severe cases, surgery may be recommended, although results can be mixed.

David A. Johnson, MD, a former president of the American College of Gastroenterology, calls the study “provocative” but suggests that its “not absolute that the two are related; there are several issues that can also play into this.”

He notes that psychological trauma can also interrupt sleep, and “sleep dysfunction may also sensitize people to recognize other conditions like reflux disease.”

However, stress can play a role too. Animal research has shown that stress can lower the resistance to stomach acid during reflux, resulting in more damage to the esophagus, notes Dr. Johnson, a professor of medicine and chief of gastroenterology at Eastern Virginia Medical School, in Norfolk. Plus, “we do know that stress in and of itself may cause people to be sensitive to gastroesophageal reflux disease,” he says.

If people truly have GERD (misdiagnosis can occur), proton pump inhibitors—drugs that are “the cornerstone of treatment”—should help, Dr. Johnson says.

Both experts recommend talking to your doctor if you have persistent heartburn symptoms.

“My advice is that they basically talk to their doctor or find a physician who is really attuned to what their particular needs are,” says Dr. Luft. “The one thing we do know for sure is that if we dont treat the patient as a whole, dealing with both their psychic injury and their medical injury, we are not going to be able to effect a cure.”