Heartburn and GERD

How common is heartburn?
Over 60 million Americans experience heartburn at least once a month, and some studies have suggested that over 15 million Americans experience heartburn symptoms each day. Symptoms of heartburn, also known as acid indigestion, are more common among the elderly and women during pregnancy.

What is heartburn or GERD?
Gastroesophageal reflux disease (GERD) is a physical condition in which acid from the stomach flows backward up into the esophagus. People experience heartburn symptoms when excessive amounts of acid reflux into the esophagus. Many describe heartburn as a feeling of burning discomfort, localized behind the breastbone, that moves up toward the neck and throat. The burning and pressure symptoms of heartburn can last for several hours and often worsen after eating food. All of us may have occasional heartburn. However, frequent heartburn (two or more times a week), food sticking, unexplained cough, blood or weight loss may be associated with a more severe problem known as GERD.

What causes heartburn and GERD?
To understand GERD, it is first necessary to understand what causes heartburn. Most people will experience heartburn if the lining of the esophagus comes in contact with too much stomach juice for too long a period of time. This stomach juice consists of acid, digestive enzymes and other injurious materials. The prolonged contact of acidic stomach juice with the esophageal lining injures the esophagus and produces a burning discomfort.

Normally, a muscular valve at the lower end of the esophagus called the lower esophageal sphincter or “LES” keeps the acid in the stomach and out of the esophagus. In GERD, the LES relaxes too frequently which allows stomach acid to reflux, or flow backward into the esophagus.

What are the treatments for infrequent heartburn?
In many cases, doctors find that infrequent heartburn can be controlled by lifestyle modification and proper use of over-the-counter medicines.

Avoid foods and beverages which contribute to heartburn: chocolate, coffee, peppermint, greasy or spicy foods, tomato products and alcoholic beverages.

Stop smoking. Tobacco inhibits saliva, which is the body’s major buffer. Tobacco may also stimulate stomach acid production and relax the muscle between the esophagus and the stomach, permitting acid reflux to occur.

Reduce weight if too heavy.

Do not eat 2-3 hours before sleep.

For infrequent episodes of heartburn, take an over-the-counter antacid or an H2 blocker (Tagamet, Zantac, Pepcid) or Prilosec OTC.

Over-the-Counter Medications
Large numbers of Americans use over-the counter antacids and other agents that are available without prescription to treat minor GI discomforts and infrequent heartburn. The U.S. Food and Drug Administration (FDA) has approved the nonprescription availability of important acid blockers, also called H2 blockers, for treatment of heartburn. Recently Prilosec OTC, a potent PPI acid inhibitor, has also been approved.

Over-the-counter medications have a significant role in providing relief from heartburn and other occasional GI discomforts. More frequent episodes of heartburn or acid indigestion may be a symptom of a more serious condition that could worsen if not treated. If you are using an over-the-counter product every week, you should consult a physician who can confirm a specific diagnosis and develop a treatment plan with you, including the use of stronger medicines available only with a prescription.

What are the complications of GERD?
When symptoms of heartburn are not controlled with modifications in lifestyle, and over-the-counter medicines are needed more often than once a week, or symptoms remain unresolved on the medication you are taking, you should see your doctor.

When GERD is not treated, serious complications can occur, such as severe chest pain that can mimic a heart attack, esophageal stricture (a narrowing or obstruction of the esophagus), bleeding or a premalignant change in the lining of the esophagus called Barrett’s esophagus.

Symptoms suggesting that serious damage may have already occurred include:

Dysphagia – difficulty swallowing or a feeling that food is trapped behind the breast bone.

Bleeding – vomiting blood, or having tarry, black bowel movements.

Choking – sensation of acid reflux into the windpipe causing shortness of breath, coughing or hoarseness of the voice.

Weight loss.

What are the treatment goals for GERD?
GERD is a problem that is symptomatic by day but much damage is done at night. Treatment should be designed to: 1) eliminate symptoms; 2) heal esophagitis (inflammation of the esophagus); and 3) prevent the relapse of esophagitis or development of complications in patients with esophagitis. In many patients, GERD is a chronic, relapsing disease. Long-term therapy is essential.

All treatments are based on attempts to: a) decrease the amount of acid that refluxes from the stomach back into the esophagus, or b) make the refluxed material less irritating to the lining of the esophagus.

What are the treatments for GERD?

Lifestyle Modification

In order to decrease the amount of gastric contents that reach the lower esophagus, certain simple guidelines should be followed:

Raise the Head of the Bed
The simplest method is to position a 4-x-4-inch piece of wood to which two jar caps have been attached as casters under the upper end of the bed posts. Failure to use the jar caps inevitably results in the patient being jolted from sleep as the upper end of the bed moves off the wood.

Change Eating and Sleeping Habits
Avoid lying down for two hours after eating. Do not eat for at least two hours before bedtime. This decreases the amount of stomach acid available for reflux.

Avoid Tight Clothing
Reduce your weight if obesity contributes to the problem.

Change your Diet
Avoid foods and medications that lower LES tone (fats and chocolate) and foods that may irritate the damaged lining of the esophagus (citrus juice, tomato juice, and probably pepper).

Curtail Habits That Contribute to GERD
Smoking, using smokeless tobacco and the use of alcoholic beverages lower LES pressure, which contributes to acid reflux.

Medical Treatment of GERD
GERD has a physical cause, and frequently is not curtailed by these lifestyle factors alone. If you are using over-the-counter medications more than once a week, or are still having symptoms on the prescription or other medicines you are taking, you need to see your doctor. If results are not forthcoming, medications may be used to neutralize acid, increase LES tone or improve gastric emptying.

What are the medications often prescribed for GERD?
Prescription medications to treat GERD include drugs called H2 receptor antagonists (H2 blockers) and proton pump inhibitors (PPIs), which help to reduce the stomach acid which tends to worsen symptoms, and work to promote healing, as well as promotility agents which aid in the clearance of acid from the esophagus.

H2 Receptor Antagonists
Since the mid 1970s, acid suppression agents, known as H2 receptor antagonists or H2 blockers, have been used to treat GERD. H2 blockers improve the symptoms of heartburn and regurgitation and provide an excellent means of decreasing the flow of stomach acid to aid in the healing process of mild to moderate irritation of the esophagus, known as “esophagitis.” Symptoms are eliminated in up to 50% of patients with twice-a-day prescription dosage of the H2 blockers. Healing of esophagitis may require higher dosing. These agents maintain remission in about 25% of patients.

H2 blockers are generally less expensive than proton pump inhibitors and can provide an adequate approach as the first-line treatment, as well as maintenance agent in GERD for some patients. In mid-1995, the FDA approved availability of some H2 blockers without a prescription in dosage levels appropriate for treatment of mild, infrequent heartburn.

Proton Pump Inhibitors
Proton pump inhibitors (PPIs), have been found to heal erosive esophagitis (a serious form of GERD) more rapidly than H2 blockers. Proton pump inhibitors provide not only symptom relief, but also elimination of symptoms in most cases, even in those with esophageal ulcers. Studies have shown proton pump inhibitor therapy can provide complete endoscopic mucosal healing of esophagitis at 6 to 8 weeks in 75% to 100% of cases. Daily proton pump inhibitor treatment provides the best long-term maintenance therapy of esophagitis, particularly in keeping symptoms and the disease in remission for those patients with moderate to severe esophagitis, plus this form of treatment has been shown to retain remission for up to five years.

Promotility Agents
Promotility drugs are effective in the treatment of mild to moderate symptoms of GERD. These drugs increase lower esophageal sphincter pressure, which helps prevent acid reflux and improves the movement of food from the stomach. They decrease heartburn symptoms, especially at night, by improving the clearance of acid from the esophagus and stomach.

Can surgery be an option when medical treatment for GERD fail?
Surgical measures to prevent reflux can be considered if other measures fail or complications occur such as bleeding, recurrent stricture or Barrett’s esophagus (abnormal transformation of cells lining the esophagus), which is progressive. The surgical technique improves the natural barrier between the stomach and the esophagus that prevents acid reflux from occurring. Consultation with both a gastroenterologist and a surgeon is recommended prior to such decision.

What types of tests are need to evaluate GERD?
Your doctor or gastroenterologist may wish to evaluate your symptoms with additional tests when it is unclear whether your symptoms are caused by acid reflux, or if you suffer from complications of GERD such as dysphagia (difficulty swallowing), bleeding or choking, or if your symptoms fail to improve with prescription medications. Your doctor may decide to conduct one or more of the following tests.

Upper GI Series
For the upper GI series, you will be asked to swallow a liquid barium mixture (sometimes called a “barium meal”). The radiologist uses a fluoroscope to watch the barium as it travels down your esophagus and into the stomach.

You will be asked to move into various positions on the X-ray table while the radiologist watches the GI tract. Permanent pictures (X-ray films) will be made as needed.

This test involves passing a small lighted flexible tube through the mouth into the esophagus and stomach to examine for abnormalities. The test is usually performed with the aid of sedation so there will be no discomfort. It is the best test to identify esophagitis and Barrett’s esophagus.

Esophageal Manometry
This is a test that involves passing a small flexible tube through the nose into the esophagus and stomach in order to measure pressures and function of the esophagus. Also, the degree of acid refluxed into the esophagus can be measured over 24 hours.

This is a Esophageal pH test where a small pH capsule the size of a large vitamin pill is attached to the surface lining of the esophagus during an endoscopy. The capsule measures acid reflux and electronically transmits the information to a receiver worn on the belt. The capsule “falls off” after several days and passes normally. The test is essentially painless.

What are some severe complications and atypical manifestation of GERD?
GERD can masquerade as other diseases.

Chest Pain: Patients with GERD may have chest pain similar to angina or heart pain. Usually, they also have other symptoms such as heartburn and acid regurgitation. If your doctor says your chest pain is not coming from the heart, don’t forget the esophagus. On the other hand, if you have chest pain you should not assume it is your esophagus until you have been evaluated for a potential heart cause by your physician.

Asthma: Acid reflux may aggravate asthma. Recent studies suggest that the majority of asthmatics have acid reflux. Clues that GERD may be worsening your asthma include: 1) asthma that appears for the first time during adulthood, 2) asthma that gets worse after meals, lying down or exercise, 3) asthma that is mainly at night. Treatment of acid reflux may cure asthma in some patients and decrease the need for asthmatic medications in others.

Ear Nose and Throat Problems: Acid reflux may cause chronic cough, sore throat, laryngitis with hoarseness, frequent throat clearing or growths on the vocal cords. If these problems do not get better with standard treatments, think about GERD.

Patients with Longstanding GERD Can Experience Severe Complications

Peptic Stricture: This results from chronic acid injury and scarring of the lower esophagus. Patients complain of food sticking in the lower esophagus. Heartburn symptoms may actually lessen as the esophageal opening narrows down, preventing acid reflux. Stretching of the esophagus and proton pump inhibitor medication are needed to control and prevent peptic strictures.

Barrett’s esophagus: The most serious complication of chronic GERD is Barrett’s esophagus. Here, the lining of the esophagus changes to resemble intestinal lining. Patients may complain of less heartburn with Barrett’s esophagus – that’s the good news

Unfortunately, this is a precancerous condition: patients with Barrett’s esophagus have approximately a 30-fold increased risk of developing esophageal cancer. These patients should be followed by endoscopy by a trained gastroenterologist familiar with this disease.

Some key points to remember about GERD

Heartburn is common, but is not a trivial condition.

If you suffer infrequent heartburn, antacids or the new H2 blockers or Prilosec OTC are now available without a prescription and may provide the relief you need.

If you are experiencing heartburn more than once a week, you may have acid reflux disease, also known as GERD, which if left untreated, is potentially serious.

If you are self-medicating for heartburn more than once a week, or if you still have symptoms on your over-the-counter or prescription medication, you need to see a doctor and perhaps be referred to a gastroenterologist.

GERD has a physical cause that’s not your fault and can only be treated by a physician.

With effective treatment, using the range of prescription medications and other treatments available today, you can become symptom-free, avoid potential complications and restore the quality of life you deserve.