Hazardous Heartburn
Amanda Steen
Dr. R. Fraser Stokes is pictured in his office on Wed. March 19 at Southwest Gastrointestinal.
Man in his sixties suffering pain from severe indigestion.
Dr. Kenneth Fasanella, a gastroenterologist at the University of Pittsburgh Medical Center
Like most people, you’ve probably experienced heartburn at one time or another. After a heavy meal or a sampling of spicy foods, you feel that burning sensation rising from your stomach up through your chest and to your throat. You grimace at the sour taste in your mouth and the feeling that something is lodged in your throat.
A few Tums or Rolaids later and you’re back to normal–no cause for alarm.
Trouble is, if you frequently experience these symptoms or if they linger for a few weeks or longer, you might have acid reflux–or gastroesophageal reflux disease (GERD), as it’s known clinically. Then you’ll probably need more than an occasional antacid.
GERD is more than just heartburn. Left untreated, it can lead to serious medical problems. So, if you suffer from frequent or persistent heartburn, don’t ignore it. Let your physician know about it, and discuss whether you’re at risk for the complications of GERD.
“I would say GERD is the number one reason why people come to see us,” says Dr. R. Fraser Stokes, a gastroenterologist with Southwestern Gastrointestinal Specialists, in Uniontown. “It’s very common, and it goes across all age spectrums, from kids all the way to the elderly, in men and women. …I think it’s been common for a long time, and I think people have put up with it and not sought medical care for it over the years, or they’ve taken over-the-counter medicines and not sought care through their physician for it.”
The rise of reflux
These days, it seems like we’re hearing more about GERD. Public awareness about this hazardous heartburn is growing, spurred in part by increased marketing of acid-blocking medications–even Larry, the Cable Guy, has gotten into the act by promoting Prilosec.
Not only are we hearing more about acid reflux, but research suggests that more and more people are experience the burn of GERD. In a 2013 study, investigators concluded that the prevalence of GERD has risen steadily since 1995. By some estimates, as many as 30 percent of Americans experience reflux symptoms at least once a week during their lifetime.
GERD occurs when the muscular valve separating the stomach and esophagus, the lower esophageal sphincter, relaxes and fails to close properly. The dysfunctional valve then allows acid and other stomach contents to flow backward, or regurgitate, into the esophagus and trigger heartburn.
The rise in reflux rates may be due to a number of factors. One is the general aging of the population–Americans are living longer, and GERD becomes more common with age. But one of the most significant contributors to the glut of GERD is Americans’ expanding waistlines, experts believe. There’s only so much room for the stomach and other organs in the abdominal cavity, and excess fatty tissue can compress and weaken the lower esophageal sphincter.
“Any time you have increased abdominal fat, there’s more pressure pushing on the stomach and causing whatever stomach contents are there to be pushed up into the esophagus,” explains Dr. Kenneth Fasanella, a gastroenterologist at the University of Pittsburgh Medical Center.
The risks of reflux
People with acid reflux usually experience classic symptoms such as heartburn, a sour taste, and belching or regurgitation of food and stomach acid. Some also experience atypical symptoms, including chest pain, swallowing difficulties, the feeling of a lump in the throat and hoarseness/sore throat.
The symptoms of GERD can mimic those of a heart attack, and sometimes it can be difficult to tell the difference, Stokes says. So it’s important to first rule out a potential cardiac cause of your symptoms, especially if you have risk factors for cardiovascular disease, such as high blood pressure, diabetes, cholesterol abnormalities, smoking and obesity. If you have symptoms only after you eat or lie down, your symptoms are relieved with an antacid, or if your primary symptoms are belching and regurgitation of stomach contents, GERD is most likely the culprit, Stokes says. However, if you experience chest pain that occurs primarily with exertion, especially if it’s accompanied by shortness of breath, sweating, nausea and pain radiating to the jaw or down the arm, seek immediate medical attention.
Repeated intrusions of stomach contents into the lower esophagus can cause inflammation that shortens the esophagus, pulling part of the stomach up through the diaphragm. The end result is a hiatal hernia, which can further exacerbate reflux symptoms.
GERD has been associated with chronic cough and chronic sinusitis, as well as lung conditions such as asthma, chronic obstructive pulmonary disease (COPD) and pulmonary fibrosis. Some people with GERD develop scarring and narrowing of the esophagus or esophagitis, an inflammation of the esophagus.
People with chronic reflux lasting at least five years, especially Caucasian men over age 50, are at greater risk of Barrett’s esophagus, changes in the cells lining the esophagus. Barrett’s is actually the body’s defense against repeated esophageal injury due to stomach acid exposure, Fasanella explains. Barrett’s tissue mimics that of the stomach and intestine, making the esophagus tougher and more resistant to the effects of stomach acid. As a result, some patients with Barrett’s esophagus may see their heartburn symptoms wane. Unfortunately, Barrett’s tissue also is unstable, so it can increase the risk of deadly esophageal cancer, although the overall risk of this malignancy is relatively low.
“The problem is that Barrett’s is an insensitive tissue, so it’s not uncommon for me to see people with significant Barrett’s who tell me that 20 to 30 years ago they had a lot of heartburn, but for the last 10 years they really haven’t had any symptoms,” Fasanella says. “The bottom line is heartburn is not a good marker for the presence of Barrett’s.”
Finding the cause
You might go for a while managing your occasional heartburn with antacids and other over-the-counter medications. But if your symptoms persist and you experience heartburn more regularly and can’t attribute it to a particular food, see your doctor. Most importantly, seek medical help if you’re taking heartburn medications daily, you experience atypical symptoms, or you develop more severe complications, such as weight loss, swallowing problems or vomiting.
In most cases, GERD can be diagnosed based on symptoms. Your physician may have you perform certain movements, such as bending forward or lying down, to see which maneuvers trigger reflux. You may be given a trial of acid-blocking medications for a few months to see if your symptoms improve.
For more persistent or severe GERD symptoms, consult a gastroenterologist. He or she may order a barium esophagram, in which you swallow a contrast agent and undergo a series of X-rays to allow the physician to assess the function of your upper digestive tract. The specialist also may recommend an esophageal pH test, in which a tiny capsule implanted on your lower esophagus measures how often stomach contents reflux into the esophagus and how much acid the reflux contains.
An upper endoscopy may be necessary, especially if you’ve had long-term GERD and have a higher risk for Barrett’s esophagus or you have more severe symptoms. In this procedure, a gastroenterologist views the esophagus through a tiny camera attached to the end of a long tube, or scope, inserted into the mouth and down the throat.
“If you suffer regularly from GERD and you’re under self-directed treatment with medications, that doesn’t eliminate your risk of Barrett’s, which is something that should be on your radar and the radar of your doctor,” Fasanella advises. “I recommend that those people who have suffered from GERD for five to 10 years bring it to the attention of their physician so that they can be considered for screening.”
Easing the burn
A key weapon in the GERD treatment arsenal is a class of medications known as proton pump inhibitors (PPIs), which include esomeprazole (Nexium), lansoprazole (Prevacid), omeprazole (Prilosec, Zegerid), pantoprazole (Protonix) and rabeprazole (Aciphex). The U.S. Food and Drug Administration has approved over-the-counter versions of Nexium, Prevacid and Prilosec.
The drugs can help heal esophageal injury from GERD and ease symptoms by blocking the production of stomach acid. The most common side effects of PPIs include diarrhea, constipation and headache. The drugs may affect the absorption of vitamin B12 and iron, raising the risk of anemia, and also inhibit calcium absorption, increasing the odds of osteoporosis and fractures, particularly among postmenopausal women who smoke. Also, some studies have found an increased risk of clostridium difficile (C.diff) bacterial infections associated with PPI use.
But overall, PPIs are generally well tolerated, Stokes says, and they’re the most effective medications for treating GERD and reversing its damaging effects.
“There’s a strong effect on inducing healing and maintaining healing with the proton pump inhibitors,” Stokes says. “If you scope someone and find an esophagus laced with ulcers and then you put them on a PPI and you scope them two months later, there’s about a 90 to 95 percent chance that it’ll all be healed.”
Patients with less frequent GERD symptoms or those who can’t tolerate PPIs may find relief from antacids, such as Tums or Rolaids, or drugs known as histamine 2 receptor blockers (H2 blockers), such as cimetidine (Tagamet), famotidine (Pepcid AC), nizatidine (Axid) and ranitidine (Zantac).
The H2 blockers are available over the counter and by prescription, and are used as needed. They work more quickly than PPIs but are not as potent and thus do not have quite the healing capacity, Fasanella says. Plus, the drugs tend to lose their effectiveness when taken continually for several weeks, as your body develops a tolerance to them, he adds.
“But, they’re good medications, and I will generally tell people who suffer heartburn only two days a week or less to take them if they really only need an as-needed medication,” Fasanella advises.
Patients who fail to gain sufficient relief from medications or want an alternative to them may choose minimally invasive surgery to manage their GERD. The standard surgical procedure is Nissen fundoplication, in which a surgeon wraps the upper part of the stomach around the lower esophageal sphincter to strengthen it. Another option is the Stretta procedure, which delivers radiofrequency energy to the lower esophageal sphincter to improve the muscle tissue.
Among the newer minimally invasive treatment options (approved in 2012) is the Linx Reflux Management System, which features a bracelet-like implant made up of magnetic beads that encircles and reinforces the lower esophageal sphincter. A 2013 study in the New England Journal of Medicine found that among 100 GERD patients, the treatment reduced esophageal acid exposure, improved symptoms and reduced the use of PPIs.
“From some of the anecdotal interactions I had with patients who had it done, they were having good results,” Fasanella says. “Its use is limited to people who have normal anatomy, meaning they don’t have a hiatal hernia, which is actually relatively rare in the reflux population. It’s fairly effective, but you just have to be carefully selected for it.”
The outlook
Regardless of the treatment you choose, a key to managing GERD is to make positive lifestyle changes, avoid foods, medications and activities that trigger symptoms, and, if necessary, lose weight (see “Action Points” for details).
“GERD can actually be an indicator that you’re not taking proper care of yourself,” Stokes says. “Be sensitive to that and try to remedy some of those lifestyle things, which will help the reflux and also help other parts of the body.”
Overall, the outlook for GERD patients is pretty good, Fasanella says: “GERD is mostly a quality-of-life issue. Mostly it’s a very manageable disease these days, with relatively minimal effort, due to the availability and effectiveness of some of the new medications that we have.”
“The beautiful thing about reflux is our treatment generally takes care of the problem pretty nicely, and almost all of our patients are under pretty good control,” Stokes adds. “If you have symptoms, don’t put up with them. Try to seek care and get it taken care of, because it can lead to long-term problems. It can really reduce your quality of life. It’s a pretty easy thing to take care of now, so why not get good treatment, prevent problems and feel good? That’s what it’s all about.”
Action points
If you’re overweight, work with your doctor to shed pounds. Obesity is a major risk factor for gastroesophageal reflux disease (GERD).
Minimize your consumption of foods that are known to weaken the lower esophageal sphincter and lead to GERD–caffeine, alcohol, chocolate, mints and fatty, fried food–as well as citrus fruits and tomato-based products, which that can contribute to acid flare-ups.
Try not to eat large meals, and do not eat anything within three hours of bedtime/lying down.
As much as possible, limit your use of anti-inflammatory medications, such as aspirin, ibuprofen (Advil, Motrin) and naproxen (Aleve), and iron or potassium supplements, all of which have gastrointestinal side effects.
A wide array of medications can cause heartburn and cause or worsen GERD. Ask your doctor if a medication you’re taking could be contributing to your GERD symptoms.
Elevate the head of your bed if you suffer heartburn while you sleep. Raising the head of the bed allows gravity to work in your favor and prevent stomach acid from rising up into the esophagus.
Limit your intake of alcohol, and if you smoke, ask your doctor about ways to quit.