Heartburn

What causes heartburn?

Each time you swallow food, it travels down the esophagus to the stomach where it is mixed with stomach acid and other powerful digestive enzymes. The stomach is lined with cells that secrete mucus to protect it from this potentially destructive cocktail. A muscular ring at the base of the esophagus, called the lower esophageal sphincter (LES), relaxes to allow food to pass into the stomach, and then tightens to prevent backflow or reflux of acidic stomach contents into the more vulnerable esophagus. Unfortunately, a number of factors can interfere with this protective mechanism.

Reflux is common, and often occurs without causing any symptoms because the body responds by quickly neutralizing and clearing the acidic contents from the esophagus. In some individuals, however, the protective mechanisms are not adequate to meet the challenge for reasons that we don't understand well. In these individuals, inflammation of the esophagus (called esophagitis) will occur and produce the classic symptoms of GERD.

What are the symptoms of GERD?

• Heartburn, a sense of burning and discomfort behind the breast bone
• Regurgitation of bitter or sour tasting stomach contents into the mouth, often accompanied by excessive salivation
• In more severe cases, damage to the throat and vocal cords, causing chronic sore throat and hoarseness, from the refluxed, acidic stomach contents
• Inflammation of the lungs, cough, and asthma if acidic fluid is aspirated, or inhaled into the lungs

With severe, persistent inflammation over a prolonged period of time, esophageal damage can produce bleeding, and stricture or scar formation that interferes with normal swallowing. In approximately 10% of these individuals, the cells of the esophagus begin to change, resulting in an increased risk of esophageal cancer.

Most episodes occur during the day; usually 30-60 minutes after eating a large or fatty meal; often with bending, lifting, straining, reclining, or exercising.

Episodes that occur at night often produce more symptoms. During sleep, the combination of a reclined position and the nocturnal slowing of the body's mechanisms for neutralizing and clearing the esophagus results in prolonged contact between the acidic stomach contents and the lining of the esophagus. Longer exposure is more likely to result in irritation and inflammation.

NOTE: There is NO relationship between the severity of symptoms and the degree of esophageal damage.

What causes GERD?

In part, GERD is a function of anatomy. Some individuals are at increased risk due to a slight abnormality in the junction between their stomach and esophagus, or because their lower esophageal sphincter is inadequate. Although we still don't know why, the esophageal lining is more susceptible to injury in some individuals than in others. In addition, having a hiatus hernia seems to increase the incidence of GERD.

Lower esophageal sphincter function may be impaired by: - Pregnancy
- Obesity
- Recurrent vomiting
- Smoking
- Fatty foods, large meals, chocolate
- Tight clothing
- Some medications
- Diseases such as diabetes

Coffee and alcohol increase stomach acid, which may result in more irritation in reflux does occur.

How do you know if you have GERD?

• If you have frequent or recurrent heartburn or indigestion, or unexplained stomach pain, talk to a health care provider. Usually the diagnosis of GERD is made based on the presentation of classic symptoms, a generally normal physical examination, and rapid symptom relief with antacids.
• You may be asked to provide stool samples for a stool guaiac test. This will identify the presence of small amounts of hard-to-see bleeding that can occur in the gastrointestinal tract.
• Other testing may be indicated when symptoms are severe, prolonged, or unclear; or do not respond to treatment. These include x-rays such as a barium swallow; or referral for endoscopy, in which a physician is able to visualize the lining of the esophagus and stomach through a tiny camera passed through the mouth.

How is GERD treated?
Treatment should decrease the amount and frequency of reflux, decrease the acidity of the stomach contents, and protect the lining of the esophagus while it heals.

Measures that support these goals include:

• Eating smaller meals with limited beverages
• Avoiding substances that delay stomach emptying or relax the esophageal sphincter, such as fat, alcohol, tobacco, peppermint, and chocolate
• Decreasing reflux pressure against the esophageal sphincter by:
  • Eating the last meal of the day at least three hours before bedtime
  • Avoiding bending, reclining, lifting, straining, and exercising within 3 hours following a meal
  • Avoiding tight clothing, belts, girdles
  • Elevating the head of your bed on 6 inch blocks (Pillows are not adequate.)
  • Initiating a plan to lose excess weight
• Decreasing stomach acidity by
  • Avoiding acidic and spicy foods, alcohol, and caffeine

Medications include:

• Antacids such as Mylanta II or Maalox TC, 1 tablespoon after meals and 1 hour before sleep, provide rapid relief, but are effective for only 2 hours. They may be adequate for occasional mild symptoms.
• Medications such as ranitidine (Zantac), famitodine (Pepcid), and nizatidine (Axid), taken twice a day, can reduce 24-hour stomach acid secretion by 60%. Available over the counter in half the prescription strength, these drugs have a delay of at least thirty minutes before they provide a relief, but last for 8 hours. They are most effective when taken before a meal.
• Stronger medications, called proton pump inhibitors, like lansoprazole (Prevacid), and omeprazole (Prilosec), are usually prescribed when other treatment has been ineffective, when symptoms are severe or recurring, or when they are indicated following endoscopy, but some clinicians recommend them as initial treatment.
• A health care provider should treat symptoms occurring three or more times a week. They will usually require regular medication, one or more times a day, every day, for at least 4 weeks.
• 85% of people with a diagnosis of GERD can expect relief and healing of inflammation with appropriate medication and lifestyle modifications.

Signs and Symptoms that indicate a need for prompt or immediate re-evaluation include:

• Heartburn or other GERD symptoms occurring more than three times a week
• Increasing frequency, severity, or duration of symptoms
• Heartburn or other chest pain in a male over 45 years old, or a female over 55 years old, especially when it is associated with activity, or occurs at any other time not associated with meals
• Any heartburn that is not relieved within minutes of taking an antacid
• Heartburn that occurs at bedtime, especially if it awakens you from sleep
• Any sign of gastrointestinal bleeding, such as vomiting that appears bloody or looks like coffee grounds, or dark, black, tarry stools.

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