ACID REFLUX
Overview
How common is heartburn?
More than 60 million Americans experience heartburn at least once a month and some studies have suggested that more than 15 million Americans experience heartburn symptoms each day. Symptoms of heartburn, also known as acid reflux and indigestion, are more common among the elderly and pregnant women.
What is heartburn or GERD?
Gastroesophageal reflux is a physical condition in which acid from the stomach flows backward up into the esophagus. People will 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. Some even experience the bitter or sour taste of the acid in the back of the 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, blood or weight loss may be associated with a more severe problem known as gastroesophageal reflux disease or GERD.
Causes
What causes heartburn and GERD?
To understand gastroesophageal reflux disease or 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 gastroesophageal reflux disease or GERD, the LES relaxes too frequently, which allows stomach acid to reflux, or flow backward into the esophagus.
Treatment Options
What are the treatments for infrequent heartburn?
In many cases, doctors find that infrequent heartburn can be controlled by lifestyle modifications and proper use of over-the-counter medicines.
Lifestyle Modifications
- Avoid foods and beverages that 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, some of which are now available without a prescription.
Over-the-Counter Medications
Large numbers of Americans use over-the-counter antacids and other agents that are available without a prescription to treat minor GI discomforts and infrequent heartburn. In 1995, the U.S. Food and Drug Administration (FDA) approved the non-prescription availability of important acid blockers, also called H2 blockers, for treatment of infrequent heartburn with dosage levels below the prescription strength formulations. It is anticipated that the FDA will approve the non-prescription availability of another distinct class of drugs, known as proton pump inhibitors (PPIs), for the treatment of infrequent heartburn, also at dosage levels below the prescription strength formulations. While these reduced strength formulations have been approved for relief of symptoms/discomfort from occasional heartburn, they are not recognized by FDA as promoting actual healing of esophagitis, whereas FDA does recognize the healing benefits of some prescription strength medications, e.g. proton pump inhibitors, when taken regularly at prescription dosages.
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 more than twice a 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 that are only available with a prescription.
Why are heartburn and GERD not trivial conditions?
When symptoms of heartburn are not controlled with modifications in lifestyle, over-the-counter medicines are needed two or more times a week, or symptoms remain unresolved on the medication you are taking, see your doctor. You may have GERD.
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 pre-malignant change in the lining of the esophagus called Barrett’s esophagus. Patients with chronic, untreated heartburn were at substantially greater risk of developing esophageal cancer, which is one of the fastest growing, and more lethal forms of cancer.
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 refluxed into the windpipe causing shortness of breath, coughing, or hoarseness of the voice.
- Weight Loss
Diagnosis
What types of tests are needed 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 in swallowing), bleeding, 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.
Endoscopy
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 sedatives. It is the best test to identify esophagitis and Barrett’s esophagus.
Esophageal Manometry or Esophageal pH
This test 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.Extra-Esophageal Manifestations (EEM): Heartburn links to chest pain; asthma; chronic cough; ear, nose and throat problems often avoid detection
Risk/Complications
GERD can masquerade as other diseases
Increasingly, we are becoming aware that the irritation and damage to the esophagus from continual presence of acid can prompt an entire array of symptoms other than simple heartburn. Experts recognize that often the role of acid reflux has been overlooked as a potential factor in the diagnosis and treatment of patients with chronic cough, hoarseness and asthma-like symptoms. In some instances, patients have never reported heartburn, and in others the potential causal link between reflux and the onset of these so-called “extra-esophageal manifestations” has not been fully recognized. Physicians are increasingly becoming aware that it is good clinical practice to evaluate the possible presence of reflux in patients with chronic cough and asthma-like symptoms, as well as the importance that acid suppression and treating underlying reflux can have in potentially improving the symptoms in these patients.
- Chest Pain: Patients with GERD may have chest pain similar to angina or heart pain. Usually, they also have other symptoms like 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; and 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 be a cause of 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: A serious complication of chronic GERD is Barrett’s esophagus. Here the lining of the esophagus changes to resemble the intestine. Patients may complain of less heartburn with Barrett’s esophagus — that’s the good news. Unfortunately, this is a pre-cancerous 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.
- Esophageal Cancer: Recent scientific reports have confirmed that if GERD is left untreated for many years, it could lead to this most serious complication — Barrett’s esophagus and esophageal cancer. Frequent heartburn symptoms with a duration of several years cannot simply be dismissed — there can be severe consequences of delaying diagnosis and treatment. This increased risk of chronic, longstanding GERD sufferers to develop cancer demonstrates the true severity of heartburn. In patients with chronic heartburn, an endoscopy will often be recommended to visually monitor the condition of the lining of the esophagus and identify or confirm the absence of any suspicious or pre-malignant lesions, such as Barrett’s esophagus. So, do not ignore your heartburn. If you are having heartburn two or more times a week, it is time to see your physician and in all likelihood a gastrointestinal specialist. In most cases an endoscopy should be performed to evaluate the severity of GERD and identify the possible presence of the pre-malignant condition — Barrett’s esophagus. The preventative strategy is to treat GERD. If it goes untreated and cancer does develop, the survival rate for esophageal cancer, at this time, is dismal.
Dr. Arturo Bravo is a digestive disease specialist trained in the most advanced endoscopic techniques. He is a diplomat of the American Board of Gastroenterology, the American Board of Transplant Hepatology and the American Board of Internal Medicine. And an Assistant Professor at Texas A&M University College of Medicine in the Department of Medicine. For more information on treatment options, or to schedule a consultation, call us at 281.970.6027.
We are conveniently located within driving distance of Cypress TX, Katy TX, Spring TX, Tomball TX, The Woodlands TX, and Houston TX.
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