Heartburn – Overview

An Article by Dr. William D. Lyday

Heartburn or GERD (Gastro-Esophageal – Reflux – Disease) is a very common problem.  In America, more than 60 million adults suffer symptoms of acid reflux each month. Acid reflux symptoms can begin as early as infancy, but symptoms usually stop as the child grows older. Pregnant women are more at risk for acid reflux. In fact, 25% of pregnant women will experience symptoms—nearly 50% of them during the third trimester.

Interesting Statistics for GERD

According to the Healthcare Cost and Utilization Project (HCUP), there were 995,402 hospitalizations for GERD in 1998. In 2005, there were 3.14 million, an increase of 216 percent. In both years, approximately 62 percent of all GERD hospital discharges involved women. In 2010, 4.7 million hospitalizations and 1,653 deaths were a result of GERD, reports the National Institute of Diabetes and Digestive and Kidney Diseases.

Gastroesophageal reflux disease (GERD) is a chronic condition that affects the digestive system. While most people experience heartburn or indigestion from time to time, if you feel that burning sensation in your chest more than twice a week, you might have GERD.

The condition is a more serious and long-lasting form of acid reflux. Most people can manage GERD with over-the-counter (OTC) medications and a few lifestyle changes.

In 2010, 4.7 million hospitalizations and 1,653 deaths were a result of GERD, reports the National Institute of Diabetes and Digestive and Kidney Diseases.

GERD is no longer thought of as a completely harmless condition. After years of stomach acid washing into the esophagus, significant damage can occur. Complications include ulceration, scarring, narrowing, internal bleeding, precancer (Barrett’s esophagus) and cancers. With early screening and active management most complications can be avoided.

There are several factors to consider in a patient who presents to the medical clinic with complaints of heartburn. How long has it been occurring, how severe, does it respond to antacids, and is the patient taking other medications which may be causing the GERD. We also need to know if there are “warning signs” such as increased pain, signs of intestinal bleeding, weight loss , or trouble swallowing. Warning symptoms may indicate underlying cancer and rapid testing should be performed. Rapid testing would usually mean a procedure known as upper endoscopy, also called EGD. This test is typically performed by a specialist physician – a gastroenterologist.

Factors Known to Worsen GERD

Obseity – many individuals will notice that as they gain weight, heartburn worsens

NSAID medications – these are very common over the counter meds (OTC) that can cause intestinal ulcers and worsen reflux symptoms. Examples of NSAIDs includes: Advil, Alleve, Motrin, Goodys Powders, Ibuprofen, Diclofenac, Excedrin, and the list goes on. NSAIDs are great for headaches and joint pain, but they can really worsen the heartburn.

Other medications that may play a role in causing increased reflux includes therapies for  – hormone replacement, birth control, steroids, blood pressure, thyroid disorders, narcotic pain medications and many more.

Metabolic abnormalities – Examples would include low thyroid production, poorly controlled diabetes, and others.

Diet – Chocolate, Caffeine, Peppermint, Alcohol all seem to worsen heartburn

Meal size and Timing – Patients with heartburn generally do better with frequent, small meals rather than large. Eating before bed is especially bad and leads to excessive night reflux.

How Do We Manage Heartburn?

The American College of Gastroenterology (ACG) and American Gastroenterology Association (AGA) provide guidelines on testing and evaluating patient with chronic heartburn. When it come to heartburn management, our primary goals are to improve symptoms, evaluate any possible complications that heartburn has caused in the esophagus, and identify cancers and pre-cancers of the esophagus. It has been estimated that perhaps 20% of the US population has GERD with 6% having more sever symptoms. The US population as of 2017 was 325.7 million; this equals around 651,000 with regular heartburn. Interestingly in Asian countries heartburn occurs in around 5 % of the population.

Initial Evaluation

The doctor will review diet, lifestyle, medication history and other habits which may be contributing to heartburn, A family history of esophageal cancer or Barrett’s esophagus is also meaningful and raises risk of malignancy. Other cancer risk factors include age >50, Caucasian, poorly controlled GERD, tobacco use, obesity, sedentary lifestyle, and poor diet.

Next Step – Treatment

Improving the symptoms of GERD is very straightforward – get rid of any factors that may be causing reflux and begin medications to reduce acid injury to the esophagus. Patients are placed on a specific diet – eliminate alcohol, chocolate and caffeine. Stop NSAIDs if possible – Advil, Motrin, Alleve, Ibuprofen, Goodys, Excedrin, Diclofenac. Use Tylenol for aches and pains. Begin a daily exercise plan, consider a nutrition consult or weight loss program if not succeeding. Avoid late night meals, and eat frequent, small meals.

Medications

We choose medications based on the severity of the symptoms. In very mild cases, we might begin with “H2 blockers” such  as Pepcid or Zantac and may be taken on an as needed basis. More severe symptoms require stronger medications – the PPIs ( proton pump inhibitors) are a much stronger class medications and are very effective in reducing acid production in the stomach – examples includes  – Nexium, Prilosec, Protonix, Aciphex, Prevacid, , and Zegrid. The medicines should be taken 1 hour before the meal and must be taken daily to have the best effect.

Only time will tell if longterm medications are needed to treat GERD. Some individuals are able to make changes in their life and reduce eliminate heartburn naturally. Others can not and may require medications for years to come.

Who Needs Additional Testing?

The AGA and ACG recommend upper endoscopy for individuals with regular heartburn having risk factors for cancer. This group includes age> 50 , males, smokers, obese, family history of Barrett’s esophagus or esophageal cancer, poor nutrition, and poorly controlled GERD. These individuals may benefit from an examination of the esophagus to ensure there are no pre-cancers or cancers.

Last Comments…

So, lets put this all together.

Download our heartburn checklist. Review this yourself and share with your physician. Diet, lifestyle, and avoiding certain medications is the key to longterm success. In more difficult cases, getting professional help from specialists in nutrition, exercise, psychology and treatment of esophageal disorders is also very important.

Also, when things just don’t seem right with your doctor, or your not getting good answers – always get a second opinion. See a reputable gastroenterologist in your area and be sure your getting the care you need.