Heartburn, acid indigestion, agita, GERD–whatever you call it, this problem has plagued humanity for millennia. It is a sensation of pain in the upper chest, behind the breastbone, or “sternum” caused by a disorder of the GI tract. It is responsible for a significant portion of the time and money we spend on our healthcare, and has an additional emotional cost, for even in these times of modern science it is hard to initially differentiate it from an oncoming heart attack. What causes heartburn and how can we fix it?
Heartburn,more properly termed GastroEsophageal Reflux Disease or GERD, occurs when stomach acid gets up into the esophagus, that muscular tube that connects mouth to stomach. While the stomach, or “gastrum”, can tolerate extremely acidic fluids, the esophagus is relatively sensitive and gets very irritated with even a little acid exposure. There are two scenarios that lead to this acid irritation. Sometimes, it is an issue of too much acid in the stomach, and it can “spill over” into the esophagus, especially when you are laying down. Other times, there is a structural problem with the barrier between these two body parts. The purse-string muscle, or sphincter, that is responsible for closing off the stomach’s upper opening may be loose or otherwise unable to function. Understanding the cause of one’s reflux can help strategize the best treatment plan.
Usually, doctors can easily determine the cause of GERD with a few tests. In one of them, a patient has to swallow a chalky barium liquid while an x ray “video” is taken. Barium shows up clearly in radiographs and the physician can thus visualize whether the sphincter muscle allows significant leakage. Another commonly used test is the Upper Endoscopy (“EGD”) in which an intestinal specialist inserts a flexible fiber optic tube down thru the esophagus into the stomach. They can then see if there are characteristic acid burns on the esophageal lining. Additionally, they can actually watch the sphincter open and close. Both the Barium Swallow and the EGD are good at detecting hiatal hernias, too. A hiatal hernia is when part or all of the stomach migrates from its usual position in the abdomen up through the diaphragm and into the chest cavity. Besides causing a sense of pressure that can be extremely uncomfortable, this also strains that sphincter muscle and allows marked acid leakage.
Regardless of the cause of GERD, the initial treatment is almost always the same. Sufferers are advised to establish habits that reduce the likelihood of acid spillover. This is best accomplished by forswearing habit, such as smoking and alcohol use, that provoke extra acid. And as stomach acid is most prone to migrating up where it doesn’t belong when you are lying down, avoiding eating right before bed as well as sleeping with your upper chest elevated can significantly reduce acid reflux.
There are also several groups of medications that address the problem of gastroesophageal reflux disease. Some agents, such as Reglan, relax the stomach so it is less likely to contract and push acid in the wrong direction. While these prescriptions really get at the “root” of the problem and prevent reflux, they have cardiac side effects and so are now rarely used. Other pills reduce acid production, so that when the stomach contents splash into the esophagus, they are not as irritating. Over the counter medications like Zantac and Pepcid fall into this category. The prescription drugs such as Nexium and Prevacid have essentially the same effect but are much more powerful and long-acting. These latter drugs are felt to be very safe short term, but long term may increase the likelihood of serious health problems such as osteoporosis.
Surgeries for GERD are reserved for refractory cases and include maneuvers to “fix” hiatal hernias as well procedures to destroy the nerves that trigger acid production. Complications tend to be frequent and results often disappointing, therefore most patients are not offered these options.
So, if you have the symptoms of heartburn, what should you do? First of all, consider seriously whether or not it could be actual heart pain! A visit to your doctor, or even the emergency room, could be necessary and lifesaving.
In the event it clearly is GERD, we usually advise several weeks of lifestyle modification (that is, no smoking or alcohol, no late meals, and to try sleeping with the head of your bed elevated) plus a short course of medication. IF this does not resolve the issue, or if it quickly recurs once the treatments are stopped, then specific testing, as noted above, is required. A gastroenterologist, or “G.I.” doctor, traditionally directs this work-up. Results of these tests will help determine the best long term management of your particular type of heartburn.
While acid reflux is usually more of a nuisance than a danger, there are instances where it presents a serious health risk. Sometimes there is so much acid leakage and irritation that the esophagus has callouses and scars and is prone to developing esophageal cancer. This is termed “Barrett’s Esophagus” and is typically treated with lifelong medication and frequent endoscopies to monitor for malignancy. Other times, the acid irritation is bad enough to provoke bleeding esophageal ulcers. So PLEASE don’t ignore your heartburn–get emergency medical attention if there is any chance is could actually be your heart, and see your doctor if you cannot cure it on your own with several weeks.