What is Heartburn?
Heartburn is a very common ailment. This is a sensation which occurs when stomach acid comes in contact with the lining of the esophagus. Normally, this is prevented by the lower esophageal sphincter. This band of muscle around the lower esophagus acts as a valve to prevent stomach contents from flowing back into the esophagus. This back flow is called gastroesophageal reflux. A hiatal hernia may worsen problems with reflux. Most symptoms from a hiatal hernia are due to reflux and are not from the hernia itself.
If reflux occurs frequently, it may cause inflammation and even ulceration of the esophagus. This is called reflux esophagitis. The inflamed lining is more sensitive to acid, and reflux may result in severe heartburn. Reflux may even cause chest pain which can mimic the symptoms of a heart attack. It is a condition which can be very painful and is often a stubborn problem to treat. Over a long period of time, scarring and narrowing of the esophagus from esophagitis may result in difficulty swallowing. This can be treated without surgery by dilating the esophagus. Chronic cough, hoarseness, sore throat, and even asthma are other problems which can be caused by or aggravated by reflux. These symptoms can be difficult to treat and can require high dose therapy for several months.
Antacids are the first line of treatment. It is important to take them as soon as even slight burning occurs. The pain is due to damage caused by the presence of acid in the esophagus. If you do not neutralize the acid promptly, it will cause further damage and pain which may not be relieved by taking antacids. Take as much antacid as you need to relieve the burning. Avoiding them will only allow the heartburn to worsen. The only side effect which occurs with any frequency is diarrhea.
Drugs to Reduce Acid Production
Prilosec® (omeprazole), Prevacid® (lansoprazole), Aciphex® (rabeprazole), and Protonix® (pantoprazole) and Nexium® (esomeprazole)are potent drugs specifically indicated for treatment of esophagitis. They are called PPIs (Proton Pump Inhibitors). They are the most powerful drugs available to suppress the production of stomach acid. In high doses these drugs can completely turn off acid secretion. They are the most effective drugs for treatment of reflux and ulcer disease. They may be safely used for long term maintenance treatment of esophagitis and reflux. Prilosec® is now available over the counter without a prescription.
The best time to take a PPI is about 30 minutes before a meal, usually before breakfast. If you need to take the drug twice a day, take it before breakfast and before supper. If you take a PPI and do not eat for several hours, it may not be as effective. For this reason, you should not take your PPI at bedtime.
Tagamet® (cimetidine), Zantac® (ranitidine), Pepcid® (famotidine) and Axid® (nizatidine) are drugs which decrease the amount of acid produced by the stomach in response to eating. They are most effective when taken twice a day, usually about a half hour before breakfast and supper. They do not completely eliminate stomach acid so antacids may still be necessary. All four of these drugs are available over the counter or in higher strengths by prescription. They are not as effective as PPIs, especially in patients with esophagitis or severe reflux.
Drugs to Improve Gastric Emptying
About fifty percent of patients with severe reflux have problems with delayed gastric emptying. If the stomach remains full, it produces excessive amounts of acid, which worsens reflux symptoms.
(See our pamphlet on Gastroparesis.)
Reglan® (metoclopramide) helps the stomach digest food more rapidly. It also strengthens the lower esophageal sphincter, thus preventing reflux. It also enters the brain and acts directly to reduce nausea.
Carafate® (sucralfate) is an anti ulcer drug which binds to inflamed areas to protect them from damage due to acid and digestive juices. This is most effective if given mixed with a small amount of water to allow the drug to coat the esophagus. It must be taken on an empty stomach to be effective.
Dietary changes are often vital to the successful treatment of severe heartburn. If certain foods cause you distress, avoid them. Even more important is to avoid overeating. You should also avoid drinking large quantities of liquids. Filling up the stomach with anything turns on acid production and makes reflux occur more often. Carbonated beverages, coffee (even decaffeinated coffee), alcoholic beverages, chocolate, onions, fatty foods, and peppermint should be avoided as they weaken the lower esophageal sphincter and worsen reflux.
Reflux at Night
Many patients are awakened at night with heartburn. This is usually the result of filling up the stomach with food or liquid before going to bed. Reflux may even occur when you are sound asleep and may not awaken you at the time. Damage to the esophagus still occurs at night and can be a major factor in the slow rate of healing of esophagitis. To prevent this you should eat a light supper early in the evening. This should be a small meal, low in fat to allow it to digest easily. After supper, you should not eat or drink anything for at least 3-4 hours before bedtime. As the stomach empties, the acid production slows down. A dose of antacid at bedtime will neutralize any remaining acid. If your stomach is empty, reflux will not occur, and you should not be awakened by heartburn. This should speed the healing of the esophagus and help eliminate heartburn.
Elevation of the head of the bed on eight inch blocks may help if heartburn awakens you at night. Sleeping on a foam wedge may also help. Smoking increases acid production and weakens the lower esophageal sphincter. This is one more excellent reason to stop smoking. Weight loss may be beneficial if you are overweight, but it does not always relieve reflux.
The Role of Endoscopy
In patients whose symptoms respond promptly to medical treatment, endoscopy is not always needed. Endoscopy should be performed if reflux has been present for many years, or if symptoms are not relieved by medications, or if chronic medical therapy is needed.
Endoscopy is often desirable in order to identify complications of reflux such as Barrett’s esophagus, ulcers, or esophageal strictures or other conditions that might cause similar symptoms.
Many patients require continuous medical therapy to control reflux symptoms. Some patients continue to have symptoms which are not completely relieved by medical treatment. In either of these situations, surgical treatment may be considered. Laparoscopic Nissen fundoplication is a very effective procedure that can be done with only a brief hospital stay. It often provides excellent relief of symptoms and improved quality of life. Over the long term, about 30% of patients will still require medication after surgery.
There are also new endoscopic procedures under development that may offer some hope in the future. Unfortunately, none of them have been shown to actually reduce reflux, and we do not recommend them.
A Final Word of Encouragement
Reflux is often a stubborn problem and may take several months to improve. Many patients do not improve on medication alone. If you diligently follow these recommendations you should notice steady improvement. If you learn how to effectively modify your diet and lifestyle to control this problem, you will feel better and may be able to minimize or eliminate the need for expensive medical therapy. Even if you do everything you are supposed to do, you may still require medication to keep your reflux symptoms under control.