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 indigestion, are more common among the elderly and pregnant women.
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.
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.
In many cases, doctors find that infrequent heartburn can be controlled by lifestyle modifications and proper use of over-the-counter medicines.
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.
When symptoms of heartburn are not controlled with modifications in lifestyle, and over-the-counter medicines are needed two or more times a week, or symptoms remain unresolved on the medication you are taking, you should 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. A 1999 study reported in the New England Journal of Medicine showed that patients with chronic, untreated heartburn of many years duration were at substantially greater risk of developing esophageal cancer, which is one of the fastest growing, and among the more lethal forms of cancer in this country.
Symptoms suggesting that serious damage may have already occurred include:
GERD is a problem that is symptomatic by day but in which much damage is done by night. Treatment should be designed to: 1) eliminate symptoms; 2) heal esophagitis; and 3) prevent the relapse of esophagitis or development of complications in patients with esophagitis. In many patients, GERD is a chronic, relapsing disease. Long-term maintenance is the key to therapy; therefore, continuous long-term therapy, possibly life-long therapy, to control symptoms and prevent complications is appropriate. Maintenance therapy will vary in individuals ranging from mere lifestyle modifications to prescription medication as treatment.
All treatments are based on attempts to a) decrease the amount of acid that refluxes from the stomach back into the esophagus, or b) make the refluxed material less irritating to the lining of the esophagus.
In order to decrease the amount of gastric contents that reach the lower esophagus, certain simple guidelines should be followed:
Alternatively, one may use an under-mattress foam wedge to elevate the head about 6-10 inches. Pillows are not an effective alternative for elevating the head in preventing reflux.
GERD has a physical cause, and frequently is not curtailed by these lifestyle factors alone. If you are using over-the-counter medications two or more times a week, or are still having symptoms on the prescription or other medicines you are taking, you need to see your doctor. If results are not forthcoming, medications may be used to neutralize acid, increase LES tone, or improve gastric emptying.
Prescription medications to treat GERD include drugs called H2 receptor antagonists (H2 blockers) and proton pump inhibitors (PPIs), which help to reduce the stomach acid that tends to worsen symptoms, and work to promote healing, as well as promotility agents that aid in the clearance of acid from the esophagus.
Since the mid 1970's, acid suppression agents, known as H2 receptor antagonists or H2 blockers, have been used to treat GERD. H2 blockers improve the symptoms of heartburn and regurgitation and provide an excellent means of decreasing the flow of stomach acid to aid in the healing process of mild-to-moderate irritation of the esophagus, known as "esophagitis." Symptoms are eliminated in up to 50% of patients with twice a day prescription dosage of the H2 blockers. Healing of esophagitis may require higher dosing. These agents maintain remission in about 25% of patients.
H2 blockers are generally less expensive than proton pump inhibitors and can provide adequate initial treatment or serve as a maintenance agent in GERD patients with mild symptoms. Current treatment guidelines also recognize the appropriateness and in some cases desirability of using proton pump inhibitors as first-line therapy for some patients, particularly those with more severe symptoms or esophagitis on endoscopy. Proton pump inhibitors will be required to achieve effective long-term maintenance therapy in a significant percentage of heartburn/GERD patients.
Proton pump inhibitors (PPIs), have been found to heal erosive esophagitis (a serious form of GERD) more rapidly than H2 blockers. Proton pump inhibitors provide not only symptom relief, but also elimination of symptoms in most cases, even in those with esophageal ulcers. Studies have shown proton pump inhibitor therapy can provide complete endoscopic mucosal healing of esophagitis at 6 to 8 weeks in 75% to 100% of cases. Although healing of the esophagus may occur in 6 to 8 weeks, it should not be misunderstood that gastroesophageal reflux can be cured in that amount of time. The goal of therapy for GERD is to keep symptoms comfortably under control and prevent complications. As noted above, current guidelines recognize that heartburn and GERD are typically relapsing, potentially chronic conditions, that symptoms and mucosal injury will often reoccur when medications are withdrawn, and hence that a strategy for long-term maintenance therapy is generally required. Occasionally, a health care plan seeks to limit use of proton pump inhibitors to a fixed duration of perhaps 2-3 months and others have even cited FDA's approval of proton pump inhibitors for up to one year, as if that means that this therapy should be withdrawn after one year. There is no well-established scientific reason that supports withdrawing proton pump inhibitors after one year as these patients will invariably relapse. All gastroenterologists have patients who continue to do very well on proton pump inhibitors after many years' use without adverse side effects. Efforts by payors to limit access to these medications are generally a cost-saving initiative. Daily proton pump inhibitor treatment provides the best long-term maintenance therapy of esophagitis, particularly in keeping symptoms and the disease in remission for those patients with moderate to severe esophagitis, plus this form of treatment has been shown to retain remission for up to five years.
Promotility drugs are effective in the treatment of mild to moderately symptomatic GERD. These drugs increase lower esophageal sphincter pressure, which helps prevent acid reflux, and improves the movement of food from the stomach. They can decrease heartburn symptoms, especially at night, by improving the clearance of acid from the esophagus. Recent developments have greatly limited the availability of one of these agents, i.e. cisapride. Cisapride had been used widely for several years in treating night-time heartburn and was also used by some practitioners in the treatment of GERD symptoms in children. More recently, rare but potentially serious complications have been reported in some patients taking cisapride. These complications seem to be related to usage in patients on contraindicated medications or in patients with contraindicated medical conditions, such as underlying heart disease. In March of 2000, the manufacturer announced that it had reached a decision in consultation with the FDA to discontinue the marketing of the drug. The product will remain available only through a limited-access program. This program has been established for patients who fail other treatment options and who meet clearly defined eligibility criteria.
|Class of Drugs||How It Works||Eliminate Symptoms||Heal Esophagitis||Manage or Prevent Complications||Maintain Remission|
|H2 Blockers Over-the-counter||mildly suppress acid||+1||0||0||0|
|Promotility||increase LES pressure; move acid from esophagus and stomach||+2||+1||0||+1|
|H2 Blockers Prescription||moderately suppress acid||+2||+2||+1||+1|
|H2 Blockers + Promotility||moderately suppress acid; move acid from esophagus to stomach||+3||+3||+1||+1|
|High Dose H2 Blockers||moderately suppress acid||+3||+3||+2||+2|
|Proton Pump Inhibitors||markedly suppress acid||+4||+4||+3||+4|
|Surgery||improve barrier between stomach and esophagus to prevent acid reflux||+4||+4||+3||+4|
Rating Scale: 0 (no effect) to +4 (nearly 100%)
From An Update on GERD Educational Slide Lecture program, ©1996 ACG.
Surgical measures to prevent reflux can be considered if other measures fail or complications occur such as bleeding, recurrent stricture, or metaplasia (abnormal transformation of cells lining the esophagus), which is progressive. The surgical technique improves the natural barrier between the stomach and the esophagus that prevents acid reflux from occurring. Consultation with both a gastroenterologist and a surgeon is recommended prior to such a decision.
There are always new treatments and possibilities looming on the horizon. There are two new endoscopic techniques for treating GERD — suturing and the Stretta radio frequency technique — which have recently been approved by the FDA for use with patients. Because these treatments are so new, we do not have any real information concerning their long-term effectiveness. They were approved by the FDA largely based on data showing that they could help reduce GERD for at least six months after treatment. At least in the foreseeable future, until long-term outcomes can be evaluated, most patients and physicians will likely be sticking with the treatment options about which there is a much greater wealth of experience, e.g. medical treatment with proton pump inhibitors and other acid suppression medications, and surgery.
A gastroenterologist is a physician who specializes in disorders and conditions of the gastrointestinal tract. Most gastroenterologists are board-certified in this subspecialty. After completing the same training as all other physicians, they first complete at least two years of additional training in order to attain board certification in internal medicine, then gastroenterologists study for an additional 2-3 years to train specifically in conditions of the gastrointestinal tract.
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.
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.
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.
Extra-Esophageal Manifestations (EEM): Heartburn links to chest pain; asthma; chronic cough; ear, nose and throat problems often avoid detection
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.
Esophageal disease may be perceived in many forms, with heartburn being the most common. The severity of heartburn is measured by how long a given episode lasts, how often symptoms occur, and/or their intensity. Since the esophageal lining is sensitive to stomach contents, persistent and prolonged exposure to these contents may cause changes such as inflammation, ulcers, bleeding and scarring with obstruction. A pre-cancerous condition called Barrett's esophagus may also occur. Barrett's esophagus causes severe damage to the lining of the esophagus when the body attempts to protect the esophagus from acid by replacing its normal lining with cells that are similar to the intestinal lining.
Research was conducted to determine whether the duration of heartburn symptoms increases the risk of having esophageal complications. The study found that inflammation in the esophagus not only increased with the duration of reflux symptoms, but that Barrett's esophagus likewise was more frequently diagnosed in these patients. Those patients with reflux symptoms and a history of inflammation in the past were more likely to have Barrett's esophagus than those without a history of esophageal inflammation.
Persistent symptoms of heartburn and reflux should not be ignored. By seeing your doctor early, the physical cause of GERD can be treated and more serious problems avoided.
How significant is your heartburn? What are the chances that it is something more serious? If you need a yardstick, here's a simple self-test developed by a panel of experts from the American College of Gastroenterology.
Remember, if you have heartburn two or more times a week, or still have symptoms on your over-the-counter or prescription medicines, see your doctor.
Take this "Richter Scale/Acid Test" to see if you're a GERD sufferer and are taking the right steps to treat it.
If you said yes to two or more of the above, you may have GERD. To know for sure, see your doctor or a gastrointestinal specialist. They can help you live pain free.
For more information about heartburn and GERD, call 1-800-HRT-BURN.
Gastroesophageal reflux disease (GERD) is a condition where acid in the stomach sweeps up into the esophagus causing unpleasant symptoms such as heartburn, regurgitation and unpleasant taste of acid in the mouth (water brash). This can also cause serious symptoms such as chest pain mimicking heart attack, hoarseness, asthma like symptoms thus causing unwanted anxiety in the patient, an undesirable hospital stay and unnecessary medical expenditures.
Acid in the stomach is the first line of defense against the food-borne pathogens that we ingest. Moreover acid in the stomach plays a role in absorption of vitamins (Vitamin B12), the digestion of proteins, and initiation of peristalsis which causes the food to move through the digestive tract.
Advancing age, obesity, regular use of aspirin and non-steroidal anti-inflammatory drugs, loss of physical mobility, and an incompetent valve between the stomach and esophagus (Lower Esophageal Sphincter or LES) are found to be among the many associated risk factors for GERD.
About 8% of males and 15% of females over 65 years suffer from GERD and potentially use an acid medication. Aging by itself can cause changes in the pressure of the LES, which may increase the risk of GERD in the elderly. Decreased physical mobility secondary to multiple medical problems including arthritis increases the risk of becoming overweight and increase the risk of GERD. Many take aspirin or other medications that may contribute to the increased occurrence of GERD symptoms in the elderly. Aging also decreases the force of swallowing contractions, which causes delayed clearance of acid when refluxed into the esophagus. Thus there is potential for increased exposure of the esophageal lining to the regurgitated acid and thus increases the risk of damage.
The management guideline for GERD in the elderly remains the same as in a young patient. However, the physician may individualize the treatment based on the patient's overall condition. The treatment can be broadly classified into lifestyle modifications, over-the-counter medications and prescribed medications.
Lifestyle modifications include raising the head end of the bed to use gravity as a leverage to allow early clearance of regurgitated acid from the esophagus. Avoiding tight fitting clothes to decrease abdominal pressure, decrease fats, chocolate, peppermint and alcohol from the diet to try to help reduce reflux.
Mild reflux symptoms can be controlled by over-the-counter medications like antacids such as TUMS® and Pepto-Bismol®, which neutralize the acids. This is only effective in 20% of the patients. They have to be taken frequently after meals (such as 1-3 hours). One of the main disadvantages is the inability of these products to heal any areas of esophageal inflammation caused by the acid reflux.
Antacids contain aluminum and magnesium which can cause constipation and diarrhea in some patients. Constipation occurs in fewer than 2 percent of persons in the nonelderly population but affects as many as 26 percent of men and 34 percent of women over 65 years of age. Patients with chronic kidney disease (CKD) should be careful with these medications as the mineral ingredients may worsen kidney function. You consult with your care provider if you have CKD.
Another class of anti-reflux medications is histamine-2 receptor antagonists (H2 blockers). Cimetidine, ranitidine and famotidine, are available over-the-counter. Although they act more slowly compared to antacids, they remain active longer compared to the latter. There are combination H2blocker/antacids which may be helpful in symptom relief.
Cimetidine and ranitidine may increase the blood concentrations of anti-seizure medications, blood thinners, and anti-arrhythmic medications. Newer generations of this class of drugs do not cause this problem.
If the symptoms of GERD persist even after using these medications for more than two weeks, you should consult your doctor.
A proton pump inhibitor is a medication that is designed to decrease the amount of acid your stomach makes by inhibiting both meal stimulated and night-time acid secretion and has better effect than H2 blockers. This type of medication is also better at healing ulcers in the esophagus and stomach.
PPIs are mostly well tolerated. The only known contraindication is very rare allergy to this drug group. The most commonly noted side effects are headache, nausea, diarrhea, abdominal pain and in some cases constipation. Very few persons need to stop taking the medication because of side-effects.
This really depends on the severity of your symptoms and response to therapy. For example mild cases may respond to treatment and therapy can be stopped after a short course of treatment. If you have inflammation of the esophagus (esophagitis) or ulcers in the esophagus/stomach you may need to continue treatment for a longer period of time and remain on maintenance therapy. When elderly patients with reflux esophagitis were followed up for a period of 3 years, 68% of them needed treatment for more than six months and 46% needed therapy for 3 years to prevent recurrence of esophagitis. Without the therapy 80-90% of the patients suffered a relapse in a period of one year.
There have been many studies addressing this issue because of concern of an interaction between PPIs and Clopidogrel. Current data suggests that it is safe to use a PPI and Clopidogrel together in patients who need both compounds. It is possible that some PPIs will have less effect on interactions with Clopidogrel and this may affect which of the PPIs your care provider will prescribe. Some PPIs have label recommendations regarding their use with Clopidogrel. Please discuss this with your care provider.
It has been suggested that people who take a PPI for a long period of time at high doses have an increased risk for fractures of the hip, wrist and spine. No evidence exists to suggest that PPIs cause or accelerate osteoporosis. If there is an increased risk of fractures on PPI it is in patients who are at increased risk because of other conditions predisposing to osteoporosis and fractures.
The FDA however, released a warning that doctors and those who take PPIs should be aware of the possible increased risk of fractures. If there is an increased risk of fracture, the overall risk is extremely small.
There has long been a concern that there might be a very gradual decrease in vitamin B12 levels over a long time in persons who take a PPI but there has not been any report of disease being caused by this. There are usually other reasons for a low vitamin B12 in older persons. There is no need to monitor vitamin B12 levels in persons taking a PPI unless they have another condition.
Available data are controversial but raise concern for an association between these medicines and C. difficile infection (a colon infection that usually happens after taking certain antibiotics). The risk is perhaps related to the degree and duration of acid suppression, other conditions increasing susceptibility of the patient to this infection and nature and strength of the strain of C. difficile infection.
This association should prompt the physicians to use PPI/H2 blockers in patients, specifically older patients on multiple medications and on frequent antibiotics for recurrent infections, only in those who need them.
This is another area of controversy with perhaps a slight increase in the incidence of pneumonia in some patients who use PPIs. This risk has been shown to be more likely with initiation and recent use of an acid-suppressive agent rather than chronic treatment.
It is true that the PPI/H2 blockers may decrease the acidic environment in the gut facilitating the existence of some pathological bacteria that may lead to pneumonia. When you have reflux, however, it may be that your reflux is responsible for the problem and not the medication.
Please consult with your care provider if you have any questions.