Expert Q & A
Personalizing the Management of Heartburn
By PETER JARET
Dr. Joel E. Richter is chairman of the department of medicine at Temple University in Philadelphia and a leading research scientist in the field of gastroenterology. He has published more than 500 articles on gastroesophageal reflux disease.
Q: What's the difference between heartburn and gastroesophageal reflux disease?
A: Gastroesophageal reflux disease, or GERD, is the medical name for heartburn that's serious enough to warrant treatment. All of us have a little heartburn now and then. It becomes a problem worth taking seriously if it interferes with quality of life — if you find yourself avoiding certain foods or being reluctant to go out to eat because you're afraid of acid reflux, for example, or if you wake in the night with heartburn. Certainly, if you have heartburn and you've unintentionally lost weight recently, have trouble swallowing or have noticed blood in your stool, you should see your doctor. These can be symptoms of more serious conditions, such as cancer.
Q: What causes acid reflux?
A: Normally, a protective valve called the lower esophageal sphincter keeps stomach contents from backing up into the esophagus. Reflux occurs if the valve relaxes when it shouldn't and acid rises up into the esophagus.
Q: How common is the problem?
A: If we use the definition of experiencing heartburn two to three times a week or more, about 20 to 40 percent of the population has GERD. So it's a very common problem, certainly the most common gastrointestinal complaint. And there's evidence that the incidence of GERD is going up.
Q: Why is it becoming more common?
A: Part of the answer is obesity. Although we don't know exactly why, obesity, especially central obesity — a fat belly, in other words — increases the risk of GERD. Excess weight may simply add pressure on the valve that normally keeps the contents of the stomach from backing up into the esophagus.
Paradoxically, another reason why GERD is more common is healthier stomachs. We now know that infection with the bacteria H. pylori, which causes stomach ulcers, also damages acid-producing cells in the stomach. By reducing acid levels, the bacteria inadvertently protect against acid reflux disease. These bacteria used to be quite common, but now that most everyone has indoor plumbing and infections are treated with antibiotics, H. pylori is far less common. Unfortunately, that means acid reflux is on the rise.
Q: Can GERD be prevented?
A: In some people, yes. If you're overweight or obese, losing weight can help, especially if you began to experience heartburn soon after gaining weight. Dieting isn't easy. But sometimes the discomfort of heartburn and the prospect of having to go on medication is enough to motivate people.
Most people get heartburn in the evening, especially if they eat a big meal and then become couch potatoes or go to bed. I tell patients to avoid eating anything within three hours before going to bed. By that time, food and liquid has passed through the stomach, and it's pretty hard to have acid reflux if your stomach is empty.
The same advice goes for people who experience reflux when they exercise. Avoid eating anything for at least two hours before you work out and you'll be less likely to have a problem.
For people who are awakened by heartburn at night, elevating the head of the bed — using gravity to keep stomach acids from backing up — can help.
Q: Are certain foods more likely to cause heartburn?
A: There's a long list of possible culprits, including spicy foods, chocolate, wine, coffee, fatty foods and so on. But most of those associations are based more on myth than on science. In my own clinical practice, I don't like to dictate what foods people should and shouldn't eat. If someone says they get heartburn after drinking alcohol or eating chocolate, I tell them to go easy on alcohol or chocolate. But if alcohol or chocolate don't bother them, why give them up? The triggers for heartburn are so different for different people that it's best to individualize lifestyle advice.
Q: How effective are over-the-counter antacids?
A: If you have occasional heartburn, simple antacids like Tums or Rolaids offer quick relief. If you know that you tend to get heartburn after eating at your favorite Mexican restaurant and drinking a few beers, I'd recommend taking a H2 blocker, such as Tagamet or Zantac, an hour before you go out to dinner to prevent heartburn. For more serious heartburn I recommend Prilosec, [a so-called proton pump inhibitor that] used to be a prescription drug but is now available over the counter. Take it for two weeks. If heartburn returns again soon after you stop, then it's time to see your doctor.
Q: What about prescription anti-reflux drugs?
A: [A number of] proton pump inhibitors are available only by prescription, and they are very effective. They work by inhibiting the production of stomach acid. There are five brands, and despite all the direct-to-consumer advertising claims, there's no evidence that the newer ones are any better than the older ones, so it's worth choosing the least expensive. When you take these medications, it's very important to eat something substantial about a half an hour later. For breakfast I'm talking about toast or cereal, not just a glass of juice or a cup of coffee. The active ingredient takes about 15 minutes to get into the bloodstream, but you need to eat something to wake up the secreting cells and have it take effect. Otherwise the drug just sits around in your bloodstream not doing anything.
Q: Are there risks to taking prescription antacids for too long?
A: These drugs are very safe, but they do have long-term side effects. They significantly lower stomach acid levels, which can increase the risk of developing pneumonia and gastrointestinal infections. There's also evidence that long-term use increases the danger of bone fractures and osteoporosis.
These are risks worth taking if you have bad reflux, but not if you don't really need to take the drugs. Certainly there's no reason to take a prescription drug every day if you only get heartburn when you travel to Europe and practice a little gluttony now and then. But if you have chronic frequently relapsing problems with GERD, or if there are signs of damage in your esophagus, then you may need to take medication daily.
I do recommend that patients who start these drugs taper off after eight to 12 weeks. If the symptoms are gone, great. If they return, then you can go back on the drug.
Q: How can you tell if symptoms of GERD have caused damage to the esophagus?
A: The best method is upper endoscopy. In this procedure, we pass a tiny tube, called an endoscope, down the esophagus and actually look at the lining and take tissue samples if need be. It's worth pointing out that about 85 percent of patients with GERD have symptoms but no evidence of damage. About 15 percent of patients show signs of damage to the esophagus. In that case, it's especially important to avoid acid reflux to prevent further problems, so we're much more likely to keep a patient on a proton pump inhibitor.
Q: When do you recommend surgery?
A: Surgery is the only way to cure GERD. It can be used to tighten up the valve that keeps acid from backing up into the esophagus. Some people have hiatal hernias — bulges in the stomach where it connects to the esophagus — which can allow food and stomach acids to back up. These can also be corrected with surgery. Unfortunately, the benefits of surgery may wear out over time and sometimes patients develop new symptoms.
Lately, some doctors have been experimenting with endoscopic treatments. These are performed via the tube I mentioned, which is passed down the throat into the esophagus. The techniques include suturing the valve, injecting medication into the valve or burning the lining to cause scar tissue, which tightens up the valve. So far, though, these techniques haven't worked very well and they carry risks. For the moment I think they should be limited to research studies.
Q: What's in the research pipeline?
A: There has been interest in a drug called Baclofen, which prevents the lower esophageal sphincter from relaxing when it shouldn't. Unfortunately, it has serious side effects, including nausea, drowsiness and increased risk of seizures, which discourage its use. One hope is that we can develop a more targeted version of the drug that doesn't have so many side effects. There's also interest in developing faster-acting proton pump inhibitors.
Fortunately, we're lucky in this field of medicine, since we already have several very effective medications. Most people with GERD are able to find relief.