Most people suffer now and then from heartburn. Heartburn has nothing at all to do with the heart. It occurs when acid from the stomach regurgitates, or backs up into, the lower esophagus, the tube connecting your mouth and stomach. Most people describe it as ranging from a sour taste in the back of the mouth to a powerful burning sensation in the mid or lower chest and throat.
Normally, this regurgitation is prevented by the esophageal sphincter, a sort of one-way valve that allows food and drink to pass down the esophagus to the stomach while preventing gastric acid and other stomach contents from traveling in the opposite direction. Heartburn often comes after you lie down with a full stomach, for instance in bed after a large or late dinner, or after exposing the esophagus to tobacco smoke, alcohol, coffee or other substances that tend to increase stomach acid or to relax the esophageal sphincter.
Heartburn is much more common than it is serious. If the symptoms are only occasional and they go away when you take an over-the-counter antacid, it is usually nothing to worry about. If, on the other hand, you have chronic problems that are not helped by over-the-counter medicines, you should talk to your doctor. You may have Gastro-Esophageal Reflux Disease or GERD.
If, on the other hand, you have chronic problems that are not helped by over-the-counter medicines, you should talk to your doctor.
What is GERD?
Like heartburn, GERD is caused by stomach acid moving the wrong way through the esophageal sphincter into the throat. Unlike garden-variety heartburn, however, GERD can be a serious long-term health problem. It can also lead to esophagitis, an inflammation of the esophagus caused by regular reflux of stomach acid back into the esophagus. Some patients with GERD develop a condition called Barrett's esophagus, in which the esophagus undergoes unhealthy changes that may increase the risk of a change to so-called dysplasia. Cells that have developed dysplasia have an increased risk of developing into a cancer.
Long-term exposure to stomach acid caused by GERD can cause a variety of problems that are grouped under the term esophagitis. These include loss of the esophagus's protective mucus layer, at times with the development of sores or ulcers. Over a prolonged period, such ulcers may produce scarring, leading to narrowing of the esophageal tube and consequent resistance to passage.
Although the effects of GERD are most often felt after going to bed, daytime regurgitation problems are not uncommon. As esophagitis worsens and becomes chronic, producing a narrowing of the esophagus, in addition to heartburn-like symptoms, such as a sour taste in the mouth or a feeling of pressure in the chest area, sufferers may feel pain when swallowing food (odynophagia) and experience the sensation that swallowed food has become stuck (dysphagia). About three-fourths of those with the disease have persistent and disturbing symptoms over many years. At least half of these experience heartburn on a daily basis and one-third need to take an anti-heartburn drug at least once a day.
In the past, esophagitis sufferers were told to raise the position of their head while sleeping and were given alkali antacids to neutralize the acid or other medicines that reduce stomach acid production, such as H2-receptor antagonists. While these can still be effective treatments, they do not work for everyone. Fortunately, today's doctors have a whole range of other types of drugs to choose from, including the very effective proton pump inhibitors (PPIs) (omeprazole or Prilosec®; lansoprazole or Prevacid®). In the many cases where esophagitis is not helped by antacids or H2-receptor antagonists, a single capsule per day of omeprazole or lansoprazole provides relief from heartburn and sour regurgitation, and promotes healing of sores and lesions within four weeks in the vast majority of patients.
Many of these new drugs also have the added advantage of being more convenient and less expensive.
Left untreated, chronic regurgitation of gastric contents can set in motion a process that may end in the development of cancer, or adenocarcinoma, of the lower esophagus. The process works like this: the body tries to protect the esophagus from the damaging effects of stomach acid by bringing tissue to the esophagus from the lining of the upper stomach, an area of the body that is able to handle contact with stomach acid safely. Unfortunately, however, moving to a new environment puts the stomach lining tissue under great stress. This stress causes a series of changes in the new tissue that can eventually lead to the development of cancer. These changes are called Barrett's esophagus.
How likely are you to develop this condition? Your risk of developing Barrett's esophagus is significantly greater if you have a history of regular GERD symptoms, if you are over 50 years old, or if your doctor finds esophageal inflammation caused by acid reflux. Barrett's esophagus is far from rare, found in 10% of patients whose persistent symptoms of GERD lead to a "scoping" of their esophagus by a physician. Not all Barrett's esophagus sufferers develop cancer, but their cancer risk is 30 to 125 times greater than that of someone without Barrett's changes.9 Recent studies suggest that there has been a dramatic increase in incidence in recent years, to the point that Barrett's esophagus now results in the most common type of upper gastrointestinal tract malignancy, especially among white men.
Drugs, Monitoring and Surgery
Because Barrett's is more or less a severe form of esophagitis, the first treatment doctors use is to try to reduce stomach acid secretion using the proton pump inhibitors (PPIs) such as omeprazole and lansoprazole. When esophagitis is very severe, double doses of PPI therapy are often necessary to eliminate symptoms of GERD. Unfortunately, these treatments do not always reverse Barrett's.
At increased risk for cancer, Barrett's esophagus sufferers must be closely and regularly monitored. Typically, this means an endoscopy, or visual examination of the esophagus using a special instrument, and biopsy, or removal of tissue samples for analysis, of the lower esophagus every 24 to 36 months. Depending on the results of these tests, the doctor may recommend either more frequent monitoring or, perhaps, surgery.
A new, relatively untested way to treat Barrett's esophagus is to remove damaged tissue from the esophagus using laser surgery, which can be less invasive than conventional surgery. However, the jury is still out on its effectiveness and you may wish to discuss with your own doctor whether this is something you should consider.
Preventing GERD Symptoms
Although those who have changes in the structure of the normal valve mechanism at the lower esophagus will experience reflux of acid and the consequent symptoms of heartburn and a sour taste, there are ways to minimize the regurgitation. Reflux is often more likely to occur after retiring at night because the esophagus loses the advantage of gravity due to its position above the acid-producing stomach. Thus, it is important to eat relatively early meals, several hours before bedtime. It is also important to eat a meal that is relatively low in fat. A dinner high in fat content will slow the rate of stomach emptying, thereby leaving both some residual meal and the added acid produced in response to the meal. Keeping the fat content of the dinner meal to a minimum encourages the stomach to empty the meal and secrete acid long before bedtime.
Certain foods will either stimulate stomach acid production or serve to relax the valve at the junction of the esophagus and stomach. To prevent symptoms, therefore, it is important to avoid these foods, particularly late in the day. Coffee, tea and hot chocolate will increase the quantity of stomach acid. Concentrated chocolate and alcohol (particularly in the so-called after-dinner liqueurs) relax the normal esophagus-stomach junction barrier. Hence, simply eating small meals relatively free of fat several hours before bedtime and avoiding chocolate-enriched desserts and liqueurs may be sufficient to greatly decrease for many people nighttime heartburn and regurgitation.
Guidelines for Treating GERD
Therapy and the Stages of GERD.
(Occasional bouts for periods of a week or longer)
- Eat early and low-fat dinners
- Elevate the head of bed (place on 6-inch blocks)
- Treat with H2-antagonists and antacids
(Months of daily symptoms of heartburn/chest pressure and poor response to H2- antagonists)
(Rapid recurrence of symptoms after course of PPI; occasional odynophagia/dysphagia)
- Gastroenterology consultation; endoscopy
- Consider surgery
(Persistent daily and nightly regurgitation, odynophagia, dysphagia,
poor response to drugs)
- Maximum dosage of PPI
- Possible surgery
(same symptoms as severe or recalcitrant GERD)
- Maximum dosage of PPI and cisapride
- Regular endoscopy and biopsy
(same symptoms as severe or recalcitrant GERD)
- More frequent endoscopy and biopsy
- Laparoscopic or conventional surgery
The Future for GERD and Barrett's
GERD is a very common condition that often leads doctors to discover Barrett's esophagus and other esophageal problems. What we do not know, however, is how many people may have Barrett's but are unaware of it because they have little or no GERD symptoms. At present, the usual advice is to have anyone with Barrett's undergo an endoscopy every 12-24 months, especially if they are over 50. This represents quite a large and expensive task, even without adding those who may have Barrett's without significant symptoms.
In the near future, we hope that non-invasive, efficient methods of diagnosing Barrett's, even in those with mild symptoms, well before it evolves into cancer, will be developed.