More Than Frequent Heartburn

When your heartburn happens all the time it may be Gastroesophageal reflux disease, also known as GERD. When heartburn becomes chronic it can cause other symptoms. Frequent coughing and difficulty in swallowing can happen. There is a sphincter muscle that is supposed to keep acid in the stomach. For some reason it will splash into the esophagus causing pain. This muscle does not work properly. Some causes are unknown and others are known.

Why Does It Happen?

Some reasons are unknown. It is known that pregnancy and smoking can cause this condition. Obesity is another reason.

Another reason for GERD is hiatal hernia. A hernia develops above the stomach in the diaphragm. The protrusion allows acid to enter the esophagus on some occasions. It is one of the causes of reflux that causes you pain. This condition is quite common. Most of them are non-serious. The risk seems to increase with age.

More Serious Issues

Sometimes GERD can develop into a more serious situation called Barrett’s esophagus. Cells of the esophagus try to mutate into stomach lining cells. This is thought to be a protective response from the stomach acid. People may have worse reflux symptoms with this disorder. However, in some cases, the symptoms may be less. Other complications can develop like strictures and ulcers. Strictures are scarring that can narrow the esophagus and make swallowing difficult. Only a doctor can tell you if you have Barrett’s esophagus. And the condition can lead to cancer. This makes regular doctor visits very important.

Dealing With Reflux

Treatment of heartburn, GERD, hiatal hernia, and Barrett’s esophagus, are similar. They all involve ways to keep acid from splashing into the esophagus. Eating smaller meals is a recommended method. Trying to lose weight is also advised. People with frequent heartburn might try elevating their head when they sleep. Also, do not eat before bedtime. For infrequent heartburn, antacids may work just fine. For more frequent, your doctor can prescribe medication that may help.

Final Thoughts

Heartburn is when acid has splashed where it is not supposed to be, the esophagus. It is also referred to as acid reflux. It causes pain and discomfort. Chronic heartburn is more serious and should be treated by a physician, as complications can develop.

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NICE recommends either a ’step up’ or a ’step down’ approach, depending on the severity of your acid reflux disease. There are 5 five levels, starting with the mildest treatment (antacids/alginates) through H2 antagonists, to rising doses of PPIs. For example, if endoscopy has shown that you have ulcers in your esophagus or Barren’s esophagus, you will start on the highest ‘healing’ dose of a PPI – level 5. The dose can eventually be cut down once the symptoms have improved, to a level that continues to keep you symptom-free.

On the other hand, if you have mild symptoms and no need for endoscopy, you may be started on level 1, with an antacid-alginate combination and advised on lifestyle. If this does not work, your doctor may add an H2 antagonist – level 2.

Depending on your progress after that, you will pass up or down the scale. All patients should have their own ‘treatment plan’ that guides them on how to manage their own symptoms, and this can often be stopped when their esophagus eventually heals and the symptoms disappear.

However, the fact that you are able to stop the treatment doesn’t mean that you can now stop going to your doctor.

Most people with gastro-esophageal reflux disease (GERD) require long term management. The guiding principle for long term management is to step down to the treatment that is least costly but still effective in controlling your GERD and acid reflux symptoms.

Finding the right level of management may take time in some patients. Patients returning with a relapse after a trial without treatment should be restarted on the initially successful therapy and then have treatment stepped down as appropriate. For patients who require only intermittent short courses of antisecretory (acid-lowering) therapy, it may be more effective to give a proton pump inhibitor at full dose than to titrate treatment up from either half dose of PPI or a standard dose of H2 receptor antagonist.

By optimizing the treatment in these ’steps’, endoscopy is kept to a minimum. If a particular acid reflux treatment successfully controls a patient’s symptoms, the doctor can be assured that the esophagitis has healed, and there is no need for further endoscopies.

Even when the patient needs to continue on long-term PPIs because of severe esophagitis (Los Angeles stages (C) and (D)), repeat endoscopy is not always needed, as it is safe to assume that if the GERD symptoms are absent, the esophagitis has healed. On the other hand, patients in these categories must have repeat endoscopies if they still have symptoms despite standard daily doses of PPIs.

The groups of patients who must be kept on continuous treatment include:

Patients with ulcers in the esophagus that have been induced by an NSAID and who have no choice but to continue with it because they have chronic pain (such as from arthritis). They should remain on maintenance doses of PPIs (level 4).

Patients with severe GERD, such as Barren’s esophagus or an endoscopy-proven ulcer, should also remain on maintenance doses of a PPI (level 4).

Patients whose very severe acid reflux disease has been complicated in the past by stricture, ulcers and hemorrhage should be left on full doses of PPIs (level 5).

‘Prokinetic’ drugs, designed to speed up the passage of food from stomach to duodenum, such as metoclopramide (Maxolon, Gastro-bid) can be added, if needed, to help prevent bloating.

Cimetidine (Tagamet) was the first of this group of acid reflux remedies. It revolutionized the treatment of gastric and duodenal ulcers, but it was marginally less successful when tried against reflux esophagitis. Patients taking it in the early trials found that their symptoms were much less, but endoscopy appearances showed that they still had a moderate degree of inflammation in the esophagus.

The early doses were possibly too low, and many people with acid reflux disease have to take double the original dose of 400 mg to keep their symptoms at bay.

Ranitidine (Zantac) is another H2 receptor antagonist. It is similar in effect to cimetidine, and the usual dose is 300 mg each evening. The dose can be raised up to as much as 1500 mg daily for added benefit, although most doctors would prefer not to go so high, and use another acid reflux treatment, probably a proton pump inhibitor, instead.

Newer H2 antagonists include famotidine (Pepcid) and nizatidine (Axid). They are similar in action to cimetidine and ranitidine, with little to choose between them.

All drugs, including these GERD and acid reflux remedies, may produce side-effects, and acid-suppressant drugs are no exception. H2 receptor antagonists should be used with caution in people with liver or kidney problems or who are pregnant or breast feeding. They may ‘mask’ the symptoms of stomach cancer, so if you have one or more of the ‘alarm’ symptoms your specialist will rule out stomach cancer before prescribing one.

Side-effects of this group of drugs are relatively rare, but they include diarrhea, headache, dizziness, rash and tiredness. Much rarer are effects on the heart rhythm, on the bone marrow and occasional reports of enlarged breasts in men (gynaecomastia) and impotence.

Cimetidine has a disadvantage compared with other drugs in this group, in that it interacts with drugs that use the same type of mechanism in the liver for their breakdown. So it cannot be taken alongside warfarin (an anti-clotting drug), phenytoin (for epilepsy) or theophylline (for asthma).

The other drugs in this group may be taken instead.

Proton pump inhibitors

Proton pump inhibitors (PPIs) act on the acid-producing mechanism at an earlier stage in the process than H2 antagonists, so that they completely eradicate acid, rather than reduce it, from the stomach contents.

The first PPI was omeprazole (Losec). It has since been joined by esomeprazole (Nexium), lansoprazole (Zoton), pantoprazole (Protium) and rabeprazole (Panel).

As with the H2 antagonists, PPIs are so efficient in removing symptoms in reflux disease, even when it is severe, that they can ‘mask’ a stomach cancer. When a person shows ‘alarm features’ the specialist team must rule out a stomach or esophageal cancer before prescribing them.

Side-effects of PPIs are similar to those of the H2 antagonists. The patient leaflet for PPIs list alt the side-effects that have been reported: they look horrendous, but it must be remembered that they are all very rare. Most people find these acid reflux remedies easy to tolerate and that they have no side-effects. However, it is important to read the leaflet, so that if a problem does arise, you can tell what it is, and deal with it accordingly.

Alcohol

I’m sorry to sound a killjoy, but if you have acid reflux disease or GERD, you must be very careful about your alcohol consumption. The neater the alcohol you drink, the more likely you are to provoke an attack of acute GERD. So, although as a lover of Malt Whiskey, it pains me to write this, ease off on the spirits. Confine yourself to the odd glass of wine, preferably with meals. That’s how the French approach alcohol, and it’s very civilized. They have less GERD than we do.

Clothing

Not all acid reflux and GERD sufferers are the same. Some can tolerate coffee or fatty foods, others can’t. Being overweight and eating large meals are certainly one of the main causes of acid reflux and GERD, and so is pregnancy (but at least that’s only a short term state).

Tight clothes can put pressure on the abdomen, so that if I were writing this book a generation ago, I would have mentioned corsets. However, I’m reliably informed (by my slim wife) that women no longer squeeze into restrictive clothing – they just ‘let it all hang out’. Any tight band across the middle, such as a belt, may induce acid reflux symptoms. I leave it to the individual woman (or man) to judge whether or not that is a factor in their GERD.

Medication

Some prescription drugs can contribute to GERD by causing the sphincter at the cardia to relax. They include the ‘tricyclics’ used to treat depression. They are usually easily spotted, because their generic name (seen in small print under the trade name) often ends in  -amine  or  -ine.  Among them are amitriptyline, amoxapine, clomipramine, imipramine, lofepramine, nortriptyline and trimipramine.

‘Anticholinergic’ or ‘atropine-like’ drugs prescribed to treat bowel spasms or irritable bowel syndrome can do their job only too well and relax the gastro esophageal sphincter, too. They include dicyclomine (also called dicycloverine), hyoscine and propantheline bromide.

Atropine sulphate tablets are given on prescription but are also available over-the-counter, mainly as Actonorm powder, which is a mixture of atropine, aluminum, calcium carbonate, magnesium, sodium bicarbonate and peppermint oil. This, too, can relax the gastro esophageal sphincter and provoke attacks of GERD symptoms.

Another group of drugs that may be one of the causes of GERD is the ‘nitrates’ prescribed to open the coronary arteries for people suffering from angina. Among them are glyceryl trinitrate and isosorbide trinitrate and mononitrate. If your chest pain becomes worse when taking these drugs, you either are having more serious heart pain than you thought, and should urgently see your doctor, or the pain is caused by GERD. Either way, you need help.

Some drugs directly irritate the esophageal mucosa. They include the aspirin-like non-steroidal anti-inflammatory drugs used to treat chronic pain; potassium salts that are sometimes used in people taking drugs to lower blood pressure; and the bisphosphonates given for osteoporosis. If you are on treatment for any of these conditions, and think you may be taking one of these types of drug, you should discuss it with your doctor.

So if you have GERD and are taking drugs for other conditions, check with your doctor that your treatment is not actually one of the acid reflux causes and thereby worsening your GERD symptoms. There are always alternative acid reflux natural treatments to be found if they are.