Handling Heartburn

Heartburn, acid indigestion, agita, GERD… Whatever you call it, this problem has plagued humanity for millennia. It is a sensation of pain in the upper chest, behind the breast bone  or sternum caused by a disorder of the gastrointestinal (GI) tract. It is responsible for a significant portion of the time and money we spend on our health care and has an additional emotional cost; for even in these times of modern science, it is hard to initially differentiate it from an oncoming heart attack. What causes heartburn, and how can we fix it?

Heartburn, more properly termed gastroesophageal reflux disease (GERD), occurs when stomach acid gets up into the esophagus, that muscular tube that connects mouth to stomach. While the stomach, or gastrum, can tolerate extremely acidic fluids, the esophagus is relatively sensitive and gets very irritated with even a little acid exposure.

There are two scenarios that lead to this irritation. Sometimes, it is an issue of too much acid in the stomach, and it can “spill over” into the esophagus, especially when you lay down. Other times, there is a structural problem with the barrier between these two body parts. The purse-string muscle, or sphincter, that is responsible for closing off the stomach’s upper opening may be loose or otherwise unable to function. Understanding the cause of one’s reflux can help strategize the best treatment plan.

Usually, doctors can determine the cause of GERD with a few tests. In one of them, a patient has to swallow a chalky barium liquid while an X-ray video is taken. Barium shows up clearly in radiographs, and the physician can see whether the sphincter muscle allows significant leakage. Another commonly used test is the upper endoscopy (EDG) in which an intestinal specialist inserts a flexible fiber optic tube down through the esophagus in to the stomach. They can see if there are characteristic acid burns on the esophageal lining. Additionally, they can watch the sphincter open and close.

Both the barium-swallow and EDG methods are good at detecting hiatal hernias, too. A hiatal hernia is when part or all of the stomach migrates from its usual position in the abdomen up through the diaphragm and into the chest cavity. Besides causing discomfort, this also strains the sphincter muscle and allows acid leakage.

Regardless of the cause of GERD, the initial treatment is almost always the same. Sufferers are advised to establish habits that reduce the likelihood of spillover. This is best accomplished by forswearing a habit, such as smoking and alcohol use, that produces extra acid. And as stomach acid is most prone to migrating up where it doesn’t belong when you are laying down, avoid eating right before bed. Sleeping with your upper chest elevated can significantly reduce acid reflux, as well.

There are also several groups of medications that address the problem. Some agents, such as Reglan, relax the stomach, so it is less likely to contract and push acid in the wrong direction. While these prescriptions really get at the root of the problem and prevent reflux, they also have cardiac side effects and so are rarely used. Other pills reduce acid production, so when the stomach contents splash into the esophagus, they are less irritating. Over-the-counter medications like Zantac and Pepcid fall into this category. The prescription drugs Nexium and Prevacid have essentially the same effect, but they are much more powerful and longer acting. These latter drugs are felt to be very safe short term, but long term use may increase the likelihood of serious health problems, like osteoporosis.

Surgeries for GERD are reserved for refractory cases and include maneuvers to fix hiatal hernias and procedures to destroy the nerves that trigger acid production. Complications tend to be frequent, and results are often disappointing; therefore, most patients are not offered these options.

So if you have the symptoms of heartburn, what should you do? First of all, consider seriously whether or not it could be actual heart pain. A visit to your doctor, or even the Emergency Department, could be necessary and lifesaving.

In the event it is clearly GERD, we usually advise several weeks of lifestyle modification. We recommend no smoking, alcohol, or late night meals and sleeping with the head of your bed elevated. In addition, we recommend a short course of medication. If this does not resolve the issue or if it quickly recurs once treatments are stopped, then specific testing, as noted above, is required. A gastroenterologist (GI) doctor, traditionally directs this work-up. Results of these tests will help determine the best long term management of your particular type of heartburn.

While acid reflux is usually more of a nuisance than a danger, there are instances when it presents a serious health risk. Sometimes there is so much acid leakage and irritation that the esophagus has callouses and scars and is prone to developing esophageal cancer. This is termed “Barrett’s Esophagus,” and it is typically treated with lifelong medication and frequent endoscopies to monitor for malignancy. Other times, the acid irritation is bad enough to provoke bleeding esophageal ulcers. So please don’t ignore your heartburn. Get emergency medical attention if there is any chance it could actually be your heart, and see your doctor if you cannot cure it on your own within several weeks.

Patrice Thornton, MD, is a primary care and family medicine physician at SVMC Northshire Campus in Manchester. It is part of Southwestern Vermont Medical Center in Bennington.