QUESTIONS & ANSWERS
GERD, ACID REFLUX,
By TIMOTHY GOWER.
Based in part on an interview with Dr. Gartth H. Ballantyne.
Reprinted from HEALTH May/June 1997, pp.100-106.
Reprinted from HEALTH, May/June, 1997, pp. 100 - 106.
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"You and your 'Let's go Mexican!"' snaps a pajama-clad woman at her dozing spouse. He awakes to find his wife, hands pressed to her breastbone, deep in physical, if not existential, anguish. It's a tense moment for this TV couple, but serenity is restored when hubby-groggy but contrite-offers to fetch his gastrically distressed partner a tablet of Pepcid AC.
Funny things are happening in the parallel universe of television commercials. Strangers sidle up to chili-chomping countermates in greasyspoon diners, eager to discuss the fastest forms of relief. Twinkly-eyed seniors share the secret to tolerating green peppers with their grandchildren. And, as if we didn't already see plenty of Brian Dennehy in just about every movie-of-theweek to hit the small screen, the bulky actor has begun to pitch us Zantac 75.
The relentless ads are meant to make us think about one of the most common maladies known: heartburn. And about how to make it go away: by heading for the antacids section in your local drugstore. It's a crowded aisle, and getting morecongested by the minute. In the past couple of years a number of new over-the-counter heartburn remedies have shown up on the shelves to compete with traditional antacid pills and cocktails. The names of the new drugs-Pepcid AC and Zantac 75, as well as Tagamet HB and Axid AR-may sound vaguely familiar. Known collectively as H2 blockers, they've been available for years as maintenance therapy for peptic ulcers (by prescription only, at double the dose or more, and minus the suffixes).
But doctors now know that most ulcers are caused by a bacterium called Helicobactorpylori and can be completely cured with antibiotics and a few swigs of Pepto-Bismol. That ripping sound you hear is the nation's ulcer patients, shredding their prescriptions for H2 blockers. Small wonder pharmaceutical companies have turned their attention to heartburn-sufferers.
It's a mighty big market they're wooing. Postmeal malaise can be a nuisance at any time of life (consider: Mylanta makes a children's version), but heartburn hits harder and more often in the middle years. Approximately 60 million Americans feel that stinging behind the sternum at least once a month, a quarter of them every day. In a survey of recurrent heartburn sufferers conducted by the United States Surgical Corporation (which manufactures devices used in surgery-yes, surgery-for heartburn), half the respondents said flaming innards had interfered with their work. And 34 percent reported that heartburn "gets in the way of sex." ("Not tonight, honey-I just had gazpacho.")
The new over-the-counter drugs certainly offer more ways to treat digestive woes, but for the customer in the aisle, the choices may bring more confusion than relief. Should you settle for an oldfashioned antacid to neutralize the burn or try a new pill to block it altogether? If you choose a blocker, is the one that "relieves" heartburn good enough, or do you need the one that promises to "prevent heartburn completely"?
Decision made? Not so fast. Some in the medical community worry that all the new remedies will encourage us to take heartburn too lightly. Their concern may be a little hard to swallow for a generation accustomed to thinking in the whimsical terms of old ad jingles ("Plop, plop / Fizz, fizz / Oh, what a relief it is!"), but gastroenterologists warn that persistent, industrial-strength heartburn is a disease and needs a doctor's attention. Treat it on your own and you risk serious consequences.
So what to do about heartburn? It's enough to keep a TV couple up all night.
No snickering - emergency room physicians frequently have to convince patients that what they need is not a defibrillator but a spoonful or two of Maalox. Even more often, someone feeling the first signs of a heart attack shrugs those symptoms off as mere heartburn, sometimes with disastrous results.
Heartburn can feel like cardiac arrest because it strikes in the general area of your heart. But while a heart attack is typically described as a crushing ache, heartburn really does burn. A heart attack can radiate to the neck and one or both arms; heartburn is sharply localized, felt in the chest and sometimes the throat. You may have a battery-acid taste in the back of your mouth, along with hoarseness or a sore throat.
Indigestion, meanwhile, is something that happens in your stomach or intestines: nausea, gas, or another digestive misadventure.
IT'S NOT ENTIRELY CLEAR why heart-burn tends to worsen with age. Some experts believe that being overweight exacerbates the problem and therefore blame the tendency to put on a few pounds with each passing year. Others point to the fact that as people get older, they are more likely to take medications known to increase heartburn.
But at any age, heartburn is a matter of personal sensitivity. Each day the average person's stomach churns out more than a quart of hydrochloric acid, a corrosive compound that's also found in industrial solvents (albeit in higher concentrations). Ads for heartburn remedies discuss stomach acid in the bitter tones most of us reserve for war criminals and telemarketers, but the acid itself is not inherently evil. Early humans probably needed it to protect the stomach from bacteria in the animal carcasses dragged home for lunch.Today stomach acid isn't strictly necessary: It helps break down dietary protein, but enzymes in the intestine can just as easily handle that chore. Still, because the stomach is lined with a layer of protective mucus, the acid doesin't cause problems so long as it stays where it belongs.
Unfortunately, it occasionally goes astray. When we swallow food, a tiny valve at the end of the esophagus opens long enough for chewed-up particles to pass into the stomach. Now and then, and especially after eating, the valve relaxes.
At times this transient opening is welcome. (We couldn't belch without it.) However, a relaxed valve also allows the acid bath in your belly to be forced back up into the esophagus, a phenomenon known as gastroesophageal reflux.
Everyone experiences reflux at least a few times a day. So why do you get heartburn, while many people are never bothered? It may be a matter of a weak valve that leaves the gullet exposed to acid for r prolonged periods. Or you may have de- veloped a hiatal hernia, a condition in which the upper part of the stomach squeezes into the chest through a hole in the diaphragm, making it easier for acid to splash up into the esophagus. More simply, the contents of your stomach may be particularly acidic, so that even a splash on the esophagus makes you reach for the Rotaids-or the lining of your esophagus may just be very sensitive.
NOT NECESSARILY, especially if you Nonly get heartburn now and then. Sometimes all you need is a glass of water to rinse acid off the esophagus. If that's not enough, experts suggest making some "lifestyle changes"-a euphemism for giving up many of the things you love to eat, drink, and inhale.
Because-brace yourself-studies show that chocolate can cause heartburn. Garlic, onions, peppermint, and just about any dish high in fat can stir up problems, too. These foods-along with all alcoholic beverages-seem to stimulate the release of hormonelike substances that can make the esophageal valve wobbly and ineffectual, says gastroenterologist Donald Castell of the Graduate Hospital in Philadelphia. And these are only the most common culprits; heartburn triggers vary from one sufferer to another.
There are also a few foods that can cause heartburn without relaxing the valve between stomach and esophagus. Citrus fruits, coffee, and anything tomatoey can irritate the esophagus on contact-no reflux required.
What's more, getting heartburn is not always a matter of what you eat but how much and what you do afterward. Any large meal can expand the stomach and force open the gateway to the esophagus. Lying down after a meal makes the problem worse, since gravity stops working in your favor. Smoking dries up saliva, which would normally protect the esophagus from stomach acid. Even squeezing into a pair of tight jeans can create pressure on the abdomen, forcing stomach acid upward.
So if you're trying to avoid heartburn, the principle is simple: Monitor your diet and habits, figure out what sparks the flame, and avoid it. You may find relief by loosening your belt a notch, for instance, to relieve abdominal pressure. Don't hit the sack right after dinner; wait at least two hours to give postmeal acid levels time to subside. Elevate your upper body while you snooze to prevent acid from creeping upward. An extra pillow won't do the trick, though. Buy an under-the-mattress foam wedge, or slip a four-by-four under the legs at the upper end of your bed. (You may want to nail a couple of jar caps into the wood to keep the bed legs from slipping.)
This is a digestive half-truth. "Stress doesn't increase the amount of acid you reflux, " says Joel Richter, a past president of the American College of Gastroenterology. "But it does increase your perception of it." Richter, of the Cleveland Clinic Foundation, coauthored a 1993 study in which adults diagnosed with severe heartburn were fed pizza (with extra cheese and pepperoni) and Cokes, then placed in various situations designed to be nerve-racking. They competed at computer games, for instance, and were timed doing math problems, all the while vying for a hundred-dollar prize. The volunteers said the stress made their reflux worse, but esophageal monitors showed that the amount of acid washing back up actually diminished during the experiment.
MAYBE YOU'VE CUT DOWN on fat, even sworn off citrus fruits, but draw the line at forsaking coffee and chocolate. Over-the-counter remedies can help if your indulgences occasionally bring suffering. As to whether you need one of the new drugs instead of the more miliar antacids, that depends: Do you nt immediate gratification? Or would rather put up with a little misery for longer payoff? Oldfangled antacids and nouveau H2 blockers will both douse r esophageal flames, but they differ in fast and how long they act.
Most antacids (such as Tums, Alkaeltzer, and Maalox) contain some type ffer that rapidly binds with stomach acid, forming a neutral compound. You still reflux, but the fluid is innocuous. Relief comes in minutes. But as your stomach contents move along into your instines, so do the neutralizing agents. If your stomach produces more acid, symptoms can return. Usually antacids are effective for just an hour or so.
H2 blockers get their name from the fact that they block histamine signals that tell the stomach to produce acid. They cost more than antacids and take longer tp ease symptoms-at least half an hour. (Relief took as long as 90 minutes in one study). But H2 blockers offer their own advantages. They last longe; the makers of Pepcid AC point to a study showing the drug stops acid production for up to nine hours. That means the drugs can effectively deliver a preemptive - strike just pop a pill 30 minutes before you sit down to that bowl of onion soup.
But which blocker should you try? Don't agonize over the choice. The makers of Pepcid AC crow about the drug's endurance, Axid AR is described as preventing heartburn completely, and the manufacturers of Tagamet HB and Zantac 75 make their own claims-but all H2 blockers are virtually identical. "No one has an advantage over the other," says Richter, "regardless of what the drug companies say."
NO. Antacids and over-the-counter NH2 blockers are fine for periodic relief, but gobbling heartburn pills for longer than three weeks is never recommended. (The big exception: You can safely use Tums or another calcium-based antacid as a daily calcium supplement.)
Overuse of some antacids can cause side effects-typically diarrhea or constipation. But what's more important, say gastroenterologists, is that if you suffer heartburn twice a week or more, you need medical attention. It's likely that you have a bona fide disease: gastroeophageal reflux disease, or GERD.
While occasional, "nuisance" heartburn is triggered by a specific food or aCtiVity, GERD doesn't require provocation. In many cases a sufferer has a hiatal hernia or a flaw in the esophageal valve that allows stomach acid to escape frequently. Either way, some damage to the esophagus is almost guaranteed.
The danger in using nonprescription drugs to treat GERD on your own, Richter says, is that they eliminate only some of the acid exposure-enough to quell symptoms but not enough to prevent longterm injury. Regular acid baths cause esophagitis, an inflammation of the esophagus's lining, in about half of all patients. Recurrent bouts of esophagitis can leave the lower esophagus crowded with scar tissue, narrowing the opening to the stomach. Patients with a stricture, as the narrowinl' is called, complain of food sticking in their throats. Usually the food can be forced down with fluids, but in severe cases a doctor actually has to extract the food and reopen the esophagus with a dilator.
Worse, this change in the esophagus's lining can develop into a precancerous condition. Esophageal cancer is relatively rare, but it kills 90 percent of its victims within five years.
Doctors say over-the-counter heartburn drugs are among the safest medications available-that is, unless trying to figure out which kind to get makes your brain implode. Here's how to make sense of those crowded drugstore shelves.
ADVANTAGES: Relatively cheap. Fast-acting-they start to work in a few minutes. Antacids contain aluminum, calcium, magnesium, or sodium, any of which will bind with the acid in your stomach to form neutral, inoffensive compounds.
DRAWBACK: A dose relieves symptoms for only an hour or so.
WHEN TO TAKE THEM: After eating. A premeal antacid is likely to clear out of your stomach before food prompts the release of irritating acid.
ADVANTAGES: The effect lasts; a dose is generally good for four hours. These drugs help some people whose symptoms aren't extinguished by antacids. The "raft" is a layer of foam that forms on top of the stomacifs contents; this protects the esophagus from acid if the valve at the top of the stomach relaxes.
DRAWBACK: They may not work if you lie down.
WHEN TO TAKE THEM: After eating, so that food doesn't destroy the protective foam.
ADVANTAGES: A dose works for at least three hours. You can use them to treat or prevent heartburn. H2 Mockers interfere with histamine, a chemical messenger that tells the stomach to produce acid.
DRAWBACKS: They're relatively expensive, and they take about half an hour to start working.
WHEN TO TAKE THEM: An hour before eating a meal you think might give you heartburn. -TG.
WHAT'S THE BEST TREATMENT FOR GERD?
TINKERING WITH YOUR DIET, headTboard, or wardrobe may minimize symptoms, but to prevent damage to the esophagus, GERD almost always requires serious medication. Prescription-strength H2 blockers were once standard therapy, but increasingly doctors are turning to newer types of drugs. Prescription-only "promotility" agents, such as Propulsid, increase the pace at which the stomach empties, giving acid less of a chance to cause trouble. The drugs also seem to make the valve close more tightly, reducing the amount of reflux that makes it into the esophagus.
For more serious cases many gastroenterologists favor a category of prescription drugs known as proton-pump inhibitors. These are acid-reducers, like H2 blockers, but far more powerful: Blockers interfere with histamine, but that's just one of three chemical messengers that signal cells in the stomach to churn out acid. Proton-pump inhibitors such as Prilosec and Prevacid prevent all three messengers from doing their job, virtually halting acid production. "Before we had proton-pump inhibitors, we had many patients who needed monthly dilations to keep their esophagus open, or else they wouldn't be able to eat," says San Francisco gastroenterologist Kenneth R. McQuaid. "The other drugs just weren't enough."
NOT IF SURGERY sounds like a good option. Going under the knife was once a last resort, but new techniques have made surgery an attractive alternative even for people whose GERD can be treated with medication. Surgeons wrap a portion of the upper stomach around the esophagus to form a collar. When food fills up the patient's stomach, it compresses the esophagus, cinching off reflux. According to the American College of Gastroenterologists, the operation can cure GERD in 90 percent of cases.
The old procedure involved a six- to ten-inch incision, a lot of pain, and a long recovery, says surgeon Garth Ballantyne of St. Luke's Roosevelt Hospital Center in New York City. Today fundoplication (for the fundus, or upper portion of the stomach) is performed with a laparoscope and requires just five tiny incisions. Many of Ballantyne's patients who opt for the procedure simply don't want to take pills for the rest of their lives. "My rule of thumb," he says, "is if a patient's symptoms are relieved by drugs, they're a good candidate for this surgery."
Even relatively minor surgery may sound like pretty radical treatment. But Ballantyne points out that the strongest acid-busting drugs can't always prevent some of the damage done by GERD. For instance, some sufferers have such bad bouts of reflux while sleeping that fluid can back all the way up the esophagus and into the windpipe and lungs, leading to pneumonia. An acid-reducing medication can't avert that problem; it just neutralizes the fluid.
Last year about 20,000 Americans underwent fundoplication-a fivefold increase in less than five years. It's not likely that the blade will ever replace the bottle and the pill in the battle against heartburn. But there's some comfort in knowing that the tools of medicine can douse even the wildest fire within. H
Timothy Gower is a writer living on Cape Cod, Massachusetts