The Medical Minute: Gastroesophageal reflux disease -- beyond heartburn

By John Messmer
Penn State Family and Community Medicine
Penn State Milton S. Hershey Medical Center
Penn State College of Medicine

About a third of the public has experienced heartburn long enough to consider it an issue, but as many as 10 percent have it daily. Normally food and liquids traveling from the mouth down the esophagus will stay in the stomach. At the lower end of the esophagus, muscles called the lower esophageal sphincter (LES) tighten around it to prevent the stomach contents from moving backward. When stomach contents move up into the esophagus, it is called "reflux" or, more specifically, gastroesophageal reflux. About a third of Americans have it frequently enough to call it gastroesophageal reflux disease or GERD.

While GERD can cause burning in the esophagus, the problem can be more than just a nuisance -- it can lead to damage. The esophagus is not designed to tolerate chronic contact with acid, which can burn it and cause scarring. The scar can contract to make the passage too narrow for food to pass readily. Chronic acid can cause the cells lining the lower esophagus to change and become malignant, particularly in tobacco users.

The stomach has digestive enzymes and sometimes bile present, which can add to the damage. Severe reflux can affect the airway, causing coughing, hoarseness, sore throat and even ear pain. In some cases, the pain from reflux mimics a heart attack.

By middle age, mild reflux is common. Unfortunately, typical American behaviors make it worse. Large meals and obesity are significant contributors. A large meal fills the stomach, increasing pressure and making it easier for food and acid to go up into the esophagus. Excess abdominal fat can increase reflux by causing external pressure against the stomach, much as a pregnant uterus does. Carbonated beverages and mint increase reflux, as do caffeine and some medications and diseases. Lying down after eating increases the risk of reflux.

Occasional heartburn can be treated with antacids, which neutralize the acid present in the stomach. The effect is short-lived, and doses may need to be repeated, but they work quickly.

Histamine-2 (H2) receptor blockers have been around for decades. This class includes cimetidine (Tagamet), ranitidine (Zantac), famotidine (Pepcid) and nizatidine (Axid). All are available over-the-counter. These medications reduce the production of acid, but they take some time to be absorbed and produce their effect. Consequently, they do nothing for heartburn when it happens. At least one, Pepcid Complete, is combined with an antacid to deal with both current and future acid. The effect of H2 blockers lasts about 12 hours.

The most powerful medications are the proton pump inhibitors or PPIs. Omeprazole (Prilosec, Zegerid), esomeprazole (Nexium), pantoprazole (Protonix), lansoprazole (Prevacid) and rabeprazole (Aciphex) are PPIs. Omeprazole is available over-the-counter. These medications reduce acid production very significantly with effects lasting 24 hours or so, but like H2 blockers, they take time to be absorbed and take effect. For those with more than occasional heartburn, a two-week course of a PPI may improve symptoms for a long time.

Of course, the first step in treating GERD is to remove the cause. Even a five- to 10-pound weight loss can reduce symptoms. Smoking cessation is essential to reduce the risk of cancer of the esophagus. Reduction in alcohol consumption and avoidance of mint, carbonated beverages and large meals helps significantly. For chronic GERD, some physicians recommend tilting the bed up at the head so the entire bed runs downhill to counter the tendency for acid to run up the esophagus. Just bending the bed in the middle, as with a hospital bed, can make it worse.

If dietary changes, weight loss and a course of acid suppression do not relieve the symptoms, it's best to have a medical evaluation. When symptoms are persistent or recurrent or there is difficulty swallowing, physicians will typically recommend evaluation by a specialist. A gastroenterologist will examine the stomach and esophagus with an endoscope, a lighted, flexible tube, and, if necessary, take biopsies of any abnormal tissue seen.

In those whose stomachs do not empty efficiently due to medical problems, additional prescription medications can help the stomach empty in the proper direction. In severe cases, GERD is treated surgically by fundoplication. The surgeon wraps the upper part of the stomach around the lower esophagus to do the work of the LES.

With over-the-counter PPIs advertised on TV and in print media, one could take GERD less seriously than it should be. Rather than just taking the popular, advertised treatment options for GERD, affected people should treat what is causing it before they suffer long-term effects.