1 | Heartburn Stomach acid in the wrong place Symptoms and Causes Heartburn is a burning sensation in your chest or throat. What causes it is stomach acid moving into the esophagus where it does not belong. This condition is known as acid reflux or GERD (gastroesophageal reflux disease). The stomach is a remarkable organ that normally produces large amounts of hydrochloric acid and other elements. This gastric acid is much, much stronger than the acid in, for example, lemons or oranges, foods thought of as being highly acidic. Acid volume in the stomach rises when someone thinks about eating food, smells it, and eats it and still goes on hours after a meal is done. A healthy stomach can tolerate being filled with acid, but the esophagus cannot. When acid gets into the esophagus, this is called acid reflux. It happens when the muscular valve that separates the esophagus from the stomach, called the lower esophageal sphincter, is weak and fails to close fully. This failure to close allows acid to migrate upward into the esophagus. The lower esophageal valve is normally tight. Take a moment to tightly bend or flex your right index finger and try to pry it open with your left index finger, and you'll note the power that muscles in a circle have to close tightly. When the valve does not close, acid reflux occurs. In patients with reflux, acid can and does move upward, especially when acid volume is high (after a big, hearty meal) or when a person is lying flat, most often at bedtime. If you've experienced heartburn from acid reflux, you are not alone. This condition bothers many people. When acid gets into the esophagus, it eventually gets pushed back down to the stomach by the muscle contractions of the esophagus. But an unhealthy or injured esophagus cannot clear itself of acid, and this inability gets worse with repeated reflux. In such cases, it takes time for the esophagus to return to health. Reflux treatments, as discussed below, must continue long enough to allow the esophagus to contract normally again and send refluxed acid back where it came from. While treating reflux for a few days or even a few weeks will quickly improve pain, which is good, much longer treatment is needed for the esophagus to regain its usual function. Some patients with reflux experience constant nausea or hoarseness as their only symptom (see Chapter 3, "Nausea and Vomiting"). The severity of symptoms from acid reflux varies greatly from one person to another. The occasional heartburn you feel when lying down after a sizable meal or that awakens you from sleep is usually manageable. However, intense heartburn and other reflux-caused problems such as choking or difficulty with swallowing need careful evaluation by a medical professional. What to Do if You Have Heartburn from Reflux First, don't worry. Acid reflux is treatable. Most patients get temporary and welcome relief from a tablespoon of antacid, a few TUMS®, or some Pepto-Bismol® or milk. Since these remedies are not meant to treat acid reflux fully, however, the symptoms will soon return. Full treatment requires medications that reduce gastric acid production. These are available off the shelf in your pharmacy or by prescription. Over-the-counter forms of these drugs are sometimes at a lower dosage than you may need, so keep in mind that dose is important. Note that higher-dose medications often need prescriptions. Note also that effective treatment takes time, at least six to eight weeks. Pain relief comes first, but esophageal healing is slower. So don't quit treatment early just because you are feeling better. Acid-Reducing Drugs There are two major classes of acid-suppressing drugs: (1) proton pump inhibitors (known as PPIs) such as omeprazole and other PPIs of similar value, and (2) H2 histamine blockers like famotidine. Both classes interrupt stomach acid production, but they differ in how they do this. If you have been prescribed omeprazole or another PPI, this may be the only drug you need to treat your reflux. Most doctors recommend taking PPIs after you wake up from sleep as that is when your stomach is empty. So, take the morning dose 20 to 30 minutes before having any breakfast. An evening dose of a PPI may become necessary if heartburn returns later in the day or evening, but that first dose upon awakening often does the job. H2 histamine blockers work differently but are also effective in suppressing stomach acid secretion. These drugs can be used instead of PPIs. If your heartburn persists or is only somewhat improved with either drug alone, we sometimes recommend that patients take both drugs: the PPI in the morning as described above, and an H2 histamine blocker such as famotidine at bedtime. That combination helps many patients who do not fully improve on just one drug. Please Note: As of this writing, the H2 blocker ranitidine, which was widely prescribed for acid reflux, has at least temporarily been withdrawn from the market. You will not find it at your pharmacy. Famotidine is still available and is equally as effective. Alternative Remedies for Heartburn Diet The other ways you can treat heartburn from reflux are important to know. As mentioned earlier, eating anything prompts the stomach to secrete acid. So, in the two hours before you go to sleep, try not to snack. If you do, try to eat things that do not contain fat. Fatty foods stay in the stomach much longer than vegetables, fruits and grains, so acid production goes on longer. This delay in stomach emptying is not helpful when you are about to lie down for sleep. Also, if you often have heartburn, try not to eat large or fatty meals. Occasional splurging is OK. After all, you are human! If you do, though, remember to not lie flat right after a big meal. By doing so, you can worsen the problem of acid flowing up into the esophagus. Bed Elevation Another "home remedy" for acid reflux that works is putting your entire bed on a slight slant with your head elevated, something I illustrate for patients with a drawn diagram. Bed elevation is helpful because when you lie down flat, the pool of acid in your stomach can easily flow into the esophagus. But with your entire body at a slight angle, simple gravity keeps stomach acid down where it belongs. To elevate the head of the bed, recruit a friend to help you lift the head end about four to five inches (ten to twelve centimeters) off the floor. Then lower it onto blocks or books so the entire bed frame is now at a slight angle. A bed so elevated does not look strange in the room. You won't slide downward, and you and others in bed with you will quickly become accustomed to this minor change in position. This method is so effective in preventing reflux that, even if you have just completed eight weeks of therapy, keep the bed elevated. A further note: bunching up pillows or getting a wedge to elevate your head while sleeping does not work nearly as well as the bed elevation just described. Some Words of Warning Medications of all kinds-pills, capsules, and tablets-have coatings that can injure the esophagus. Unless you have restrictions on water intake, if you have reflux, drink plenty of water or other liquids to wash down all medications. If you are having trouble swallowing, you likely need special care. If such care is not immediately available, it is best to chop food into small pieces before you eat it or make a smoothie that will glide down more easily (see Chapter 2, "Trouble Swallowing"). If your acid reflux is accompanied by swallowing difficulties or if the reflux has been present for many years, the esophagus should be evaluated via endoscopy. In an endoscopy procedure, physicians look directly at the esophagus and stomach with a flexible device called an endoscope. With the scope, they can photograph, biopsy, or completely remove any tissue of concern. In cases of long-term acid reflux, scar tissue can form at the lower esophagus. Long-term reflux can also lead to a condition called Barrett's metaplasia, a tissue change in the lower esophagus that can become tumorous over time in some patients. Such conditions need to be treated using endoscopy, which, among other benefits, can ensure that any narrowing of the esophagus is not due to a tumor. If your voice is hoarse or you have pain around your larynx (the "voice box" that resides in your throat about where your neck and shoulders meet), refluxed acid may be going up into the throat as far as your larynx. In these cases, it is often worthwhile to have an ear, nose, and throat (ENT) specialist inspect your larynx for signs of acid injury. If your heartburn pain doesn't improve a week or so after your reflux treatment begins, consult your prescribing caregiver. The problem you have may not be directly caused by acid. For example, people who have impaired immune functions due to cancer chemotherapy, HIV, diabetes, or other illnesses can experience a fungus infection of the esophagus called candidiasis. Therapy for candidiasis requires a prescription drug to eliminate this fungus. Finally, but by no means an afterthought, large amounts of acid in the throat can enter the lungs, an important concern that should be addressed with your physician, especially if you have had heart or lung disease, a chronic cough, or shortness of breath for any reason. At the same time, you can act immediately to help prevent high-volume acid reflux using the simple...
