Heartburn Esophageal Reflux and GERD
Heartburn Esophageal Reflux and GERD
Heartburn Esophageal Reflux and GERD
Heartburn Esophageal Reflux and GERD
Heartburn is that uncomfortable, indigestive-like, burning sensation you feel, sometimes after eating, sometimes at night, which is felt in the stomach and chest areas. It doesn't have the heart "alarm" symptoms like pain with exertion that radiates to the shoulder, arm, or jaw, shortness of breath, or the feeling that an elephant is sitting on your chest. It actually has to do with the esophagus literally being burned with stomach acid. This is a very uncomfortable situation which tends to occur over and over, especially with late night or irregular eating habits. If left untreated it tends to get worse, and can have complications ranging from minor to very serious.
Let's talk about the regular interaction of the esophagus with the stomach. There is a muscular ring at the bottom of the esophagus called the upper gastric sphincter. It opens to admit food and fluids to the stomach, and closes to prevent them from going back up the esophagus. This is good because the esophagus doesn't have the tough, acid-resistant lining that the stomach does. In fact if acid gets in the esophagus it literally starts to digest the lining, leading to a condition called erosive esophagitis. There are things which can affect the upper gastric sphincter. One is a neuropathy which is the nerve damage of diabetes. Another is hiatal hernia where the sphincter is in the chest and doesn't function correctly. Sometimes it doesn't work as well with older age. Sometimes the lower gastric sphincter at the outlet of the stomach doesn't open normally, as with a duodenal ulcer, and this causes back pressure on the upper gastric sphincter. When acid stomach contents go back up the esophagus, this is called reflux, hence, the condition is often referred to as reflux esophagitis.
Now let's turn our attention to the production of this acid in the stomach. The parietal cells of the stomach lining produce acid through specialized structures called cannuliculae. The actual biochemical process is called the proton pump mechanism. It releases hydrogen in its proton form to acidify the gastric juice to a pH of between 1 and 2 in children and 3-5 in adults. The acid is later neutralized in the small intestine. The normal body pH is slightly alkaline at 7.4, so it's no wonder that normal tissue is damaged by the secreted acid.
The main treatment for esophagitis is protein pump inhibitors like omperazole. These reduce the acidity of the stomach secretions. They do not work like antacids which directly reduce stomach acids. The PPI's (Proton Pump Inhibitors) are absorbed into the blood by way of the small intestine and reach the parietal cells by way of the bloodstream some time later. This is why you can't say, "I have heartburn: I think I'll take an omperazole." They don't work that way. You have to take them ahead of a meal, probably by at least an hour or so. They are usually enteric-coated so they don't become activated until they reach the upper small bowel. There are some new PPI's (Proton Pump Inhibitors) which are not enteric-coated and are combined with sodium bicarbonate. They do start to work a lot faster right in the stomach and might be taken after a meal.
Now let's talk a little bit about why reflux esophagitis, or heartburn, is becoming more frequent in the population. One reason is the epidemic of obesity. Over 60% of Americans meet the criteria for obesity, and it doesn't seem to be getting better. The type of obesity (abdominal) which surrounds the intestines causes increased pressure within the stomach and overwhelms the upper gastric sphincter. Consequently, one adjunctive medical treatment for reflux esophagitis is weight loss. A second factor causing increased reflux is the aging population. The incidence of reflux increases with each decade of aging. The reason for this is not clear except that all bodily functions seem to fall off with age. A third factor might be the irregular eating habits of our society with lots of in-between meal snacks. Another factor might be our diet itself, though dietary treatment of esophagitis alone hasn't proven very effective.
We do have an excellent treatment for heartburn in the PPI's. One reason patients may have continuing symptoms is that they don't know how to take these medicines. They take them, then skip a few days, then take them when they have heartburn. As we alluded to before, this will lead to ineffective results.
One side note is that heartburn occurs at night in up to 80% of patients. This is why we used to tell patients to elevate the heads of their beds. The problem with night time heartburn is that it can seriously interfere with normal sleep patterns, whether the patient is aware of this or not. The heartburn patient often complains of daytime sleepiness and decreased productivity as a result. Sometimes getting the patient to take the PPI correctly alleviates the problem; sometimes he might have to be placed on twice daily PPI's or take supplementary medicines like antacids.
The occurrence of complications was mentioned. Certainly chronic heartburn and sleep abnormalities fall into this category. A more serious complication is erosive esophagitis leading to cancer of the esophagus. This type of cancer is increasing in direct proportion to the incidence of esophagitis. It is a difficult cancer to treat, and its possible presence has to be kept in mind with esophageal symptoms. If these symptoms are persistent the patient will probably need endoscopy where the physician directly inspects, and biopsies if necessary, the lining of the esophagus.
So, check with your doctor if you keep having heartburn. Keep in mind the things which aggravate reflux esophagitis like obesity. Ask a lot of questions, and learn to take your medicines properly by understanding how and why they work. Most cases of heartburn can be controlled with the proper combination of available treatments.
John Drew Laurusonis M.D.
Doctors Medical Center
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