By Steven A. Porter, M.D.
Premium Health News Service
5:30 AM EDT, June 26, 2013
Pharmacy shelves are full of medications for reflux "heartburn." Most of us know the symptoms: a burning sensation in the chest with belching, sour stomach fluid coming up into the mouth--or worse yet, awakening suddenly choking on burning acid in the airway. These symptoms are very common, affecting 40 percent of Americans monthly and 18 percent of Americans weekly.
In addition to annoying symptoms, untreated reflux could eventually cause death due to esophageal cancer. One of the most deadly cancers, it currently strikes about 14,000 Americans every year. But the numbers are growing rapidly. Research shows that the increase in reflux and cancer is directly related to the nation's increase in obesity.
There is a correlation between increased weight and heartburn, and another correlation between weight loss and improvement of heartburn symptoms. In 1991, 15 percent of Americans were considered obese and 30 percent were considered overweight. Today 30 percent are obese with 60 percent overweight.
WHAT IS HEARTBURN OR REFLUX?
The stomach normally produces acid to aid in the digestive process. The problem is not the acid itself but when the acid comes up, or refluxes, into the esophagus. To understand the nature of acid reflux it's helpful to understand a little bit of human anatomy.
We are able to breathe because the rib cage and diaphragm function like a bellows. The diaphragm is a sheet of muscle separating the chest cavity from the abdominal cavity. In the middle of this muscle is a hole, or hiatus, that allows the esophagus to join with the stomach. When you inhale, your diaphragm contracts and expands the chest cavity, allowing air to flow into your lungs. As your rib cage expands, it decreases chest pressure and increases abdominal pressure.
Reflux can happen because gases and fluids tend to flow from high-pressure areas, like the abdomen, to low-pressure areas, or the chest. When you inhale, the pressure can force acid up from the stomach into the esophagus and even up into the mouth or airway.
Of course, our bodies are naturally designed to keep this from happening. Acid reflux occurs only when something goes wrong. Factors that allow reflux include:
1. TLESR, or transient lower esophageal sphincter relaxation. The lower esophageal sphincter is a weak ring of muscle that closes off the bottom of the esophagus from the top of the stomach, preventing acid from rising. But sometimes the sphincter relaxes when it shouldn't.
2. Delayed acid clearance. When sleeping, we stop producing saliva, which helps clear acid from the esophagus. Saliva also contains growth factors that heal the esophagus from the damaging effects of acid.
3. Reduced resistance to injury. Once your esophagus or stomach are injured -- for instance, if you have an existing ulcer--the injured tissue loses its protective defenses and is much more susceptible to further injury.
4. Delayed stomach emptying. Food and acid can sometimes sit in the stomach longer than usual.
5. Sleep apnea. The partial blockage of your airway can cause your chest to expand harder than normal. This pulls more acid into your esophagus.
6. Hiatal hernia. This condition occurs when a portion of your stomach protrudes into your chest cavity through the hiatus. It forces the lower esophageal sphincter open and basically brings the food and acid up into your chest.
In the long term, acid reflux can lead to ulceration or stricturing (narrowing) of the esophagus, which makes it difficult to swallow. It can also lead to Barrett's esophagus, a mutation in the lower esophageal tissue that can eventually develop into esophageal cancer.
Cigarette smoke and alcohol, especially in combination, can worsen esophageal injuries. The theory is that the esophagus is protected from toxins in cigarette smoke by a mucus lining, as well as the swallowing of saliva, which washes acid out of the esophagus. Alcohol dissolves the mucus layer and also dissolves the smoke toxins so they are absorbed directly through the esophageal surface. If you have acid reflux, smoking and drinking can greatly increase your risk of complications, including the development of esophageal cancer.
If you have acid reflux, avoid the following:
1. Eating large volumes of food
2. Eating less than three hours before bedtime
3. Caffeine, including coffee and soft drinks
4. Liquor, including wine and beer
5. Citrus, tomato, and cranberry fruits and juices
6. Ice cream or milkshakes
7. Chocolate (one of the worst offenders)
8. Sour cream
9. High-fat desserts
10. Peppermint (one of the most potent esophageal sphincter relaxers of all! Avoid those after-dinner mints)
11. Wearing overly tight clothing.
HOW IS REFLUX DIAGNOSED?
Your doctor may suspect reflux based on your symptoms, and will typically confirm the diagnosis with an upper endoscopy, especially if any red-flag symptoms are present. These flags may include:
1. Difficult or uncomfortable swallowing
2. Unexpected weight loss
3. Vomiting blood or material that looks like coffee grounds
4. Black, tarry stools
An onset of symptoms after age 50
A sudden disappearance of reflux symptoms without any change in lifestyle, body weight or medication may suggest the development of Barrett's esophagus--a mutation that will protect you against reflux but can lead to cancer of the esophagus.
The antacid aisle at the drug store can be confusing. There are dozens of options, which offer different results, and it's important to have a basic understanding of how they work and what can be expected of each type.
--Acid neutralizers, such as Tums, Rolaids, Alka-Seltzer, Maalox and milk of magnesia. These medications work by neutralizing the acid already produced in the stomach and are largely available over the counter. They can be effective for occasional symptomatic reflux. If you have other medical conditions--especially kidney disease--use caution with over-the-counter preparations containing calcium magnesium or phosphate. It's also important to know that Alka-Seltzer contains aspirin. For acid reflux, use the Alka-Seltzer Heartburn preparation, which does not contain aspirin.
--H2 blockers, or histamine blockers, such as Pepcid, Zantac, Tagamet and Axid. These medications work by blocking much of the acid produced in the stomach. They are available in both over-the-counter and prescription strength. H2 blockers are more effective for frequent heartburn treatment and for healing injury to the esophagus than the acid-neutralizing medications.
--Proton pump inhibitors (PPIs), such as prescription-strength Prilosec, Nexium, Aciphex, Protonix, Zegerid, Prevacid and Kapidex. They block the final common pathway of acid production in the stomach and are the most effective for the healing and maintenance of symptoms. Prilosec has an over-the-counter option but it's not time-released and therefore not as effective as the prescription strength. Most of these medications should NOT be taken with Plavix, an antiplatelet agent for the prevention of heart attack or stroke. PPIs may interfere with the effect of Plavix. If you take Plavix and are on a reflux medicine, check with your doctor or pharmacist to be sure it's safe.
If you want to avoid taking prescription medication for acid reflux--or if you've tried it and your reflux is still a problem--you might consider the following treatments:
1. Surgery can tighten the junction of the stomach and the esophagus.
2. Lifestyle modification, primarily weight loss, can have dramatic results. But even if you don't have a lot of weight to lose, eating smaller meals and going to sleep with an empty stomach can help.
3. Elevating the head of the bed a few inches with wooden blocks can make a difference. Let gravity help you.
I hope you now have a good idea of what acid reflux is, how it develops and the possible treatment and lifestyle options that can help alleviate its uncomfortable symptoms. This information may help prevent potential complications that can result from untreated, long-term exposure of the esophagus to acid. If you have frequent symptoms--especially a red-flag symptom--it might be worthwhile to see a castroenterologist near you.
(Dr. Steven A. Porter is recognized as one of the nation's leading gastroenterologists, specializing in colonoscopy, upper endoscopy, pancreatic and biliary issues. He and his physician assistant, Phil Merrill, provide many other GI services, including treatment for reflux, irritable bowel, Crohn's, colitis and liver and bile duct disorders. Dr. Porter practices in Ogden, Utah.)
(WhatDoctorsKnow is a magazine devoted to up-to-the minute information on health issues from physicians, major hospitals and clinics, universities and health care agencies across the U.S. Online at http://www.whatdoctorsknow.com.)
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