Uncontrolled Heartburn Leads to Serious Complications

Aga Khan Musoleum in Aswan, Egypt. (Dr. Noorali Bharwani)
Aga Khan Musoleum in Aswan, Egypt. (Dr. Noorali Bharwani)

About 10 to 20 per cent of the population has heartburn (gastroesophageal reflux disease – GERD).

Excessive reflux of acidic, often with alkaline bile salt and duodenal contents, results in a multitude of symptoms for the patient including heartburn, regurgitation, cough, and dysphagia.

There are also associated complications of reflux including erosive esophagitis, Barrett’s esophagus (a pre-malignant condition), stricture and cancer of the esophagus.

Your risk of heartburn and inflammation of the esophagus (esophagitis) increase if you have hiatal hernia, if you smoke, if you are pregnant, if you have scleroderma, or drink excessive alcohol. You should avoid food that’s acidic or high in fat – like citrus fruits, tomatoes, onions, chocolate, coffee, cheese, and peppermint. Spicy foods or large meals can also cause heartburn.

You shouldn’t worry about occasional heartburn. It is quite common. But frequent heartburn which does not respond to increased medications should be investigated. It is called refractory gastroesophageal reflux disease. Weight loss and difficulty swallowing are other red flags. Investigations should be carried out to see if you have complications like Barrett’s esophagus (a pre-malignant condition), strictures, esophageal ulcer, or bleeding.

Diagnostic tests required are as follows:

  • Upper endoscopy with biopsies – also known as gastroscopy (scope test) to check for infection, inflammation, ulcers or cancer. This is the first step in the diagnostic and therapeutic process.
  • Ambulatory acid (pH) probe test. A monitor is placed in your esophagus to identify when, and for how long, stomach acid regurgitates.
  • Esophageal manometry. This test measures the rhythmic muscle contractions in your esophagus when you swallow. Esophageal manometry also measures the coordination and force exerted by the muscles of your esophagus.
  • Barium x-ray of your upper digestive system.

Management of GERD

Common questions that arise regarding management of GERD include which medications are most effective with no side effects, when surgery may be indicated, which patients should be screened for Barrett’s esophagus and helicobacter pylori infection.

There are four primary treatment goals: 1. relief of symptoms, 2. prevention of relapse, 3. healing of inflamed esophagus, and 4. prevention of complications of esophagitis.

To start with, we should attempt to suppress gastric acid production and reflux into the esophagus. This is done by the use of lifestyle modifications (e.g., elevating the head of the bed, modifying the size and composition of meals) and use of appropriate medications.

Uncomplicated reflux can be managed with antacids that neutralize stomach acid. It may provide some relief but will not heal inflamed esophagus. Overuse of some antacids can cause side effects, such as diarrhea or sometimes kidney problems. In the absence of alarm symptoms, endoscopy is not necessary to make an initial diagnosis of GERD.

Persistent heartburn will require medications to reduce acid production. These medications (H-2-receptor blockers) include cimetidine (Tagamet HB), famotidine (Pepcid AC) and nizatidine (Axid AR).

Next line of management will be to use medications that block acid production and heal the esophagus. These medications – known as proton pump inhibitors (PPI) – are stronger acid blockers than H-2-receptor blockers and allow time for damaged esophageal tissue to heal. Examples include lansoprazole (Prevacid 24 HR) and omeprazole. PPI should be taken 30 to 60 minutes before the first meal. PPIs are the most effective medical therapy, and all PPIs provide similar relief of GERD symptoms.

It should be remembered that two common types of GERD medicines (H-2 receptor blockers and PPI) have been associated with B-12 deficiency to varying degrees. Also, there is a risk of hip fractures. With either type of medication, the risk of B-12 deficiency was significantly increased when taken daily for two years or more.

If medical treatment fails then, one should consider surgical options. Anti-reflux operations are aimed at creating an effective barrier to reflux at the gastroesophageal junction There are various types of anti-reflux operations that are successful. Laparoscopic fundoplication is the gold standard for surgical treatment of severe GERD and results in approximately 95 per cent patient satisfaction (World J Gastrointest Surg. 2016 Jan 27).

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Control heartburn and acid reflux.

Calgary, Alberta. (Dr. Noorali Bharwani)
Calgary, Alberta. (Dr. Noorali Bharwani)

As you may know, heartburn has nothing to do with your heart. Heartburn is a symptom of acid reflux from your stomach to the esophagus.

Heartburn is a common gastric complaint. For example, in the U.S. it affects more than 60 million people each month. Yes, each month. When does it become a disease? When the reflux symptoms occur frequently. Then it is called gastroesophageal reflux disease (GERD). If not treated then it gets complicated.

Distinguishing between heartburn, acid reflux, and GERD may be hard, because they may all feel the same. However, understanding the differences can help a person find the right treatment. Difference lies in the severity and frequency of the symptoms and the damage inflicted by the acid to the esophagus and lungs. Yes, it can damage your lungs.

Reflux can also occur in infants. Infant reflux occurs when food refluxes from a baby’s stomach, causing the baby to spit up. This is rarely serious and becomes less common as a baby gets older. It’s unusual for infant reflux to continue after age 18 months.

Reflux in adults is fairly common. In 2005, a systematic review of population-based studies found the prevalence of reflux to be 10 to 20 per cent in Europe and North America and less than five per cent in East Asia. If reflux is not controlled then the acid will damage the esophagus causing inflammation, narrowing, ulcers and bleeding.

Managing early stage of heartburn and reflux

In early stages if occasional reflux is the only symptom then you can take care of it by simple life style changes: eat small meals, avoid any food that gives you heartburn, avoid big spicy meal, do not lie down after eating, do not smoke or drink alcohol, lose weight and use antacid, like Rolaids or Tums.

Managing late stage of heartburn and reflux

If measures like life style changes and antacids do not help then there are medications called H-2-receptor blockers and proton pump inhibitors (PPI) that can be tried.

H-2 receptor blockers

These medications reduce the production of acid in the stomach. H-2-receptor blockers include cimetidine (Tagamet HB), famotidine (Pepcid AC), nizatidine (Axid AR) and ranitidine (Zantac). H-2-receptor blockers don’t act as quickly as antacids, but they provide longer relief and may decrease acid production from the stomach for up to 12 hours.

Proton pump inhibitors (PPI)

These pills block acid production and heal the esophagus. They are stronger acid blockers than H-2-receptor blockers and allow time for damaged esophageal tissue to heal. Examples include lansoprazole (Prevacid 24 HR) and omeprazole.

According to Choosing Wisely (2017 Consumer Reports prepared in cooperation with the American Gastroenterological Association), in most cases, you don’t need a PPI for heartburn. More than half of the people who take PPIs probably do not need them.

You can get relief from a less powerful drug. And when you do need a PPI, you should take the lowest dose for as short a time as possible. Preferably for less than one year. Although generally well-tolerated, these medications might cause diarrhea, headache, nausea and vitamin B-12 deficiency. If you take it for more than a year then the risk of complications include: fractures, kidney problems, heart attack, dementia, pneumonia and colitis.

While you are being treated with different pills, you will probably undergo investigations like upper GI endoscopy, ambulatory acid (pH) probe test, esophageal manometry and x-ray of your upper digestive system. If indicated, your specialist will consider you for a surgical procedure.

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Medical Management of Heartburn can be Challenging

An American Robin at Echo Dale Regional Park in Medicine Hat, Alberta. (Dr. Noorali Bharwani)
An American Robin at Echo Dale Regional Park in Medicine Hat, Alberta. (Dr. Noorali Bharwani)

More than one-third of the population has symptoms of heartburn secondary to gastro-esophageal reflux disease (GERD), with about one-tenth afflicted daily. Infrequent heartburn is usually without serious consequences, but chronic or frequent heartburn (recurring more than twice per week) can have severe consequences.

Here are some points to remember to prevent complications secondary to reflux:

  1. Lifestyle modifications may or may not help. But it is worth trying. That means try and avoid stressful situations and learn to sleep well.
  2. Weight loss has been shown to be beneficial for individuals with recent weight gain or those with a BMI over 25.
  3. Elevation of the head of the bed and avoidance of late evening meals, particularly with high fat content, has shown to be beneficial for individuals with nocturnal symptoms or sleep disturbance.
  4. Avoid food that trigger heartburn such as chocolate, caffeine, citrus foods, spicy foods, carbonated beverages, etc., has been shown to be beneficial only if an individual can identify a specific trigger.

If a person has classical symptoms of GERD not relieved by conservative measures then it is worth trying a trial of medications called proton pump inhibitors (PPIs). There are several medications in this group and they all have very similar effect in terms of symptom relief or healing of erosive esophagitis (inflamed esophagus).

Some examples of PPI are: omeprazole (Losec), lansoprazole (Prevacid), pantoprazole (Tecta), esomeprazole (Nexium).

The PPI should be taken once a day, usually 30-60 minutes before the first meal of the day. The pills should be tried for a month or two to see if there is any relief of symptoms before ordering invasive investigations. If there is symptom relief then the patient can be put on maintenance therapy using the lowest effective dose, which could include on-demand therapy.

Some patients may have side effects from these medications such as headache, rash, diarrhea or constipation, nausea or abdominal pain. Dose reduction or change of pill may help.

If the PPI agents do not help then further investigation should be undertaken to make a diagnosis and check for complications such as acute inflammation or malignancy.

PPI has long-term side effects such as vitamin B12 deficiency, increased risk of infection, such as colitis with Clostridium difficile, warns Health Canada advisory issued in February 2012. They also warn that the high rate of seniors on PPIs raises worries about C. difficile outbreaks in hospitals and nursing homes.

C. difficile is a bacteria capable of causing life-threatening cases of diarrhea (10 bowel movements a day) and conditions like colitis.

By lowering stomach acid levels, PPIs might affect the body’s absorption of calcium, which in turn could lead to osteoporosis and fractures. Researchers found a link between long-term use of PPIs and hip fractures. Their results also suggested that the risk increased the longer people were taking PPIs.

If you suffer from GERD then try conservative measures such as: lifestyle changes, weight loss and eat smart by avoiding foods that bother your stomach. If you need to use PPI then try lower dose and short duration of treatment.

Finally, my British teacher used to advise his patients to avoid hurry, worry and curry!

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Heartburn is the Most Common Gastric and Intestinal Symptom Seen by Family Physicians

Looking for something deer? (Dr. Noorali Bharwani)
Looking for something deer? (Dr. Noorali Bharwani)

Heartburn is due to the reflux of stomach acid and food into the esophagus, the throat, or the lungs. It is the most common gastric and intestinal disorder seen by family physicians. The condition is also known as gastroesophageal reflux disease (GERD).

Occasionally, patients with gastric reflux may present with chest pain. It is not a good idea to tell a patient with a history of reflux that the chest pain is due to GERD. It is imperative that the patient should be first investigated for a heart condition. If that is normal then the patient should be investigated for GERD.

Some patients with GERD may present with symptoms of chronic cough, asthma and laryngitis. Other atypical symptoms include dyspepsia, upper abdominal pain, nausea, bloating and belching, though these are symptoms also seen in other conditions. So each patient should be evaluated carefully.

Most patients with GERD are in the age group 70 to 79 years. Lowest incidence of GERD is in the age group 20 to 29. As the person ages the frequency and duration of esophageal acid exposure, and severity of esophagitis (inflammation of the esophagus) increases.

There are many reasons why GERD symptoms get worse. Some medications and posture may aggravate the symptoms. Obesity is a major risk factor for acid damage to the esophagus. Patient should be immediately investigated with endoscopy (scope test) if there is a history of weight loss, difficult or painful swallowing or there is presence of anemia.

Endoscopic examine of the esophagus, stomach and duodenum is a good diagnostic test for patients with a history of reflux. Patients with uncomplicated reflux may not need a scope test unless the diagnosis is not clear. But patients with complicated reflux should be scoped.

Treatment of reflux is mostly medical. Start with lifestyle changes. Avoid food that gives you heartburn. Lose some weight. Weight loss has been shown to be beneficial in patients who are overweight.

Elevation of the head of the bed and avoidance of late evening meals, particularly with high fat content, has shown to be beneficial for individuals with nocturnal symptoms or sleep disturbance.

Avoidance of food triggers such as chocolate, caffeine, citrus foods, spicy foods, carbonated beverages, etc., has been shown to be beneficial only if an individual can identify a specific trigger.

If a patient presents with typical symptoms of GERD then a trial of medication is indicated. Most commonly used pills fall under the category of proton pump inhibitors (PPI). Some examples of PPI are pantoprazole (Tecta, Pantoloc), omeprazole (Losec), lansoprazole (Prevacid), rabeprazole (Pariet). There are no clear differences between PPIs in terms of symptom relief or healing of inflamed esophagus (erosive esophagitis).

For best effect, PPI should be taken 30-60 minutes before the first meal of the day. Symptoms more likely to respond to PPI therapy include upper abdominal pain, early sense of fullness and belching. Antacids have a relatively short duration of action and their use can be associated with significant side effects.

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