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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Important Things to Know About Indigestion and Heartburn

Roman Bridge of Cordoba (Dr. Noorali Bharwani)
Roman Bridge of Cordoba (Dr. Noorali Bharwani)

Let us start with the word “dyspepsia.” Dyspepsia is a Greek word that means bad or difficult digestion. Some people use the word dyspepsia to mean heartburn.

When a patient says to me, “Doctor, I have dyspepsia or indigestion” then I have to ask more questions. I need to know exactly what the symptoms are. There may be chronic or recurrent pain in the upper abdomen. There may be upper abdominal fullness and feeling full earlier than expected when eating. There may be bloating, belching, nausea, or heartburn.

There is a condition called functional dyspepsia or it used to be called non-ulcer dyspepsia. That means symptoms of dyspepsia are there but there is no pathological finding to account for that. Functional dyspepsia is estimated to affect about 15 per cent of the general population in western countries.

I found an interesting short article in the Canadian Medical Association Journal (CMAJ March 3, 2015) by Sadowski and van Zanten titled “Dyspepsia.”

If the person has alarm symptoms like vomiting, bleeding or anemia, abdominal mass or unintended weight loss, and difficulty swallowing food then he should be referred for an urgent endoscopy of the esophagus, stomach and duodenum.

Endoscopy is the preferred diagnostic modality if alarm symptoms are present. If a person with dyspepsia undergoes endoscopy, the most common endoscopic findings for new cases are reflux esophagitis (40 per cent), and gastric and duodenal ulcers (10 percent). No time should be wasted doing barium studies. Doctors should avoid performing an endoscopy for dyspepsia without alarm symptoms for patients under the age of 55 years.

Patients with alarm symptoms who undergo gastroscopy will have clinically significant peptic ulcer disease in 13 per cent of cases and gastric cancer in four per cent of cases. Because the prevalence of serious abnormalities increases with age, an endoscopy should be considered for those aged 55 years or older with new-onset symptoms.

Upper gastrointestinal barium studies are less accurate than endoscopy and should not be used if alarm symptoms are present.

Patients should not be maintained on long-term PPI (proton pump inhibitors used for treating reflux and peptic ulcers) therapy without an attempt to stop or reduce PPI at least once per year in most patients. Examples of PPI are – Losec, Prevacid and Nexium.

Up to 30 per cent of patients with dyspepsia in a Canadian population were found to be taking non-steroidal anti-inflammatory drugs (NSAIDS) including acetylsalicylic acid (Aspirin). Eliminating the use of NSAIDS or dose reduction is often effective for dyspepsia.

The article suggests that an eight-week trial of once-daily PPI therapy can be considered in patients with reflux-like dyspepsia. Those requiring continuous acid-suppressive therapy for symptom control should use the lowest effective dose and try stopping the treatment at least once per year because of potential adverse effects (e.g. bone fractures and infection with Clostridium difficile) of long-term PPI use. Older adults should use the drugs only for the shortest duration possible.

If your symptoms do not disappear after taking PPI for four to six weeks then PPI should be discontinued and further investigations should be done to rule out serious pathology. Patients with new-onset dyspepsia should be tested for Helicobacter pylori infection. Its prevalence in Canada is about 30 per cent, but declining in younger Canadians.

Finally, take it easy on hurry, worry and curry. That is what one English surgeon advised me many years ago.

Start reading the preview of my book A Doctor's Journey for free on Amazon. Available on Kindle for $2.99!