How do you envision your stomach? Is it a calm place, quietly digesting a bowl of warm chicken soup? Or a dark vat filled with powerful acids capable of attacking the toughest piece of meat and turning it into liquid? If you’ve ever suffered from gastroesophageal reflux, you probably realize that the second image is closer to reality.
The human stomach has powerful acids capable of digesting most any food that passes into it. Once the food goes down the esophagus and reaches the stomach, with its strong lining, a muscle closes tightly above it (called the lower esophageal sphincter muscle). With the lower esophageal sphincter closed, stomach acids can do their tough job without interruption.
Reflux occurs when these stomach acids back up into the esophagus and cause damage. Acid on the lining of the esophagus creates an uncomfortable burning sensation, known as heartburn. Sometimes reflux causes a regurgitation of a small amount of the sour-tasting liquid into the mouth.
Nearly everyone suffers from heartburn at one time or another. About 20 percent of Americans have episodes at least once a week. Simple heartburn can usually be treated by self-help measures. If you have been using over-the-counter remedies for two weeks or more, you should see a doctor. Longer and more frequent episodes of heartburn may indicate a more serious problem known as gastroesophageal reflux disorder (GERD).
Since the lining of the esophagus is not made to withstand the assault of stomach acids, individuals with chronic heartburn eventually develop other symptoms such as a hoarse voice, sore throat, wheezing and difficulty swallowing. The most serious complication of GERD is Barrett’s esophagus–severe damage to the lining of the food tube that doctors believe may be a precursor of esophageal cancer.
Reasons for Reflux
Reasons that stomach acids wash up into the esophagus are numerous. A common problem is simply that the stomach is overly full. Sometimes the production of stomach acid is increased. A hiatal hernia–a break in the muscle wall that allows a portion of the stomach to protrude above the diaphragm–may also be involved.
In many cases, the sphincter muscle becomes weak or overly relaxed. Cigarette smoking, chocolate, peppermint, fatty foods, coffee and alcoholic beverages can relax or weaken the sphincter muscle. When the stomach is full and the sphincter muscle is weak, the esophagus is vulnerable.
Added pressure to the sphincter muscle might also come from pregnancy, obesity, tight clothes, coughing, sneezing or sudden physical exertion. The oldest, quickest way to douse the fire of heartburn is to take an antacid such as Tums, Rolaids, Maalox, Gaviscon or Mylanta. All are inexpensive and readily available without a prescription. Your great grandmother may have kept a roll of Tums in her purse.
Antacids neutralize the acid–usually an effective remedy for occasional or mild heartburn. But long-term use of antacids can lead to side effects such as diarrhea and a change in the way the body breaks down and uses calcium. A second over-the-counter option is the histamine2 or H2 blocker. They offer a more effective option since they reduce the production of stomach acid instead of merely neutralizing it. They take longer to work, however, so they are sometimes prescribed in conjunction with antacids.
H2 blockers include cimetidine (Tagamet HB), famotidine (Pepcid AC), nizatidine (Axid AR) and ranitidine (Zantac 75). All are available over the counter or in stronger prescription-strength formulations. When prescribed for four to six weeks, they are usually effective for mild to moderate cases of gastroesophageal reflux. Anyone using these agents should check with the pharmacist about possible drug interactions with prescription items they may be taking.
Other drugs which might occasionally be prescribed include those designed to strengthen the sphincter and speed the process of emptying the stomach from below. These agents, known as prokinetic agents, include bethanechol (Urecholine) and metoclopramide (Reglan).
Since they were introduced, proton pump inhibitors such as omeprazole (Prilosec), lansoprazole (Prevacid) pantoprazole (Protonix), rabeprazole (Aciphex) and esomeprazole (Nexium) have become a mainstay of treatment. They are particularly effective for the more difficult cases. These drugs block virtually all acid secretion, and they are effective for nearly all patients.
Medications alone may never cure the discomfort of GERD. Lifestyle changes are a very important part of treatment as well. Some of these recommended changes include:
• Avoid or minimize intake of foods that relax the sphincter or increase pressure. Some examples include peppermint, chocolate, fatty foods, coffee, and alcohol.
• Stop smoking.
• Limit high-acid foods during flair-ups. Some high acid foods include tomatoes, peppers and citrus fruits that can irritate the lining.
• Lose weight.
• Wear loose clothing.
• Refrain from eating three hours before bedtime and avoid exercise or bending over right after meals.
• Replace large meals with several smaller ones.
• Raise the head of your bed six to eight inches.
Surgery is rarely needed for GERD, and its effectiveness has been questioned. Proton pump inhibitor therapy and lifestyle changes bring relief to most patients; when they don’t, doctors use a variety of tests and procedures before proceeding. Eating is one of life’s great pleasures. With effective treatments for heartburn and GERD now readily available, there’s no reason anyone should have to suffer a fiery aftermath.
Michelle Herbert Thomas, PharmD, CDE
Clinical Director
Richmond Apothecaries, Inc.
