GERD: Putting Out the Fire of Heartburn-- Paulo Pacheco, MD-- 11/25/03
By Paulo Pacheco
Chronic heartburn cannot only cause daily discomfort, but left untreated it can also lead to more serious problems. Luckily, there are many treatments, from drugs to self-care to surgery, but what really works, and what is best for you? Gastroenterologist Paulo Pacheco, MD, co-author of Living With Chronic Heartburn, answered these questions and more.
The opinions expressed herein are the guest's alone and have not been reviewed by a WebMD physician. If you have questions about your health, you should consult your personal physician. This event is meant for informational purposes only.
Moderator: Dr. Pacheco, we've seen plenty of news over the last few years about the rise in obesity and its correlation to diabetes, heart disease, and high blood pressure. Are GERD and other related problems also on the rise as a result of our collective weight gain?
Pacheco: Yes, absolutely. Obesity has a multitude of potential problems associated with it, one of them being acid reflux. There is a well-known correlation between obesity and heartburn. The pressure applied to the abdominal wall from obesity actually places pressure upon the stomach and thereby causes the normal acid contents of the stomach to reflux upward into the esophagus, which is normally free of any acid. When the acid contacts the esophagus (more common in obesity) patients suffer from chest discomfort, aka heartburn.
As we see the problem of obesity growing in the U.S., we have subsequently found a greater recognition of problematic heartburn in the U.S. In fact, anywhere from 25 to 40 million Americans suffer from heartburn at least weekly. One of the best primary treatments for heartburn sufferers is a weight loss plan and many patients have markedly improved symptoms with weight loss.
Moderator: Does exercise help alleviate symptoms? Or does it "stir" things up and make it worse?
Pacheco: This is a great question and a very common one. Basically there are two perspectives on exercise with heartburn. Although there is little scientific data to suggest exercise either improves or worsens heartburn, there is clearly an association with worsening heartburn in patients who have extreme exercise, such as marathon runners, high-impact aerobic exercise, and heavy weight-bearing, such as squatting or bearing down on the abdominal wall. This can occur even on an empty stomach, although heartburn symptoms are much worse in these patients if they have eaten within two to three hours of this type of activity.
On the contrary, exercise that is light and paced, such as stationary bicycle exercises or light treadmill exercises, as well as yoga and light weight lifting, are extremely helpful in heartburn patients, as these exercises allow for weight loss over time. The overall sense of well-being gained from light exercise, with its associated (hopefully) weight loss, makes it a part of my normal recommendations in heartburn patients. I have found clinically that light exercise is a very good therapeutic modality in patients with heartburn, and most patients alleviate their symptoms.
In my recently published book, Living with Chronic Heartburn, I have specific chapters dedicated to weight loss and exercise, with very specific recommendations about this. Obviously, as I'm sure we will discuss in future questions, diet is also a very important factor in symptom relief.
Member question: Can stomach pain give you the same symptoms as a heart attack?
Pacheco: Yes. One of the most important factors in the evaluation of stomach pain is whether or not this discomfort is gastrointestinal in origin. In particular heartburn or gastritis, which although typically benign diseases, can be mistaken for much more serious problems, such as a heart attack, angina, or cardiac ischemia, which are all potentially ominous and life-threatening forms of abdominal or chest pain. The most important part of the initial evaluation of such pain should result in an electrocardiogram (EKG) to clarify and rule out cardiac disease or a potential heart attack.
Any patient with such pain that has not been evaluated by any physician (cardiologist or gastroenterologist) should certainly see their doctor immediately, particularly if the pain is associated with shortness of breath, dizziness, light headedness, or arm pain. These patients should go to the nearest emergency room, if they could not see their physician immediately.
Once a cardiac evaluation is performed and a doctor has ensured you or the patient that this is not a heart condition, then a referral to a gastroenterologist such as myself would be a good way to start the education on heartburn treatment.
It's important to note that most patients with chest or abdominal pain who do not have cardiac problems upon evaluation typically have either acid reflux or gastritis as a cause for this pain. Heartburn, the most common cause of chest pain, is a benign condition; however, persistent or chronic symptoms can lead to serious problems in the future and therefore these patients should seek the attention of a gastroenterologist.
Member question: My GERD is so bad that even water will give me heartburn. I've tried all kinds of prescription meds. They work for a while and then they will have no benefit to me. I sleep with my head elevated, no tight clothing, and try to eat the correct foods. What would you suggest next for me?
Pacheco: It seems as though you are already fairly well educated, if not extremely well educated, in the subject of heartburn, and your approach thus far has been on target. Wearing tight-fitting clothing clearly worsens heartburn by placing pressure on the stomach inducing the acid reflux.
Although you have even placed your head of the bed up high, which can often help most patients, diet is the most important way to reduce the symptoms. The major inducers of heartburn are:
In addition, large meals, specifically the typical American habit of three meals per day can also induce reflux because the large volume of food in the stomach not only dilates the stomach, but it also expands the junction between the esophagus and the stomach. A small valve called the lower esophageal sphincter typically protects us from acid reflux into the esophagus and many patients with heartburn have already a weakness in this valve. By eating large meals, this valve further allows for worsened reflux, given the distention from the meal.
If you are overweight that is another area that you should focus on and particularly even consider a short-term (one to three months) investment in a strict weight-training/weight loss regimen should you or any other patient have a problem losing weight.
Some patients, and possibly you, have lost weight, eat perfectly healthy diets that do not induce reflux, and still suffer from the symptoms. This category of patient is a much smaller percentage, which you may fall under. Patients like this may require long-term medicine therapy. The medicines are typically prescription medicines and vary in doses. I typically prescribe these medicines in patients suffering, as you have, from this condition, and I help them focus on diet and weight loss.
If success is not met, then the options are two: the first is continued long-term use of acid reducing medicines, at possibly higher than typically prescribed doses. This should certainly be followed along with a specialist such as myself in this area to supervise you throughout the treatment process. The second option would be surgery, and the success with surgery, although not 100%, can be quite good, in the range of 65 to 70% (depending on the study, some studies suggest better response than others).
I typically reserve surgery as an option in my patients until I have helped the patient work on all the issues we have discussed. However, surgery, in particular what is called a nissen fundoplication, is the surgical treatment of choice in such patients. This surgery is done laparoscopically and usually requires only a one- to two-day hospitalization, with no major surgical scars or complications. Despite the rather safe profile in such surgeries, we obviously try to avoid this unless all options have failed. If you have been unsuccessful in all my prior recommendations and you still suffer from overwhelming heartburn, you should certainly discuss this potential surgical option with your physician.
Member question: With all of the holiday parties starting, I'm concerned about my husband. He has a pretty good handle on his heartburn, but the food and drinks at parties may cause problems. Help!
Pacheco: You may need to politely, with a smile on your face, stand beside him and coach him a bit on when to stop overindulging himself on the finer things surrounding holidays. The fact is that most patients around Thanksgiving or the other holidays eat beyond the acceptable amount of fat and, unfortunately, this often leads to horrible reflux in even those who do not typically experience it.
I typically suggest to people like you or your husband to think strongly about those one or two items that you love on the table that you keep going back to, knowing well that the result will be a tough night in bed. For some these may be cookies; for others this may be wine; for others this may be sweet potatoes with a lot of butter; for others this may be chocolate. The best advice I would give you would be to take one or two samplings rather than eight or 10, and this reduction in consumption will result in a better night at home.
It is understandable and acceptable to enjoy foods that may induce reflux for this one-day occasion, however, moderation, particularly in those items that you may eat excessively, would be the most important way to minimize the after effects. Believe it or not, having a spouse or partner aware of this, quietly coaching, in my view, is a good idea. If the patient knows they have heartburn, even before such events taking an extra dose of heartburn relief medicine before such a dinner would be advisable.
Member question: My husband had been taking Prilosec, and now that it is over the counter he has tried it and it is not working. How can they say it is the same when it isn't the same? Now our insurance will not pay for prescription Prilosec. What is a person to do?
Pacheco: This is an extremely difficult dilemma in the current environment of health care, particularly with regard to prescription medicines. Prilosec, until very recently, was made by one company, but since it recently lost its patent this has allowed for many other companies to make this medicine and place it on the over-the-counter market. Although the chemical structure should technically be the same, there are subtle variations between different makers of the same drug and this may be impacting his response.
Another important factor is that the over-the-counter Prilosec is actually half of the milligram dose of the previously prescribed dose of Prilosec, and he may, in fact, be taking half of the milligram dose, even though it's still one tablet. Over-the-counter Prilosec has only been authorized in 10-milligram tablets, whereas prescription Prilosec is 20 milligrams. If he thinks he is taking the same one tablet per day, he may actually need to take two tablets.
If he is already doing that, and he is not receiving any benefit, then your doctor may be able to discuss this with your insurance company and they typically will approve a prescription for another more effective medicine. This is relatively common and often easily ameliorated by a simple phone call or letter from your doctor arguing for another prescription drug.
Member question: Besides avoiding some types of food and taking Protonix as prescribed what vitamins, minerals, or foods would help the healing process. I have a small hiatal hernia along with acid reflux. I have had my esophagus stretched due to significant stricture. The tissues at the base of my vocal cords and the top of my esophagus are inflamed and swollen causing difficulty in swallowing and the feeling of something stuck in my throat.
Pacheco: Unfortunately, you have suffered the consequences of severe reflux disease and the fact that you have strictures (for those who do not know what this means, it is a narrowed esophagus from chronic reflux that causes irreversible scarring). This condition, unfortunately, affects a very small percentage of patients with heartburn.
It can be extremely uncomfortable and difficult to manage, as you well know. You should certainly be followed very closely by your gastroenterologist, which I suspect you are doing, given that your doctor has already dilated your strictures.
The problem is that the scar tissue adds a second insult to the injury of your hiatal hernia (a hiatal hernia is when the sphincter at the gastroesophogeal junction is not only loose, but it is also a loosening that results in the stomach sliding up into the chest). The hiatal hernia makes reflux worse and this probably has led to your chronic reflux and stricture formation. Once the stricture has formed the normal wave-like movement of the esophagus to help the normal esophagus clear acid is also diminished. This is called peristalsis.
Since you have reflux and a hiatal hernia and now difficulty with peristalsis, treatment becomes a bit more complicated, although not impossible. I would certainly advise continuation of your strict diet including head of bed elevation, as this will help nature's gravity move acid downward and out of contact with your esophagus. As stated earlier, if you are overweight weight loss would be helpful.
Other medicines besides the protonics may not only be helpful, but may allow for much more pain relief. A medicine I typically suggest in patients like you is liquid Carafate, as this coats the entire length of the esophagus and soothes and reduces reflux symptoms.
Unfortunately, there is no scientific data at this time supporting any vitamin or mineral effective to reduce symptoms in patients like you. If you maintain strict adherence to what I've mentioned, you should feel significantly better.
Moderator: We are almost out of time. Do you have any final comments for us, Dr. Pacheco?
Pacheco: In summary, the main messages I would like the readers to take home is that although heartburn is a significant problem in the U.S. affecting millions of people, most of you can obtain excellent relief with dedicated commitment to healthy eating and daily habits. You should not be concerned unless you fall into a much more rare category of patient where symptoms persist despite my recommendations. Even in these patients, conditions such as esophageal cancer are extremely infrequent.
I would advise those readers who want more information in a very easily readable source to pick up my recent book, Living with Chronic Heartburn, which outlines what we have discussed, including alternative therapies, actual diets, and outlines of exactly what is available for them, and all treatment options.
As you embark on the holiday season, enjoy yourselves and enjoy your food, but remember to eat in moderation, so you enjoy the holiday even more and do not find yourself up in bed every night suffering from your indulgences.
Moderator: Thanks to Paulo Pacheco, MD, co-author of Living With Chronic Heartburn, for sharing his expertise with us today.
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