Dialogue on Heartburn -- John Bryant Wyman, MD and Chandra Prakash, MD, MRCP -- 05/22/01

Last Editorial Review: 6/4/2004

WebMD Live Events Transcript

The opinions expressed herein are those of the guest's alone. If you have questions about your health, you should consult your personal physician. This event is meant for informational purposes only.

Moderator: Welcome to WebMD Live. Our guests today are Dr. John B. Wyman and Dr. Chandra Prakash of the American Gastroenterological Association (AGA). You may ask a question at any time.

Moderator: Welcome to WebMD Live, Dr. Wyman and Dr. Prakash. How are you today?

Prakash: Doing well, thank you.

Wyman: Doing good, thank you.

Moderator: Before we begin taking questions, can you each please tell everyone a little bit about your background and area of expertise?

Prakash: I am a gastroenterologist. I am based in St. Louis. I am a faculty member at the Washington University School of Medicine. I am an assistant professor of medicine. I see a lot of patients with GERD in my practice.

Wyman: I am John Wyman. I am at the University of Wisconsin, a professor of medicine. My interest is in motility gastrointestinal disorders.

Moderator: Let's get started with our member questions.

johnsmom2_webmd: How do you feel about the use of Reglan in children, and do the effects of this medication outweigh the possible side effects?

Prakash: I am not a pediatrician, I only see adult patients, and I do not use Reglan very often at all.

mikecons_webmd: I'm 23 and have heartburn. Is it normal to have it at such a young age?

Prakash: It is not uncommon to see heartburn in young individuals. If your heartburn is constant or regular or several times a week you probably need to be evaluated and treated. On the other hand, if you only have it very occasionally you will probably be all right taking over-the-counter medication or antacids.

Wyman: I draw the line if a person has heartburn 3 or more times per week. Then I begin more formal treatment.

rollwitz35_msn: I have a question about acid reflux. I have been told by a doctor that I have "slight" reflux, but now and then I wake up in the middle of the night with acid coming up in my throat and even in my nose. Is there any treatment for this?

Prakash: It seems like you do have reflux disease, and what we in general do for patients with symptoms of reflux is to give you medicines to decrease the production of acid in your stomach. Now, if you only have the symptoms at night, sometimes it is useful to elevate the head end of your bed on blocks or bricks about four inches thick when you sleep at night. Some of the other measures that are recommended include trying to lose weight and avoiding fatty foods, alcohol, smoking, et cetera.

Wyman: I would stress to not eat or drink anything within three hours of lying down. That alone may prevent the symptoms from occurring. I urge you to see your doctor because nighttime reflux is thought to be the most dangerous in causing chronic complications in the esophagus.

Moderator: Why is nighttime reflux more serious than daytime reflux?

Prakash: When a person is recumbent, the affects of gravity are eliminated so the acid tends to hang around the swallowing tube for a longer time, hence exposing the patient to a higher likelihood of complications.

Wyman: The complication is chronic inflammation of the lining of the esophagus caused by the acid that is in contact with the lining for hours when one is recumbent. The complications are stricturing, which is scaring of the esophagus, which can cause obstruction, ulceration of the esophagus that can result in hemorrhage, and the formation of an abnormal lining of the esophagus that can become cancerous.

Moderator: Member question: I can't eat or keep down fried food or sometimes things like baked potato w/butter. I'm taking Pepcid AC all the time if I want to eat in a restaurant. It's expensive! Help me, please.

Dr. Prakash: It is well known that foods are that are rich in fat tend to cause relaxation of a little valve at the junction of the swallowing tube and stomach. That is why we recommend patients with reflux disease to decrease their intake of fat-rich foods.If over-the-counter medications alone do not control regular or constant symptoms, then your doctor can prescribe a stronger medicine to decrease acid in your stomach, which might help you.

Wyman: Another complication of fatty foods is that they are retained in the stomach for a much longer period of time than are carbohydrates and protein. Reflux occurs more often when the stomach has food in it than when it's empty.

paige18_webmd: How do you determine if your reflux is at the point where you need a prescription medication to treat it?

Prakash: Usually we tend to treat patients who have symptoms at least three times per week or more often than that.

shala4_webmd: Does heartburn sometimes manifest itself as drainage in the throat or is it always like classic heartburn?

Prakash: These days it is becoming increasingly recognized that there are some patients who do not manifest the classic or typical symptoms of heartburn or acid regurgitation in the back of the throat. Some of the other conditions that can be caused by acid reflux include asthma, laryngitis, sometimes sinusitis, sore throat, chest pain, sometimes aspiration phenomena or rarely erosion on teeth. So if you have sinus drainage and your ENT physician cannot find another reason for this, it could possibly be related to reflux. We usually approach this in two ways. First, your gastroenterologist could put a little probe into your swallowing tube and measure acid for a 24 hour period. On the other hand, your doctor could treat you with acid medication and see if your symptom goes away.

Wyman: I think that covers it.

Moderator: Member question: I just had a wire inserted thru my nose and into my stomach to measure for acid. What do the pH levels mean? I see levels on the meter like 7.7 and 3.8 I don't understand what the levels mean. Could you explain it to me?

Wyman: The pH is the measurement of acid, and we believe that anything below pH 4 causes the damage to tissue that we have talked about before. So we hope by using prescription medications or even by surgery to prevent acid being refluxed into the esophagus that we can protect the lining of the esophagus and these other structures that have been described and prevent that damage from occurring. So a pH of 7 is very safe. A pH of 3.8 probably can result in chronic inflammation.

Prakash: Everyone has a degree of acid splashing to the esophagus during a 24-hour period. So if the acid drops below 4 as Dr. Wyman talked about for short periods of time, it may not mean a whole lot. On the other hand, if the pH remains below 4 for more than about five or six percent of the day, which is about an hour during a 24-hour period, that is significant and abnormal.

mommyme1_webmd: My husband takes many asthma medications. Could his inhalers be contributing to his heartburn?

Prakash: The answer is yes. Some of the medicines used for asthma tend to relax the sphincter between the esophagus and the stomach. On the other hand, the asthma could also potentially be related to reflux. It is important that your husband's pulmunologist and gastroenterologist talk to each other and decide if either of the scenarios are occurring in his situation.

paige18_webmd: I was taking Prilosec but read some bad things about it's long-term effects. Do you have any thoughts on this?

Prakash: For the average patient, long-term use is probably safe. In fact, there have been studies where patients have been given Prilosec for over 10 years without any serious long-term side effects. Your doctor is the best person to decide if you can benefit from long-term treatment with medications of this kind.

Wyman: Prilosec has been taken by humans since 1979 and is the safest in this family of drugs that I prescribe.

johnsmom2_webmd: Can long-term intake of acid inhibitors stop the natural acid makers from making the acids we need to digest food?

Prakash: Even the strongest acid suppression medications used these days prescribed at high doses do not cut acid out completely from the stomach. Even if it did, the likelihood of having problems with digestion per se is probably negligible. We usually do not worry about eliminating acid causing problems for patients, it is usually the other way around.

Wyman: I can only add that acid probably is not necessary for digestion it is a fine tuner to how our gastrointestinal system works. Probably the greatest concern is that we swallow micro-organisms all of the time and these can grow within the small intestine. We believe that acid is the barrier to most of these. But in answer to the question, when one stops these medications, the acid reducing cells surge forth and secret acid, so they do not stop it permanently.

coric_msn: Is it normal to experience heartburn before you eat or drink anything in the morning?

Prakash: Usually our patients complain of heartburn after meals. Sometimes there can be a sensation of heartburn even without acid in the swallowing tube. At other times small amounts of acid can generate a lot of symptoms. The best way to find out if your heartburn in the morning is related to acid reflux is to be treated with a potent acid inhibition medication for a week or two and see if your symptom goes away.

Wyman: There is a condition we call functional heartburn which has nothing to do with acid and is somehow related to the nerve supply to the muscle of the esophagus or the muscle itself. So a trial with a potent medication to reduce that secretion would be in order.

Moderator: Member question: Does chewing gum affect heartburn?

Prakash: Chewing gum does a couple of things that I can immediately think about. On the one hand it increases salivation and saliva. In other words, the opposite of acid. On the other hand, when you chew gum you tend to swallow a lot of air and burp.While it may not affect heartburn very much directly, it may increase belching and burping, which sometimes go together with GERD and reflux disease.

cherylk25_webmd: I have just switched from omeprazole to ranitidine and am finding my nighttime heartburn getting much worse. Should I talk to my doctor about switching back? My concern is I am only 33 years old and I don't want to be taking omeprazole for the rest of my life.

Prakash: If your nighttime heartburn has increased since you were switched off the omeprazole [Prilosec], it is imperative that you be put back on the medication. However, it is sometimes not that easy, depending on what kind of insurance you carry. At your age, if you have significant reflux that is confirmed on testing, and if you do not want to take medications for the rest of your life, getting more invasive therapy like surgery is an option, but this decision should be made between you and your doctor.

Wyman: I would like to add that I personally think that rantidine has little place in the treatment in GERD disease. This can raise the pH usually to only 3, whereas omeprazole will raise it to about 4 for hours at a time. Omeprazole is a very safe agent and people have been taking it daily for over 20 years with no severe side affects. You should ask your doctor to give you omeprazole again to protect your esophagus.

jessica105_webmd: what's the difference between meds like Tums/Rolaids and Tagamet/Zantac. Which should I take for heartburn?

Prakash: Tums and Rolaids are antacids and they neutralize acid. They do nothing to the stomach's ability to make acid. Therefore, their affect only lasts for a short time, and large amounts may have to be taken for complete relief. Medicines like Tagamet decrease acid formation by the stomach to a certain degree, especially in the doses available over the counter. What you need for your reflux symptoms really depends on how often you have symptoms. If you only have symptoms very occasionally then medications like Tums, Rolaids and Tagament may be enough, especially if they take your symptom away. However, if you have symptoms more often than three to four times per week and if these over-the-counter medications do not control your symptoms completely, you may need to see your physician for a prescription acid-suppressing medication.

Wyman: For occasional heartburn, a change of habits might be of benefit. Don't eat or drink anything within three hours of going to bed. Cut down or stop caffeine or tobacco. Changing these things can stop heartburn.

Moderator: Members, we are approaching the end of our discussion. Please send in any final questions you have for our guests.

cstrotmeyer_webmd: Are heartburn and stress related?

Prakash: There may not be a very simple answer to this. There are situations where symptoms coming from gastro organs are exaggerated during periods of stress. This is especially true if there is an element of visceral hypersensitivity, where the organs are highly reactive to stress hormones and nerve impulses. This is a situation where the patient's symptoms are out of proportion to whatever is causing those symptoms. Now this situation can coexist with GERD. There is also some indication that acid generation may go up during periods of stress, although it is unclear if this increased acid translates into more heartburn symptoms from GERD.

Wyman: Heartburn may have nothing to do with acid as we have said before. The symptom caused by stress may be interpreted as heartburn and yet obviously it has something to do with the stressful episodes. If this happens, one might try over-the-counter medications, and if no benefit is given from this then probably the symptom has nothing to do with acid. It is a stress-related symptom that would be relieved when the stress is relieved.

Moderator: Member question: We are now seeing a lot on television about digestive enzymes as a supplemental "vitamin". Are using these a good idea?

Wyman: The use of supplemental enzymes and vitamins is probably a waste of money if the person is eating a balanced diet. The available enzymes are usually pancreatic enzymes. Our pancreas has a great capacity of producing enzymes that digest dietary protein and fat, and unless one has diagnosed pancreatic disease the enzymes that one takes by mouth are digested by our own pancreatic enzymes and so it serves no purpose. Most of the vitamins that are taken supplementally are also in excess of what our bodies need, so that most of these end up in the toilet. Certainly supplemental vitamins are appropriate for some people who are unable to eat a balanced diet. The very young and the very old often are candidates for supplemental vitamins.

Prakash: We are not saying that patients who have vitamins and other enzymes prescribed by a physician should not take them. We are just suggesting that patients who decide to pick up these supplements from the grocery store may not necessarily benefit from them.

Moderator: We are just about out of time. Dr. Wyman, before we say goodbye, do you have any closing comments?

Wyman: I am very pleased that people are sending these questions to us and I would hope that this kind of dialogue can continue with all physicians. It is very important to understand how they function and how they don't function, and perhaps we as physicians can help them.

Moderator: Dr. Prakash, would you like to make any final comments before we leave?

Prakash: It was a pleasure answering these questions. I am impressed by how much insight our members have into their disease. I would urge all patients with GERD to follow their physicians' instructions.

pokus1_msn: Thank you.

johnsmom2_webmd: Thank you very much for taking this time to chat with us.

Moderator: Unfortunately, we are out of time. Thank you very much for joining us today, Dr. Wyman and Dr. Prakash. It was a pleasure having you both on WebMD Live. Thank you for sharing your knowledge and expertise with us.

Wyman: Thank you.

Prakash: Thank you.

Moderator: Members, thank you for all of your great questions. For more information , please visit the AGA web site at www.gastro.org. You can also visit the WebMD Heartburn Center and our message boards on digestive disease. Thanks, everyone, and have a great afternoon.

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