An Educational Resource For Heartburn And Acid Reflux

There are a wide range of both lifestyle changes and medications that can ease your suffering. Below, gastroenterologist Dr. Steve Peikin of the Robert Wood Johnson School of Medicine, introduces a full range of techniques to tame the flames of heartburn, and talks about the symptoms that may be a sign of something more serious.

How prevalent is heartburn in the United States?
Heartburn is extremely common in the United States. It's one of the most common reasons why people go to gastroenterologists, and also to their family doctor. Actually about 25% of the population take antacids at least once or twice a month, and 7% of the population experience heartburn every day.

What do you recommend to patients that can help alleviate heartburn and reflux?
I tell patients to avoid foods that can precipitate heartburn. These are foods that can relax the little valve at the end of the esophagus that tries to prevent the acid from coming up-the so-called lower esophageal sphincter. The foods that tend to relax that sphincter are peppermint, chocolate, nuts, caffeine and greasy foods. Carbonated beverages may cause a lot of gas, which causes belching and the belching brings the fluid back up with it, so I advise against carbonated beverages as well.

Also, a lot of reflux occurs at nighttime. When you're lying down, it's easier for stomach contents to travel backwards into the esophagus. So elevating your head at night in bed can help prevent reflux. I advise patients not to eat for three or four hours before lying down, because eating food causes a surge in acid secretion.

Since most people who have heartburn don't have serious complications, it's perfectly reasonable to self-medicate by going to the drugstore and buying the various heartburn remedies that are on the market.

With these lifestyle changes and an occasional antacid or H2 blocker, some people will find relief. But some people are going to need prescription medication. The options are prescription strength H2 blockers, or more commonly, the proton pump inhibitor class of drugs, which are very potent and very effective in treating reflux.

How do antacids work to fight heartburn?
Antacids neutralize acid in the stomach so that when the fluid from the stomach comes back up into the esophagus, it's less acidic. The benefit of an antacid is that it works immediately. You don't have to wait for it to be absorbed by the body. It works quickly. The bad news is that it doesn't last that long and you may end up having recurrent heartburn and need to take antacids more frequently.

How do H2 blockers work?
Histamine is a chemical in the body, and it is a very potent stimulator of acid secretion. The H2 blockers block the ability of histamine to attach to the surface of acid-secreting cells in the stomach, so acid formation is blocked.

But the only way for the blocker to attach to the cells is for it to get absorbed through the intestine and into the blood stream. This absorption process takes time. H2 blockers last longer than antacids, but they take anywhere from 20 minutes to an hour to work.

There are products that combine an antacid and an H2 blocker, so you get the quick onset of action from the antacid and a sustained relief from the H2 blocker.

Since H2 blockers take time to work, how do you recommend people time their medication?
If you are going to have meal that you think will cause heartburn, and maybe you're going to have some alcohol, you could take an H2 blocker, or a combination H2 blocker/antacid before the meal, and try to ward off heartburn symptoms.

What is a proton pump inhibitor and how does it work?
Proton pump inhibitors are some of the most effective medications available for heartburn.

There are actually three different ways that the acid-producing cells in the stomach are stimulated to secrete acid. One is with histamine, as we discussed. Another is through gastrin, which is a hormone in the body that stimulates acid secretion. The third is with acetylcholine, which, again, stimulates acid secretion. Each of these ways stimulate the specific stomach cells to produce acid. The acid is released from these cells by a pump, called the "proton pump". The proton pump inhibitors, or PPIs, block the pump from releasing the acid.

What if lifestyle modifications and OTC medications don't work?
If you have found that the lifestyle changes and over-the-counter medications have not worked, you could consider prescription medication, like a prescription-strength H2 blocker or a proton pump inhibitor.

Also, if you have more unusual symptoms related to reflux-laryngitis, chronic cough, or non-cardiac chest pain that causes a pressure sensation in the middle of the chest, you probably should use a PPI.

When is heartburn a sign of a more serious condition?
You should be more concerned if you experience so-called "alarm" symptoms. If you have trouble swallowing, have burning in your esophagus when you swallow, experience choking at nighttime, have frequent coughing at nighttime, or have black, tar-like stools-these are all alarm symptoms.

Also, if you have heartburn on a regular basis, even just one or two times a week, then sometimes you can develop complications of reflux. It may just be inflammation of the esophagus. It could be bleeding from ulcers in the esophagus. It could be a narrowing of the esophagus from scarring, which could give you trouble swallowing. Finally, sometimes acid can damage the lining of the esophagus causing a precancerous condition of the esophagus called Barrett's esophagus, which may lead to cancer of the esophagus. Some of the risk factors for Barrett's esophagus include: if you've had heartburn for many years, if you're a white, if you're male or if you're over the age of 50.

How common is Barrett's esophagus and cancer of the esophagus?
It is not common. In general, of those people who have acid reflux, less than 10% are going to develop Barrett's esophagus, the precancerous changes. And those people who develop Barrett's esophagus, less than 10% of those will go on to develop adenocarcinoma of the esophagus. So you shouldn't worry too much.

Nevertheless, if you've had heartburn for many years and you are over the age of 50, it may be reasonable to have an endoscopy performed, just to make sure you don't have Barrett's esophagus. And if you have any of the alarm symptoms, then you should also have endoscopic evaluation of the upper GI tract.