Heartburn and Gastroesophageal Reflux Disease

Heartburn and Gastroesophageal Reflux Disease

Maurice N. Atiyeh, M.D.

Heartburn, a very common complaint, is often described as a discomfort, burning in quality that is felt in the lower retrosternal area in the chest. Moreover, it is sometimes also described as a "sour stomach" or "bitter belching" or even "indigestion." This unpleasant sensation may also radiate to the entire area behind the breast bone, and sometimes to the throat, back, and arms. Infrequently it may be severe enough to cause a degree of pain that mimics symptoms of a heart attack.

How Frequent is this Complaint?
Heartburn is the most frequent symptom related to the digestive system. Statistical surveys carried out a few years ago showed that about forty percent of American subjects of various ages complain of heartburn at least once monthly and about ten percent may have it daily. A pregnant woman is the most likely individual to complain of heartburn on a daily basis. It is, indeed, so common that many disregard it and consider it an acceptable nuisance and, therefore, do not report it to their physician. Especially that they often can relieve themselves by resorting to any of the different over-the-counter medications. Most of these medications, including Zantac, Tagamet, Alka Seltzer, Maalox, Mylanta and Gaviscon provide transient relief to a degree. However, a drawback of this attitude is that very often those who find themselves in need of such medication more than two to three times a week may be having severe inflammation of the esophagus without being aware of the internal damage in the esophagus. Many endoscopic surveys related to this problem showed that resorting to over-the-counter therapy may temporarily alleviate the discomfort while the inflammation may keep going on in the esophagus.

What Causes Heartburn?
A well functioning esophagus is endowed at its lowest end, where it joins the stomach, with a set of special neuromuscular tissue that stays contracted most of the time to prevent acids produced by the stomach from refluxing back to the esophagus. This junctional high pressure zone between the stomach and the esophagus is called a sphincter. It tends to remain closed and thus protect the esophagus, except on swallowing food or liquids, or on belching.

Unfortunately, this sphincter does not always carry out its functions properly, either due to inherent defect or due to external factors that interfere with its function. Sometimes the sphincter is dislocated upward by a shortened esophagus or by virtue of the presence of a hiatus hernia. This situation is frequently conducive to gastric acid refluxing back into the esophagus. A hiatus hernia may be rarely present at birth, but it often develops four to five decades later in life and thus, older people are more likely to suffer of its sequelae than younger people. Other neuromuscular factors that increase the severity and frequency of heartburn is an acquired or inherent weakness in the propulsive contractions of the muscles of the esophagus. This leads to a failure in clearing the lumen of the esophagus from the injurious acids that may reach it while sleeping or reclining.

Other factors that promote acid reflux are:

Heartburn, the symptom of an acid reflux event is frequently noted within one hour of a big meal. This is more likely to be felt on reclining and more so if the subject lies on his right side.
Body movements that increase abdominal pressure, including bending over, lifting heavy objects, and straining may aggravate heartburn. Running may also do the same.
Drugs that decrease lower esophageal sphincter pressure include nicotine through smoking, calcium channel blockers used to control high blood pressure, theophylline and Albuteral used in asthma, nitrates used in angina, and progesterone.
Certain foods may also lower the pressure in the sphincteric area and promote acid reflux. Examples are fats, chocolates, coffee, onions, and alcohol, especially red wine.
Factors that may aggravate an already sensitized esophagus and thus cause heartburn include anxiety and emotional stress, as well as certain foods like citrus products, tomato based products, pizza, and spices.
Certain drugs may be directly injurious to the esophagus. These include iron preparations, potassium chloride tablets, tetracycline, quinidine, and most medications that are used for arthritis. Fortunately, the new drugs that came to the market last year to treat arthritis, namely Celebrex and Vioxx, are less likely to cause an injury to the stomach or esophagus.

What are the Consequences of Acid Reflux in Addition to Heartburn?
Lately it has been recognized that acid reflux can cause a variety of other medical problems beside the annoyance of heartburn and mild esophagitis.

(1) The most serious sequelae of acid reflux is the development of a chronic esophagitis that often leads to a change in the nature of the mucosal cells that line the inside walls of the esophagus. Those cells acquire some of the characteristics of the cells that line the small intestine, a condition that is called metaplasia. This change is a warning sign that the esophageal cells are going through a change that may eventually lead to cancer of the esophagus. Cancer of the esophagus, as is well known, carries a high mortality rate even when it is amenable to surgery. This condition was described by Dr. Barrett many decades ago and so it is called Barrett’s esophagus.

It is to be stressed that people who have Barrett’s esophagus do not necessarily have severe heartburn. Actually, in most cases, the heartburn is mild and the individual may not be aware of its presence.

What is more causatively associated with the development of Barrett’s esophagus is the duration of the heartburn, rather than its severity. The longer the duration, the higher the risk of acquiring Barrett’s esophagus and that explains why this condition is more common in subjects who are over fifty years of age. Nowadays it is recommended that any middle-aged person whose heartburn goes back to more than two years should have his esophagus directly tested by means of endoscopy and tissue biopsies. For the sake of a balanced view, however, on this important subject it is to be stressed that the risk of developing cancer after diagnosing Barrett’s esophagus is low, except in those whose endoscopic biopsies already show dysplastic changes in the esophageal mucosal cells. Dysplasia refers to a change in the characteristics of the nuclei of the cells and in the content and nature of DNA that is carried within their nuclei.

In conclusion, it is to be stressed that heartburn that lasts more than two years, irrespective of its severity, calls for one endoscopic procedure, at least, to check whether a Barrett’s esophagus is present. If none is found, no further surveillance is needed.

(2) Stricture. Once the sequelae of chronic and severe inflammation in the esophagus that is caused by reflux acidic gastric juice is the development of a circumferential scar that narrows its lumen. The patient may then complain, on swallowing, of a localized, persistent discomfort in the chest secondary to the bolus of food hanging at the narrow site. Due to improved public awareness and early treatment of esophagitis and heartburn and due to the presence of more potent medications than in the past, this condition is now, fortunately, much less encountered.

(3) Acid reflux may cause a variety of non-esophageal complications that may appear irrespective of the severity of the heartburn. Indeed, many of those patients may not complain of frequent heartburn.

Some examples of these complications include chronic coughing, sore throat, laryngitis, and asthma. Both the patient and the doctor may often become puzzled by these problems for which they may not easily find an explanation.

Management of Heartburn
In the majority of subjects whose heartburn is infrequent, no extra measures are needed and the sporadic use of over-the-counter preparations is very often satisfactory.

On the contrary, all those suffering of complications, long duration of symptoms, or resistant to treatment need to have intensive diagnostic and therapeutic measures. If endoscopic procedures or other tests confirm the diagnosis, one can resort directly to intensive treatment that utilizes the newest compounds like Prilosec, Prevacid, and Aciphex for whatever is necessary and this could mean many years of treatment. These compounds block the production of acid by the gastric cells. Their use has proved very effective in treating the inflammation in the esophagus and consequently abolishing the discomfort of heartburn in the majority of patients. They also have proven to be safe. Unfortunately, the symptoms of heartburn, with or without esophagitis, tend to recur a few weeks to a few months after stopping the medication. In such a situation one can either resume taking those potent medications for life, or can resort to surgery. Some patients may try less potent medications like Zantac, Axid, Pepcid, or Tagamet, etc. with satisfactory relief, but these medications are often less likely to be effective.

Role of Surgery
In the past, anti-reflux surgery entailed opening the chest and/or the abdomen. Nowadays, surgery can be performed through a thin scope inserted percutaneously and the repair is performed laparoscopically. This means less pain, shorter hospital stay, and the success rate is similar to open surgery. Surgery is likely to be considered in young patients suffering recurrent and frequent heartburn, patients who bleed from Barrett’s esophagus or linear gastric erosions, and the problematic cases of laryngitis and asthma. The patient, older in age, can take gastric acid suppressants indefinitely, especially if they have other morbid conditions that increase the risk of surgery. These medications prove to be safe and so far there are no known risk factors associated with prolonged use.

In conclusion, heartburn, a commonly innocuous and widespread symptom, could affect the well being and quality of life of a significant percentage of sufferers. Moreover, it may cause various medical problems, including difficulty swallowing, bleeding, cancer of the esophagus, chest pain that may mimic heart attacks, and various extraesophageal complications in the pharynx, vocal cords, and airways.

The permanent cure is surgical, but usually there is no need to resort to this measure, particularly since current medications are relatively safe and very effective in controlling the symptoms, healing the inflammation, and preventing complications. The indications for surgery are nowadays limited to certain groups of patients.

Dr. Atiyeh practices in Northern Virginia.