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What You Need to Know About Heartburn

When heartburn isn’t indigestion

What seems like heartburn may, in fact, be a heart attack. If you think you have heartburn but the chest pain keeps getting worse, you feel pressure instead of just burning, or if you are sweaty and short of breath, don't take a chance. Call an ambulance.

Most physicians consider chest pain a heart symptom until they can prove otherwise.

Heartburn, also called acid indigestion, is a burning sensation in the chest, sometimes accompanied by acid backup in the throat, nausea, belching, bloating, and other unpleasant symptoms. Nearly everybody has had it at some time, especially after eating too much rich food. Fatty, fried, and spicy foods, alcohol, coffee (including decaf), peppermint, and chocolate can bring on heartburn in some people, though various studies incriminate different foods and beverages. Smoking is a major culprit.

The sphincter (ring muscles) in the lower oesophagus at the entrance to the stomach normally keeps traffic moving in a southward direction. But in heartburn, the sphincter relaxes allowing digestive juices and sometimes bits of food to move back into the oesophagus and throat.

Simple heartburn usually goes away on its own, or with the help of an occasional antacid. But if it becomes frequent or chronic, it may be classified as gastroesophageal reflux disease (GERD), a more serious problem.

What causes GERD?

Apart from smoking and overeating, your genes may predispose you. Pregnancy is another factor, and so is obesity. Some medications bring on GERD. Sleep apnoea (usually associated with obesity) increases the risk.

GERD can interrupt your sleep, leave you tired during the day. It can also cause laryngitis, hoarseness, difficulty swallowing, and chronic cough. Indeed, more than half of those with GERD have these symptoms without realizing they are having reflux, which makes the condition hard to diagnose. It's thought that 25% of all cases of unexplained asthma are actually the result of GERD – the acid causes spasms in the airway. Sinusitis and dental erosion can also result from GERD. And in some people with long-term GERD, acid reflux damages the lining of the oesophagus This can lead to a condition called Barrett's oesophagus In about 4% of cases, Barrett's oesophagus turns malignant – a cancer than can be aggressive and hard to treat.

But you can have GERD with no oesophageal damage — a condition non dubbed non-erosive reflux disease, or NERD. This may sound simply like a less severe version of GERD, but in fact it may be an entirely different disorder. People who have NERD may not respond as well to the standard medications for GERD.

BEST ADVICE:
If you have chronic heartburn, or even if you just have persistent unexplained symptoms such as poor sleep, laryngitis, hoarseness, or difficulty swallowing, see a doctor. If it turns out you have GERD or even NERD, there's a great deal that can be done to relieve your symptoms and prevent oesophageal damage, or heal it if it occurs.

Sometimes these measures are enough to prevent heartburn.

Avoiding the burn

Lose weight. Extra pounds can bring on heartburn or make it worse. Exercise and portion control can help.
Don't eat within three hours of bedtime
Avoid large meals
Stop smoking
Cut back on alcohol
Avoid spicy, fatty, or fried foods, chocolate, peppermint, or whatever you think causes heartburn.
Don't drink milk to ease heartburn. It may feel soothing at first, but can promote acid production later
Elevate the head of your bed. Put blocks under the headboard to raise it by at least 10-15cm (4-6 inches). It's important to raise your upper body, not just your head. Let gravity help keep stomach acid down in your stomach. A foam wedge can also help.
Cut back on fluids with meals
Chew gum after meals. This stimulates saliva production, a good buffer to stomach acid.
Wear comfortable, loose-fitting clothes. Tight pants and belts put pressure on the stomach.

Antacids — old standbys.

For occasional discomfort, over-the-counter (OTC) antacids provide short-term relief. They come in a variety of flavors, forms (chewables, liquid, foams), and combinations of ingredients. A single brand (Maalox for example) may have several formulations.

The following compounds are used in most antacids:

Calcium carbonate (Tums, Calcium-rich Rolaids, Amitone, and generics) works well, although it may cause constipation and in the long term may promote kidney stones in some people.
Aluminum compounds (AlternaGel, Amphogel, and generics) are slower acting and may cause constipation or, at high does, calcium depletion.
Magnesium compounds (Maalox, Mylanta, Rolaids, and generics) may act as laxatives. Overuse can bring on low blood pressure and irregular hear rhythms, especially in older people.
Combinations of aluminum and magnesium (such as Maalox and Riopan).
Simethecone, an anti-foaming afent that is supposed to reduce the size of gas bubbles, is found in may brads. It has never been proved effective.
Sodium bicarbonate (baking soda) is the active ingredient in fizzy antacids like Alka-Selzter and its generics. Such products are high in sodium and often contain aspirin, which can contribute to heartburn. Not recommended.

Any antacid can cause acid rebound if you use it regularly and then abruptly stop. Antacids may interact with other medications. As with any over the counter (OTC) medication, read the label, and talk with the pharmacist if you have questions.

H-2 blockers — the new antacids

Histamine antagonists (also know as H-2 blockers) block histamine, a chemical that stimulates acid production. Thus they actually reduce the production of stomach acid instead of simply neutralizing it. Originally prescription drugs, most are now also sold OTC in smaller doses – and they are heavily advertised. Brands include Zantac 75 (ranitidine), Pepcid AC (famotidine), Axid AR (nizatidine), and Tagamet HB (cimetidine).

It takes about 30 minutes for the drugs to start working, so take them before a meal or before you think you are likely to get an attack (for instance, at bedtime). Their effects last 3-5 hours. You should not take them regularly for more than 2 weeks unless your doctor advises it. If you are taking other medications, there may be interactions. Be sure to read the labels carefully, or ask your pharmacist.

H-2 blockers can relieve GERD as well as NERD in some people. They are not the drug of choice for relieving an inflamed esophagus — but in some cases they help.

PPIs — the next step

Proton pump inhibitors (PPIs) go further than H-2 blockers; they block the secretion of acid into the stomach by turning off acid production by certain cells. Thus PPIs not only alleviate symptoms of GERD, but also allow the esophagus time to heal if it has been damaged. One of these drugs, Prilosec (omeprazole), is OTC. The others — Nexium (esomepraxole), Prevacid (lansoprazole), Aciphex (rabeprazole sodium), and Protonix (pantoprazole) — are available only by prescription. These drugs work best when taken 30 to 60 minutes before eating.

But there is a sown side: doctors worry about people self-prescribing Prilosec and never getting the medical attention they need. Many doctors think PPIs are overused. Though PPIs will prevent acid reflux, they may not stop all reflux. Bile, which is also damaging, may be released into the esophagus. They may also interfere with the absorption of some minerals. Finally these drugs are expensive.

Other options

Pro-motility drugs such as Propulsid or Reglan by benefit certain people with GERD, but they have serious side effects. In a few cases, surgery can correct GERD — though this is only a last resort.

UC Berkeley Wellness Letter, September 2006
http://www.wellnessletter.com

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