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Overview

  • How common is heartburn?

    More than 60 million Americans experience heartburn at least once a month and some studies have suggested that more than 15 million Americans experience heartburn symptoms each day. Symptoms of heartburn, also known as acid indigestion, are more common among the elderly and pregnant women.

  • What is heartburn or GERD?

    Gastroesophageal reflux is a physical condition in which acid from the stomach flows backward up into the esophagus. People will experience heartburn symptoms when excessive amounts of acid reflux into the esophagus. Many describe heartburn as a feeling of burning discomfort, localized behind the breastbone, that moves up toward the neck and throat. Some even experience the bitter or sour taste of the acid in the back of the throat. The burning and pressure symptoms of heartburn can last for several hours and often worsen after eating food. All of us may have occasional heartburn. However, frequent heartburn (two or more times a week), food sticking, blood or weight loss may be associated with a more severe problem known as gastroesophageal reflux disease or GERD.

Causes

  • What causes heartburn and GERD?

    To understand gastroesophageal reflux disease or GERD, it is first necessary to understand what causes heartburn. Most people will experience heartburn if the lining of the esophagus comes in contact with too much stomach juice for too long a period of time. This stomach juice consists of acid, digestive enzymes, and other injurious materials. The prolonged contact of acidic stomach juice with the esophageal lining injures the esophagus and produces a burning discomfort. Normally, a muscular valve at the lower end of the esophagus called the lower esophageal sphincter or “LES” — keeps the acid in the stomach and out of the esophagus. In gastroesophageal reflux disease or GERD, the LES relaxes too frequently, which allows stomach acid to reflux, or flow backward into the esophagus.

Treatment Options

  • What are the treatments for infrequent heartburn?

    In many cases, doctors find that infrequent heartburn can be controlled by lifestyle modifications and proper use of over-the-counter medicines.

    Lifestyle Modifications

    • Avoid foods and beverages that contribute to heartburn: chocolate, coffee, peppermint, greasy or spicy foods, tomato products and alcoholic beverages.
    • Stop smoking. Tobacco inhibits saliva, which is the body''s esophagus.  A 1999 study reported in the New England Journal of Medicine showed that patients with chronic, untreated heartburn of many years duration were at substantially greater risk of developing esophageal cancer, which is one of the fastest growing, and among the more lethal forms of cancer in this country.

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      • Dysphagia: difficulty swallowing or a feeling that food is trapped behind the breast bone.
      • Bleeding: vomiting blood, or having tarry, black bowel movements.
      • Choking: sensation of acid refluxed into the windpipe causing shortness of breath, coughing, or hoarseness of the voice.
      • Weight Loss
  • What are the treatment goals for GERD?

    GERD is a problem that is symptomatic by day but in which much damage is done by night. Treatment should be designed to: 1) eliminate symptoms; 2) heal esophagitis; and 3) prevent the relapse of esophagitis or development of complications in patients with esophagitis.  In many patients, GERD is a chronic, relapsing disease. Long-term maintenance is the key to therapy; therefore, continuous long-term therapy, possibly life-long therapy, to control symptoms and prevent complications is appropriate. Maintenance therapy will vary in individuals ranging from mere lifestyle modifications to prescription medication as treatment.

    All treatments are based on attempts to a) decrease the amount of acid that refluxes from the stomach back into the esophagus, or b) make the refluxed material less irritating to the lining of the esophagus.

  • What are the treatments for GERD?

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    In order to decrease the amount of gastric contents that reach the lower esophagus, certain simple guidelines should be followed:

    • Raise the Head of the Bed. The simplest method is to use a 4"" piece of wood to which two jar caps have been nailed an appropriate distance apart to receive the legs or casters at the upper end of the bed. Failure to use the jar caps inevitably results in the patient being jolted from sleep as the upper end of the bed rolls off the 4"".

      Alternatively, one may use an under-mattress foam wedge to elevate the head about 6-10 inches. Pillows are not an effective alternative for elevating the head in preventing reflux.

    • Change Eating and Sleeping Habits. Avoid lying down for two hours after eating. Do not eat for at least two hours before bedtime. This decreases the amount of stomach acid available for reflux.
    • Avoid Tight Clothing. Reduce your weight if obesity contributes to the problem.
    • Change Your Diet. Avoid foods and medications that lower LES tone (fats and chocolate) and foods that may irritate the damaged lining of the esophagus (citrus juice, tomato juice, and probably pepper).
    • Curtail Habits That Contribute to GERD. Both smoking and the use of alcoholic beverages lower LES pressure, which contributes to acid reflux.

    Medical Treatment of GERD

    GERD has a physical cause, and frequently is not curtailed by these lifestyle factors alone. If you are using over-the-counter medications two or more times a week, or are still having symptoms on the prescription or other medicines you are taking, you need to see your doctor. If results are not forthcoming, medications may be used to neutralize acid, increase LES tone, or improve gastric emptying.

  • What are the medications often prescribed for GERD?

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    H2 Receptor Antagonists

    Since the mid 1970''s approval of proton pump inhibitors for up to one year, as if that means that this therapy should be withdrawn after one year. There is no well-established scientific reason that supports withdrawing proton pump inhibitors after one year as these patients will invariably relapse. All gastroenterologists have patients who continue to do very well the 1 last update 2020/06/04 on proton pump inhibitors after many years''s esophagus.Since the mid 1970''s approval of proton pump inhibitors for up to one year, as if that means that this therapy should be withdrawn after one year. There is no well-established scientific reason that supports withdrawing proton pump inhibitors after one year as these patients will invariably relapse. All gastroenterologists have patients who continue to do very well on proton pump inhibitors after many years''s esophagus.

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    This test involves passing a small flexible tube through the nose into the esophagus and stomach in order to measure pressures and function of the esophagus. Also, the degree of acid refluxed into the esophagus can be measured over 24 hours.

    Extra-Esophageal Manifestations (EEM): Heartburn links to chest pain; asthma; chronic cough; ear, nose and throat problems often avoid detection

Risk/Complications

  • GERD can masquerade as other diseases

    Increasingly, we are becoming aware that the irritation and damage to the esophagus from continual presence of acid can prompt an entire array of symptoms other than simple heartburn.  Experts recognize that often the role of acid reflux has been overlooked as a potential factor in the diagnosis and treatment of patients with chronic cough, hoarseness and asthma-like symptoms. In some instances, patients have never reported heartburn, and in others the potential causal link between reflux and the onset of these so-called "" has not been fully recognized. Physicians are increasingly becoming aware that it is good clinical practice to evaluate the possible presence of reflux in patients with chronic cough and asthma-like symptoms, as well as the importance that acid suppression and treating underlying reflux can have in potentially improving the symptoms in these patients.

    • Chest Pain: Patients with GERD may have chest pain similar to angina or heart pain. Usually, they also have other symptoms like heartburn and acid regurgitation. If your doctor says your chest pain is not coming from the heart, don''s Esophagus: A serious complication of chronic GERD is Barrett''s esophagus — that''s esophagus have approximately a 30-fold increased risk of developing esophageal cancer. These patients should be followed by endoscopy by a trained gastroenterologist familiar with this disease.
    • Esophageal Cancer: Recent scientific reports have confirmed that if GERD is left untreated for many years, it could lead to this most serious complication — Barrett''s esophagus. So, do not ignore your heartburn. If you are having heartburn two or more times a week, it is time to see your physician and in all likelihood a gastrointestinal specialist.  In most cases an endoscopy should be performed to evaluate the severity of GERD and identify the possible presence of the pre-malignant condition — Barrett''s esophagus may also occur. Barrett''s esophagus likewise was more frequently diagnosed in these patients. Those patients with reflux symptoms and a history of inflammation in the past were more likely to have Barrett''t ignore frequent heartburn — instead consult with your physician regarding an endoscopy and treatment to achieve early symptom resolution.
    • If you suffer infrequent heartburn, antacids, or H2 blockers (now available without a prescription) or proton pump inhibitors (pending release at reduced strength over-the-counter dosages) may provide the relief you need.
    • If you are experiencing heartburn two or more times a week, you may have acid reflux disease, also known as GERD, which, if left untreated, is potentially serious.
    • If you are self-medicating for heartburn two or more times a week, or if you still have symptoms on your over-the-counter or prescription medication, you need to see a doctor and perhaps be referred to a gastroenterologist.
    • GERD has a physical cause that''t ignore frequent heartburn — instead consult with your physician regarding an endoscopy and treatment to achieve early symptom resolution.
    • GERD has a significant role in asthma, chronic cough and ear, nose and throat problems — all referred to as extra-esophageal manifestations (EEM) although this connection may often go unrecognized. GERD should be actively considered in physician evaluations of these conditions, or it could go undetected.
    • With effective treatment, using the range of prescription medications and other treatments available today, you can become symptom free, avoid potential complications and restore the quality of life you deserve.

Self-Test

  • Do you have GERD?

    Measure Yourself on the Richter Scale/Acid Test

    How significant is your heartburn? What are the chances that it is something more serious? If you need a yardstick, here''re a GERD sufferer and are taking the right steps  to treat it.

    1. Do you frequently have one or more of the following:
      1. an uncomfortable feeling behind the breastbone that seems to be moving upward from the stomach?
      2. a burning sensation in the back of your throat?
      3. a bitter acid taste in your mouth?
    2. Do you often experience these problems after meals?
    3. Do you experience heartburn or acid indigestion two or more times per week?
    4. Do you find that antacids only provide temporary relief from your symptoms?
    5. Are you taking prescription medication to treat heartburn, but still having symptoms?

    If you said yes to two or more of the above, you may have GERD. To know for sure, see your doctor or a gastrointestinal specialist. They can help you live pain free.

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GERD and the Elderly

  • What is GERD?

    Gastroesophageal reflux disease (GERD) is a condition where acid in the stomach sweeps up into the esophagus causing unpleasant symptoms such as heartburn, regurgitation and unpleasant taste of acid in the mouth (water brash). This can also cause serious symptoms such as chest pain mimicking heart attack, hoarseness, asthma like symptoms thus causing unwanted anxiety in the patient, an undesirable hospital stay and unnecessary medical expenditures.

  • Why do we have acid in the stomach?

    Acid in the stomach is the first line of defense against the food-borne pathogens that we ingest. Moreover acid in the stomach plays a role in absorption of vitamins (Vitamin B12), the digestion of proteins, and initiation of peristalsis which causes the food to move through the digestive tract.

  • What are the risk factors for GERD?

    Advancing age, obesity, regular use of aspirin and non-steroidal anti-inflammatory drugs, loss of physical mobility, and an incompetent valve between the stomach and esophagus (Lower Esophageal the 1 last update 2020/06/04 Sphincter or LES) are found to be among the many associated risk factors for GERD.Advancing age, obesity, regular use of aspirin and non-steroidal anti-inflammatory drugs, loss of physical mobility, and an incompetent valve between the stomach and esophagus (Lower Esophageal Sphincter or LES) are found to be among the many associated risk factors for GERD.

  • How does aging affect GERD?

    About 8% of males and 15% of females over 65 years suffer from GERD and potentially use an acid medication. Aging by itself can cause changes in the pressure of the LES, which may increase the risk of GERD in the elderly. Decreased physical mobility secondary to multiple medical problems including arthritis increases the risk of becoming overweight and increase the risk of GERD. Many take aspirin or other medications that may contribute to the increased occurrence of GERD symptoms in the elderly. Aging also decreases the force of swallowing contractions, which causes delayed clearance of acid when refluxed into the esophagus. Thus there is potential for increased exposure of the esophageal lining to the regurgitated acid and thus increases the risk of damage.

  • What tests may your physician offer to diagnose GERD?
    1. EGD (Esophago-Gastro-Duodenoscopy) ‒‒ This test is also called an upper endoscopy or gastroscopy. For this test you will be given medicine to make you sleepy. A small tube is then inserted through the mouth, down into the esophagus and then through the stomach into the first part of your small bowel. The test only takes about 15 minutes but can give a lot of information about whether you have an ulcer, inflammation in your stomach and esophagus, and whether you might have a cancer or a narrowing of your esophagus.
    2. Swallowing Test ‒‒ This is an X-ray that evaluates how your esophagus works. You will swallow a dilute solution of barium (a dye to visualize the esophagus in X-ray) and photographs are taken as you swallow. This can be very helpful in determining where the problem might be in your esophagus.
    3. Manometry Study ‒‒ This test diagnoses whether you have a problem with the way your esophagus squeezes, and finds out the condition of your LES.
  • How do we treat GERD in the elderly?

    The management guideline for GERD in the elderly remains the same as in a young patient. However, the physician may individualize the treatment based on the patient's overall condition. The treatment can be broadly classified into lifestyle modifications, over-the-counter medications and prescribed medications.

    Lifestyle modifications include raising the head end of the bed to use gravity as a leverage to allow early clearance of regurgitated acid from the esophagus. Avoiding tight fitting clothes to decrease abdominal pressure, decrease fats, chocolate, peppermint and alcohol from the diet to try to help reduce reflux.

  • What are the medications used for treatment of GERD?

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    Antacids contain aluminum and magnesium which can cause constipation and diarrhea in some patients. Constipation occurs in fewer than 2 percent of persons in the nonelderly population but affects as many as 26 percent of men and 34 percent of women over 65 years of age. Patients with chronic kidney disease (CKD) should be careful with these medications as the mineral ingredients may worsen kidney function. You consult with your care provider if you have CKD.

  • What is an H2 blocker?

    Another class of anti-reflux medications is histamine-2 receptor antagonists (H2 blockers). Cimetidine, ranitidine and famotidine, are available over-the-counter. Although they act more slowly compared to antacids, they remain active longer compared to the latter. There are combination H2blocker/antacids which may be helpful in symptom relief.

  • What are the side effects of H2 Blockers?

    Cimetidine and ranitidine may increase the blood concentrations of anti-seizure medications, blood thinners, and anti-arrhythmic medications. Newer generations of this class of drugs do not cause this problem.

    If the symptoms of GERD persist even after using these medications for more than two weeks, you should consult your doctor.

  • What is a proton pump inhibitor (PPI)?

    A proton pump inhibitor is a medication that is designed to decrease the amount of acid your stomach makes by inhibiting both meal stimulated and night-time acid secretion and has better effect than H2 blockers. This type of medication is also better at healing ulcers in the esophagus and stomach.

  • What are the side-effects of a PPI?

    PPIs are mostly well tolerated. The only known contraindication is very rare allergy to this drug group. The most commonly noted side effects are headache, nausea, diarrhea, abdominal pain and in some cases constipation. Very few persons need to stop taking the medication because of side-effects.

  • How long should I take this type of medicine?

    This really depends on the severity of your symptoms and response to therapy. For example mild cases may respond to treatment and therapy can be stopped after a short course of treatment. If you have inflammation of the esophagus (esophagitis) or ulcers in the esophagus/stomach you may need to continue treatment for a longer period of time and remain on maintenance therapy. When elderly patients with reflux esophagitis were followed up for a period of 3 years, 68% of them needed treatment for more than six months and 46% needed therapy for 3 years to prevent recurrence for 1 last update 2020/06/04 of esophagitis. Without the therapy 80-90% of the patients suffered a relapse in a period of one year.This really depends on the severity of your symptoms and response to therapy. For example mild cases may respond to treatment and therapy can be stopped after a short course of treatment. If you have inflammation of the esophagus (esophagitis) or ulcers in the esophagus/stomach you may need to continue treatment for a longer period of time and remain on maintenance therapy. When elderly patients with reflux esophagitis were followed up for a period of 3 years, 68% of them needed treatment for more than six months and 46% needed therapy for 3 years to prevent recurrence of esophagitis. Without the therapy 80-90% of the patients suffered a relapse in a period of one year.

  • I take clopidogrel, can I take a PPI?

    There have been many studies addressing this issue because of concern of an interaction between PPIs and Clopidogrel. Current data suggests that it is safe to use a PPI and Clopidogrel together in patients who need both compounds. It is possible that some PPIs will have less effect on interactions with Clopidogrel and this may affect which of the PPIs your care provider will prescribe. Some PPIs have label recommendations regarding their use with Clopidogrel. Please discuss this with your care provider.

  • I have osteoporosis, can I take a PPI? Does it mean that I will have an increased risk of a hip fracture if I do take it?

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    The FDA however, released a warning that doctors and those who take PPIs should be aware of the possible increased risk of fractures. If there is an increased risk of fracture, the overall risk is extremely small.

  • I have a low vitamin B12 can I take a PPI?

    There has long been a concern that there might be a very gradual decrease in vitamin B12 levels over a long time in persons who take a PPI but there has not been any report of disease being caused by this. There are usually other reasons for a low vitamin B12 in older persons. There is no need to monitor vitamin B12 levels in persons taking a PPI unless they have another condition.

  • Does acid suppression by PPI/H2 blockers increase the incidence of Clostridium difficile associated diarrhea?

    Available data are controversial but raise concern for an association between these medicines and C. difficile infection (a colon infection that usually happens after taking certain antibiotics). The risk is perhaps related to the degree and duration of acid suppression, other conditions increasing susceptibility of the patient to this infection and nature and strength of the strain of C. difficile infection.

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  • Does use of PPI/H2 blockers increase the incidence of pneumonia in the elderly?

    This is another area of controversy with perhaps a slight increase in the incidence of pneumonia in some patients who use PPIs. This risk has been shown to be more likely with initiation and recent use of an acid-suppressive agent rather than chronic treatment.

    It is true that the PPI/H2 blockers may decrease the acidic environment in the gut facilitating the existence of some pathological bacteria that may lead to pneumonia. When you have reflux, however, it may be that your reflux is responsible for the problem and not the medication. 

    Please consult with your care provider if you have any questions.

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