2006-10-07 / Columnists

Maintaining Your Health on Mackinac

Heartburn Can Be a Potentially Serious Problem
By Yvan Silva, M.D.

Heartburn is an uncomfortable, burning sensation felt in the upper abdomen, lower chest, and throat, commonly after overindulging in a large meal, alcohol, or spicy foods. Digestive acid flows backward from the stomach up into the esophagus, the lining of which is especially sensitive to it. This reflux causes damage to the lining, the extent of which is related to the frequency of the occurrence and the duration of exposure to the acid. Normally, the digestive acid remains in the stomach because there is a valve-like ring, a sphincter, that prevents reflux. Medically termed Gastro-Esophageal Reflux Disease (GERD), recurring reflux of acid up from the stomach into the esophagus, can result in potentially serious complications.

There are several reasons for chronic, recurring heartburn. Too much alcohol, caffeine, and spicy foods cause the sphincter to relax and allow reflux. Being overweight, overeating, pregnancy, or lying down too soon after a large meal can put pressure within the abdomen on the sphincter. Hiatal hernia is a condition where the stomach protrudes upward into the chest through the diaphragm and this predisposes to reflux. While this is not uncommon, it is frequently not symptomatic.

The physiology of the human stomach is quite well known. In fact, the earliest in vivo (human) experiments were done right here on Mackinac Island by Dr. William Beaumont. It's not the acid, but what it does when it refluxes into your esophagus that causes the problems. The lining of the stomach is compatible with acid, but the lining of flat cells (squamous cells) in the esophagus just cannot stand acid. Acid burns off cells, causes damage that requires the body to try to regenerate the lining and over time, repeated episodes of reflux will alter the lining, thickening and narrowing the esophagus, leading to constriction and eventual obstruction and, as is now known, a pre-cancerous state predisposing to cancer of the esophagus.

Now, while an attack of dyspepsia or stomach upset is well known to most, reflux should only be occasional; those with repeated episodes and longstanding symptoms have GERD and should seek medical attention. The problem lies in an innate dyscoordination of motility of the esophagus which propels food down into the stomach and the valve between the two, the Lower Esophageal Sphincter (LES), which when normal, prevents reflux upward. Its function can be measured by computerbased testing and the whole problem can be assessed by Xrays and endoscopy, direct visualization of the interior of the pharynx, esophagus, stomach, and duodenum.

GERD can mimic heart attacks, and this is driving hundreds of thousands of Americans to emergency departments every year. A recent Harris survey indicates that 19 million Americans have symptoms of GERD: heartburn at least twice a week, and relief obtained by taking some form of stomach medication. Experts believe that this figure is underestimated because the disease can often be non-symptomatic. As a society, we believe that heartburn and indigestion are trivial, and many live with the disease with constant attention to diet and medications, often at considerable cost. Because the public continues to suffer needlessly and people are unaware of effective treatments, large numbers get to an emergency room complaining of crushing chest pain, afraid of the consequences of coronary disease.

More than six million patients go to emergency departments with a variety of chestrelated symptoms every year. It is estimated that about 20 percent of them have serious heartburn or reflux disease. Indeed, about 75,000 to 150,000 heart catheterizations turn out to be normal. Patients get stress tests, EKGs, and other expensive tests before a heart attack is ruled out. About $3 billion is spent per year to care for patients who enter emergency departments and are admitted to cardiac care units for treatment. Abroad estimate of the cost of these misdiagnoses attributable to non-cardiac causes is around $750 million. Reflux disease can cause or contribute to other conditions. Some studies have shown that of the nation's 12 million asthmatics, 70 to 80 percent suffer from reflux, and the same in cases of people with chronic hoarseness of voice.

If heartburn is bothersome or recurrent, the first step is to examine your lifestyle. When symptoms are mild, a change in habits may suffice. When they become severe, lifestyle changes in conjunction with drugs or, when indicated, surgery can make the condition easier to control. Eating smaller meals and waiting at least three hours after a meal to go to sleep can help. Certain "triggers" can be identified and avoided, such as spicy foods, alcohol, caffeine, nicotine, chocolate, garlic, onions, and tomato-laced foods are common. Smoking is a potent cause, and air swallowed during smoking adds to the potential for reflux. Losing weight, if needed, produces relief, as the weight puts pressure on the abdomen and the stomach. Other measures are wearing loose garments and sleeping in an inclined bed; raising the head of the bed six inches can work, while raising your head on pillows will not.

In the past 20 years, new knowledge on how the stomach produces acid, what causes ulcers, and how the LES protects the esophagus from acid has revolutionized treatment. Antacids may be adequate for management of occasional heartburn, but when it becomes chronic, specific drugs are indicated. H2 receptor blockers like Pepcid and Zantac reduce acid production but they don't work as quickly as antacids. They should be taken 30 minutes before meals and prior to bedtime. Another group of drugs called proton-pump inhibitors are most effective. Omeprazole, Prevacid, and others are available. Most of them require a prescription. They work to suppress acid and also to heal injury in the esophagus.

Medical attention is warranted for frequent or severe symptoms. Heartburn that occurs several times a week, that returns soon after antacids have provided relief, and heartburn that awakens at night requires testing. Burning of the pharynx and larynx, also silent, can cause chronic coughing and injury to the lungs. Over a chronic period, damage to the esophageal lining can cause ulcers, bleeding, and eventual narrowing that will

require intervention. In a small percentage of cases, repeated damage in the esophagus leads to a diagnosis of Barrett's esophagus, a particular change in the lining cells that is precancerous. When damage is severe, surgery for removal of the affected section of the esophagus is needed.

Definitive diagnosis is made by endoscopy - a slender tube with a camera is inserted into the esophagus and stomach via the mouth and visualization and videography carried out with biopsy of suspicious areas. This provides the baseline for treatment. Computer-based pressure testing, manomety and motility studies, provide further valuable information about the weakness or incompetence of the LES.

More patients are being selected for surgery when it is evident that the valve between the stomach and esophagus is weak or incompetent, leading to repeated episodes of reflux through the day and increasingly during the night. Reflux can be silent, that is, there are no recognized episodes of heartburn. Silent reflux also causes repeated throat infections, and can damage the vocal cords, resulting in hoarseness or chronic cough, and can even damage teeth.

Carefully selected patients, on the basis of history and relevant tests, a trial of diet and medications, when indicated, are offered surgery to prevent ongoing reflux. The so-called fundoplication operation can be done through a laparoscope when the stomach is wrapped around the lower end of the esophagus; a collar-like segment results and reflux is permanently ameliorated. Some cases require open surgery to achieve this objective. Severe reflux disease, when diagnosed and treated, still requires a lifetime of medical follow-up.

GERD is mostly related to the aging process, although the condition is seen in children and adolescents who are born with a weak gastroesophageal valve mechanism. Commonly associated with a hiatal hernia, reflux can occur in the presence of this condition or even without it. The hiatal hernia is an anatomical condition where the upper portion of the stomach is able to enter the lower chest, sliding in and out of the opening where the esophagus enters the abdominal cavity. GERD is best evaluated and assessed by a qualified gastroenterologist. Referral to a surgeon specializing in these types of procedures becomes relevant when there are indicators that surgery will be necessary.

Dr. Silva is a professor of surgery at Wayne State University and a resident of Woodbluff on Mackinac Island.

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