At my Grandmother’s house, there was little for children to do after dinner but play games and eavesdrop on the grownups who sat around the table for hours after the end of the meal. Back then, the adults seldom talked about “diseases,” but they did seem to think that bodies, like cars, had parts that could be relied upon to malfunction with age and abuse. Dining room table wisdom held that “heartburn” was the expected result of overindulgence in rich food, alcohol, coffee and cigarettes, and that Alka Seltzer was the best remedy. I can still recall the fizz of the tablets dissolving in water.
Renaming a symptom
Heartburn is a vivid word image for the most common gastric complaint – distressing, burning pain just beneath the breastbone. With time, technology, and advertising, heartburn has been replaced by the anatomically correct term gastro-esophageal reflux (GER), which accurately describes the source of the symptom: acid splashing up into the esophagus from the stomach. However, renaming a symptom, heartburn, with its cause, reflux, does not make it a disease, no matter how many TV commercials advertising drugs for GERD (gastro-esophageal reflux disease) say otherwise. Diseases are sometimes associated with GER, but they are diseases that promote reflux, diseases treated with medications that promote reflux, or diseases that result from stomach acid eating away the sensitive lining of the esophagus.
How the esophagus works
Stomach acid is potent stuff, necessary to break down food and to kill off the bacteria that come along with it. Acid also helps with the absorption of vital substances like calcium, iron and Vitamin B12. The stomach lining produces acid and is remarkably resistant to its corrosive effects, unlike the lining of the esophagus above. The job of the esophagus, a muscular tube, is to assist gravity in getting food from the mouth to the stomach via a series of coordinated contractions. In its lowest portion, the esophageal muscle works like a valve. It opens to let food into the stomach and closes to hold it there as digestion begins. The esophagus can also reverse its normal action, opening the valve and emptying the stomach in a hurry, propelling its contents back out the mouth. This very unpleasant action, called vomiting, is perceived mainly as a squeezing, muscular sensation rather than a burning pain, because the exposure of the esophagus to the upward rushing acid is short-lived.
Reflux is backwards, upward flow of stomach contents to the esophagus
Reflux is a more leisurely affair. The muscular valve at the junction of the esophagus and the stomach is not a tight one, and it is subject to the effects of foods and drugs, and diseases that limit its responsiveness (see sidebar). Reflux is more common in people with hiatal hernias – upward slippage of the stomach top into the chest through a weak spot in the diaphragm (muscle between the abdomen and chest). With a stomach full of actively digesting food, reflux can occur simply with lying down or bending over, positions that limit gravity’s help in holding stomach contents down. And held down they must be, for at least awhile, because the stomach is a reservoir where the initial breakdown of food occurs.
The abdomen is a crowded space
The reservoir sits like a pool behind a dam, awaiting opening of the pyloric valve between the stomach and small intestine. The stomach shares close quarters with the liver, spleen, pancreas, small intestine and colon – and with fat tucked around all these organs. The more fat -and the tighter belts and pants are – the less the space available. The upper valve, between the esophagus and the stomach, is the weak link when pressure rises; it gives way while the pyloric valve holds fast, and stomach contents flow into the esophagus. The upper valve also yields in pure overeating (e.g. hot-dog eating contests), when the stomach fills faster than digestion can proceed.
Acid in the wrong location causes trouble
Chronic exposure to stomach acid inflames the lining of the esophagus, and then diseases appear – shallow erosions, deeper ulcers, and scars that interfere with swallowing. Risk of esophageal cancer rises. Acid reflux can go as high as the mouth and erode the enamel of the teeth, add to gum disease, and produce mysterious sore throats and hoarseness. Lung problems and asthma are more frequent in people with chronic reflux.
Reducing stomach acid works, but may cause other problems
Heartburn sometimes requires medical evaluation (see sidebar), but is often responsive to simple antacids like Maalox that temporarily lower stomach acidity. Powerful, safe and effective drugs called proton-pump inhibitors (Prilosec, Nexium, etc.) block the last step of acid production in the stomach. Reflux goes on, but stomach contents are no longer corrosive. But no drugs are free of unintended consequences. Without acid, food digestion is slower. Risks of pneumonia and gastrointestinal infections in long-term users rise, suggesting that in an acid-free environment, bacteria survive in the gut and spill upward into the respiratory tract. Some researchers believe that proton-pump inhibitors also turn acid production off in osteoclasts, cells that build bone, resulting in an increased rate of hip fractures in long-term users. One very worrisome statistic in the age of altering stomach acidity is a rise in rates of esophageal cancer, though the cause of the rise is not fully understood. Lack of stomach acid, however, has long been known to be a risk factor for the development of stomach cancer.
New generations have replaced my grandparents and TV and social media outdraw after-dinner talk, but heartburn, though renamed, is still just a symptom of a mechanical problem – acid reflux. Blunting the effects of acid with over-the-counter or prescription drugs is a temporary solution that does nothing for the inciting problem – the reflux. Weight loss, smoking cessation, elevation of the head of the bed (on 6-9” blocks), avoidance of large meals and offending foods and drugs, and allowing several hours to elapse between meals and bedtime are the keys to taming reflux and keeping GER from becoming GERD.
Common Factors in Patients with Heartburn:
• Obesity, the most common factor.
• Diabetes (delays stomach emptying)
• Pregnancy (space shortage + hormone effects)
• Medications: antihistamines, antidepressants, narcotics, calcium channel blockers for high blood pressure and heart disease, progesterone, anticholinergics (bladder control drugs), some sedatives and tranquilizers
• Foods: fried foods, chocolate, alcohol, caffeine and others.
• Smoking(stimulates stomach acid)
• Asthma and anti-asthmatic medications
• Hiatal hernia
• Stomach outlet obstruction by ulcer or tumor
Seek a Medical Evaluation for Heartburn that:
• Wakes you up at night
• Happens regularly, more than once a week
• Is unresponsive to simple antacids like Maalox or Rolaids
• Recurs promptly after antacids or drugs wear off
• Has associated symptoms: nausea, vomiting, abdominal pain, difficulty swallowing, increasing abdominal girth, or blood in the stool