Asked by Loretta Torti, Encinitas, California
I keep having this terrible heartburn. It hurts to elevate my legs. Food feels like it's coming back up, and it burns very badly. Sometimes it makes me cough. What should I do?
Dr. Otis Brawley
Chief Medical Officer,
American Cancer Society
Acid reflux is when the acidic liquid in the stomach rises up into the esophagus or higher into the throat, nose or mouth. This fluid can burn the esophagus, causing chest pain, which is often referred to as heartburn. Acid reflux occurs in virtually everyone occasionally. People who have it more frequently have what is referred to as gastroesophageal reflux disease, known by the acronym GERD.
When it occurs frequently, acid reflux can actually damage the throat, causing trouble swallowing, change in or loss of voice, as well as the feeling of a lump in the throat. Aspiration or breathing in of the stomach contents can lead to cough and in more serious cases, a burning of the lungs and "aspiration pneumonia." Long-term burning of the esophagus can lead to a condition known as Barrett's esophagus, which can progress on to esophageal cancer.
It is estimated that 10 to 20 percent of adults in the Western world have GERD. It is believed about 5 percent of people in Asia have it. This disease is more common among people who are overweight and sedentary. It can be worsened by certain foods such as chocolate, fatty foods, spicy foods, citrus juices and alcohol. Smoking also worsens reflux. Pregnant women often have it as well.
The initial approach is use of an over-the-counter oral antacid medication such as calcium carbonate or aluminum hydroxide to try to overcome the burning pain. Patients who need further therapy are often given acid-reducing H2 blocker medications such as cimetidine (Tagamet), famotidine (Pepcid), nizatidine (Axid) or ranitidine (Zantac). If symptoms do not improve, patients are given proton pump inhibitors such as omeprazole (Prilosec), lansoprazole (Prevacid), and esomeprazole (Nexium). Some of these drugs are available without prescription. Lifestyle changes such as avoidance of foods that cause symptoms, exercise and weight loss often help. Some people find taking a walk for 20 minutes every day helps.
Many people have worse symptoms when lying down. Raising the head of the bed 6 to 8 inches with blocks can be helpful. Extra pillows to raise the head do not help -- bending in the middle of the torso increases pressure on the stomach and forces stomach fluid up the esophagus, worsening symptoms.
In the past we frequently used drugs to stimulate gastric emptying, such as bethanechol or metoclopramide, but realization that these drugs often cause serious side effects has caused them to be used to treat only extremely severe GERD. Surgery is a treatment of last resort. This procedure, called the Nissen fundoplication, can be done through a scope placed in the chest. The esophageal-gastric junction is modified or reshaped to decrease the tendency of fluid to reflux up into the esophagus.
I should note that a hiatal hernia, which is the top of the stomach being in the chest, above the diaphragm, increases risk of GERD, but occurs more often without GERD than with.
An internist or family physician can treat most patients with reflux, but patients with symptoms that don't respond to treatment should be seen by a gastrointestinal specialist, who may do additional testing such as an upper GI endoscopy. Diseases that occasionally mimic GERD include esophagitis, which can even be caused by pills for other illnesses; peptic ulcer disease; inflammatory diseases; and the Zollinger-Ellison syndrome, which is a rare disease in which gastric acidity is increased because of an endocrine disorder.
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