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Harvard Commentaries
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Harvard Commentaries
Reviewed by the Faculty of Harvard Medical School


Man to Man Man to Man
 

GERD -- Heartburn and More


January 24, 2013

By Harvey B. Simon M.D.

Harvard Medical School


You have seen the ads for heartburn remedies. An overweight man eats a big meal late at night, perhaps followed by some coffee and a rich chocolate dessert. That's an extreme.

For many men, heartburn comes on even when they do right things. Doctors call this gastroesophageal reflux disease, or GERD. Sometimes, heartburn is not the most bothersome symptom — it might be a persistent cough or hoarseness. But once you know you have GERD, you can control it and prevent complications.

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What is GERD?

Every time you swallow, ring-like muscles of the lower esophagus, called the lower esophageal sphincter (LES), relax so food can go into your stomach. When your stomach is full, it's normal for a tiny amount of food can sneak back into the esophagus while swallowing. But for people wh0 have GERD, substantial amounts of stomach acid and digestive juices get into the esophagus. The stomach has a tough lining that resists acid, but the food pipe doesn't. Its sensitive tissues are injured by acid, and, if the acid makes it all the way to the mouth, other structures can be damaged.

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Common Causes of GERD

Poor function of the LES is responsible for most cases of GERD. Various substances can make the LES relax when it shouldn't, and others can irritate the esophagus, making the problem worse. Other conditions can simply put too much pressure on the LES. These are some of the foods and drinks that adversely affect LES function:

  • Foods
    • Garlic and onions
    • Coffee, cola drinks and other carbonated beverages
    • Alcohol
    • Chocolate
    • Fried and fatty foods
    • Citrus fruits
    • Peppermint and spearmint
    • Tomato sauces
  • Medications
    • Alpha blockers (for treating prostate problems)
    • Nitrates (for treating angina)
    • Calcium-channel blockers (for treating angina and high blood pressure)
    • Tricyclics (for treating depression)
    • Theophylline (for treating asthma)
    • Biphosphonates (for treating osteoporosis)
    • Anti-inflammatories (for treating arthritis, pain and fever)
  • Other offenders
    • Smoking
    • Obesity
    • Overeating
    • Tight clothing around the waist
    • Hiatus hernia (part of the stomach bulges through the diaphragm muscle into the lower chest)

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Symptoms of GERD

Heartburn and "acid indigestion" are the most common complaints. A burning pain is typical, and when it's accompanied by burping or bloating, GERD is the likely cause. But GERD can sometimes cause chest pain that's severe enough to mimic a heart attack or belly pain that mimics an ulcer.

If the acid makes it all the way to the throat and mouth, it can cause other problems. And since these problems can occur in the absence of heartburn, they are often misdiagnosed. Here are some of the stealthy signs of GERD:

  • Mouth and throat symptoms
    • A sour or bitter taste in the mouth
    • Regurgitation of food or fluids
    • Hoarseness or laryngitis, especially in the morning
    • Sore throat or the need to clear the throat, especially after meals
    • Tooth erosions
    • Feeling that there is a "lump in the throat"
  • Lung symptoms
    • Persistent coughing without apparent cause, especially after meals
    • Wheezing, asthma

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Complications of GERD

About 20 million Americans have GERD. Most of them have heartburn; many experience throat or lung symptoms. But a few people with GERD develop complications.

The most common is esophagitis, an inflammation of the food pipe. It produces consistent burning pain that can make swallowing and eating difficult. Left untreated, the inflammation can cause ulcers of the tube's lining and/or bleeding. Repeated cycles of esophagitis and healing can lead to a scarring and narrowing or stricture of the tube.

Severe esophagitis only strikes about 2% of men with GERD. An even smaller number develop Barrett's esophagus, a condition in which severe inflammation and acid cause pre-malignant changes in the cells that line the esophagus. But even with these changes in the cells, very few actually develop cancer. To prevent that, patients with severe esophagitis should have lifelong acid-suppressing medication. People with Barrett's esophagus need periodic endoscopies to detect changes that could become cancerous.

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Diagnosing GERD

Most people with GERD don't need any tests to diagnose the condition. It's usually diagnosed based on symptoms and a trial of medication to see if it helps.

If your symptoms are typical and mild, you may even be able to treat yourself. Similarly, if doctors suspect you have uncomplicated GERD, they may recommend a trial of medication and lifestyle changes as the next step. If your symptoms improve, you probably won't be asked to have additional tests.

GERD can be puzzling, however, so if the diagnosis is uncertain, tests may be necessary. Esophageal monitoring is a good way to diagnose GERD. One type, pH monitoring, measures the level of acid in the esophagus over a 24-hour period, while manometry measures the pressure in the esophagus during swallowing to see if the muscles are working normally.

Endoscopy is the best way to detect the complications of GERD, including inflammation, ulcers, strictures and abnormal or malignant cells. After giving you sedatives and numbing your throat, your doctor will pass a fiber-optic tube through your mouth into your esophagus and stomach. Endoscopy allows the physician to inspect and photograph your tissues and to perform biopsies on any suspicious areas.

Endoscopy is an important test, but it's not risk free, so it should only be done when necessary. Here are some warning symptoms that may call for endoscopy:

  • Longstanding or severe GERD
  • GERD that does not respond to medication or lifestyle changes
  • GERD that begins after age 50
  • GERD that is accompanied by loss of appetite or weight, vomiting, bleeding or anemia, difficulty swallowing, or the sensation of food sticking on the way down.

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Treating GERD

Lifestyle

You can control many symptoms of GERD with these simple lifestyle modifications:

  • Don't smoke. It's the first rule of preventive medicine, not just for GERD, but for heart and lung disease, too.
     
  • Avoid your trigger foods.
  • If you're taking certain painkillers, antibiotics or other medications that can irritate the esophagus or contribute to GERD, ask your doctor about alternatives. Don't stop treatment on your own.
  • Avoid large meals and try to be up and around for 30 minutes after you eat. (It's a great time to help with the dishes, guys.) Don't lie down for two hours after you eat, even if it means giving up that bedtime snack.
  • Use gravity to keep the acid down in your stomach at night. Propping your head up with an extra pillow won't do it. Instead, place four- to six-inch blocks under the legs at the head of your bed. A simpler — but very effective — approach is to sleep on a large wedge-shaped pillow. Your bedding store may not carry one, but many maternity shops do. That's because GERD is so common during pregnancy. (You won't be the only man either looking for a pillow in a maternity shop because GERD is so common among men.)
  • Chew gum, which will stimulate acid-neutralizing saliva.
  • Lose weight.
     
  • Avoid tight belts and waistbands.

Medications

If you doubt that GERD is a big problem in the United States, just check out your local pharmacy. You'll find a vast array of over-the-counter (OTC) products to treat it. There are also many prescription medications behind the pharmacist's counter that can help:

  1. Proton pump inhibitors (PPIs). PPIs are the most effective medications for GERD because they do the best job of turning off the stomach's acid production. They act rapidly. But even after you feel better, it may take 6 to 12 weeks to heal an inflamed food pipe. Because GERD tends to recur, patients usually need long-term therapy. People with severe esophagitis or Barrett's esophagus may need high-dose, lifelong treatment. Fortunately, side effects are uncommon: diarrhea, rash, or headache occur in fewer than 3% of patients. Long-term use, particularly at high doses, can increase the risk of osteoporosis ("thin bones") and fractures. There are now several PPIs to choose from. Check with your pharmacist to see which ones are can be purchased without a prescription and which are available as less expensive generics. Examples include omeprazole (Prilosec over-the-counter and generics), pantoprazole (Protonix and generics) and lansoprazole (Prevacid over-the-counter and generics).
  2. H2-receptor blockers. These popular drugs are widely available OTC in low doses and by prescription in full doses. H2 blockers can provide temporary relief for mild GERD, but are less effective than PPIs. Examples include cimetidine (Tagamet), ranitidine (Zantac), famotidine (Pepcid) and nizatidine (Axid).
  3. Antacids. Antacids don't reduce the amount of acid produced by the stomach, but they do neutralize some of it. Many are available OTC. They reduce acid faster than acid-suppressing medications, but provide only temporary relief for mild heartburn. In general, liquid antacids work faster than chewable tablets. Antacids that contain magnesium can produce loose stools. Those with calcium can be used as dietary supplements to build stronger bones, but men should not overdo it. That's because they can cause constipation. Also, high doses of calcium (above 1,200 mg a day) may increase the risk of advanced prostate cancer.
  4. Coating agent. Sucralfate (Carafate) is a prescription drug that protects the esophagus and stomach by forming a protective film on the surface. It is very safe, but long-term benefits are unclear.
  5. Motility agent. Metoclopramide (Reglan), another prescription drug, promotes normal contractions of the esophagus and helps the stomach empty faster. Some people have side effects, such as drowsiness, agitation and tremors, which limit its usefulness. But Reglan can help some patients with GERD.

Surgery

Lifestyle modifications and medications — particularly the PPIs — have been so effective that surgery for GERD is recommended much less often than it used to be. Surgery can be very beneficial for patients with severe GERD who don't respond fully to medication and, perhaps, for young people who are leery of taking lifelong medication.

The major advance is the use of laparoscopic surgery for GERD. While the patient is under general anesthesia, the surgeon makes several small incisions through which a fiber-optic tube and tiny surgical instruments are inserted. The most popular GERD operation is the Nissen fundoplication, in which the upper portion of the stomach is wrapped around the lower esophagus to prevent reflux. New approaches include using radiofrequency energy to tighten the LES (the Stretta procedure) and tightening the LES with sutures (the Bard system).

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Getting the Better of GERD

GERD is a problem of modern life. Smoking, poor eating habits, obesity, alcohol abuse and stress all fuel the fire of heartburn. A little heartburn from time to time is no big deal, but persistent GERD can lead to serious complications. Fortunately, this modern problem can be solved with old-fashioned lifestyle changes, modern drug therapy with PPIs or other agents, and with new surgical options.

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Harvey B. Simon, M.D. is an Associate Professor of Medicine at Harvard Medical School and a member of the Health Sciences Technology Faculty at Massachusetts Institute of Technology. He is the founding editor of the Harvard Men's Health Watch newsletter and author of six consumer health books, including The Harvard Medical School Guide to Men's Health (Simon and Schuster, 2002) and The No Sweat Exercise Plan, Lose Weight, Get Healthy and Live Longer (McGraw-Hill, 2006). Dr. Simon practices at the Massachusetts General Hospital; he received the London Prize for Excellence in Teaching from Harvard and MIT.

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