Heartburn and Reflux
Everyone occasionally has heartburn. This occurs when stomach acid flows backward into the esophagus, the food pipe that carries food and liquid to the stomach. A sphincter, or specialized muscle, is located at the end of the esophagus. Known as the lower esophageal sphincter (LES), this muscle contracts much the same as the anus does. The sphincter should maintain a certain pressure to keep the end of the esophagus closed, so that stomach juices are not admitted. The LES muscle should only open when food is passed into the stomach.
However the LES muscle does not always work perfectly. It can be easily overcome by a number of factors, the most common being eating a large meal. Along with swallowed air, a large meal causes pressure in the stomach to rise, thereby overpowering the LES muscle. Other factors that reduce the LES pressure and allow reflux are:
- Nicotine (cigarettes)
- Fired or fatty foods
- Citrus fruits and juices
- Lying flat
- Hiatus Hernia
- Certain prescription medicines
Is Heartburn Serious?
Heartburn and reflux are extremely common, with 10 percent of the population experiencing them daily. Twenty-five percent of pregnant women have heartburn. Even though heartburn is common, it is rarely life threatening. Severe cases, however, can result in injury to the lower esophagus that requires treatment.
What Is A Hiatus Hernia?
The esophagus passes through a flat muscle, called the diaphragm, which separates the lungs from the abdomen. When the opening in the diaphragm enlarges, a portion of the stomach can protrude (herniate) through it into the chest. This is called a hiatus hernia. A persistent hiatus hernia may produce significant heartburn. However many people who experience heartburn do not have a hiatus hernia and, likewise, many people with a hiatus hernia do not experience heartburn. These two conditions can occur independently of each other.
The primary tests used to diagnose reflux are:
- Upper GI series
The patient drinks liquid barium and x-rays are taken of the esophagus and stomach and how they function.
- Upper GI endoscopy
The patient is mildly sedated and a flexible fiberoptic scope is inserted into the esophagus to visually inspect it and the stomach.
- Esophageal manometry
This test measures the pressures within the esophagus, especially the LES pressure.
Besides heartburn, the major problems that can develop with long-term reflux are:
- Chronic bleeding and anemia.
- Scar formation and narrowing of the lower esophagus. A stricture usually can be treated by dilatation.
- Barrett's esophagus, which occurs when long-term reflux irritates the lower esophagus so that the stomach lining actually grows into the esophagus. In these cases, there is a slight but definite, risk of a subsequent malignancy.
- Lung problems when reflux results in stomach fluid trickling into the breathing tubes, causing wheezing, bronchitis, and even pneumonia. This often occurs at night when the patient is lying down.
General measures the patient can take to reduce reflux are:
- Eat smaller and more frequent meals.
- Avoid eating before going to bed.
- Eliminate excessive bending, lifting, abdominal exercises, girdles and tight belts, all of which increase abdominal pressure and provoke reflux.
- If overweight, lose weight. Being overweight promotes reflux.
- Eliminate or significantly reduce consumption of nicotine (cigarettes), fatty foods, alcohol, coffee, chocolate, and peppermint.
- Elevate the head of the bed 8" to 10" by placing pillows or a wedge under the upper part of the mattress. In this way, gravity keeps stomach juices out of the esophagus while the patient sleeps.
- Prescription medications 3/4 check with the physician regarding side effects of prescription drugs. Some drugs actually lower the strength of the LES muscle. These include anti-spasmotics (Levsin, Librax, Bentyl), calcium channel blockers (Procardia, Cardizem Calan, Isoptin), anti-depressants (Elavil, Doxipia) and others.
Other treatments include:
These can and should be used often. Generally, antacids should be taken 30 to 60 minutes after eating and at bedtime. Liquids are preferred to tablets, with the strongest being Maalox II, Mylanta II, Gelusil II, and Extra Strength Riopan.
- Alginic Acid and Antacids
Two products, Faviscon and Algicon, place a layer of foam over the fluid in the stomach to prevent reflux. These tablets should be chewed well and used 30 to 60 minutes after eating and at bedtime.
Medicines are now available that effectively reduce and even eliminate the secretion of stomach acid and increase the strength of the LES muscle. These medicines represent the most important method of treating reflux. Other medications such as Reglan (generic: metoclopramide), Urecholine (generic: vethanechol), and Propulsid (generic: cisapride) directly increase the strength of the LES muscle.
Surgery is rarely required in treating reflux. However, when an intensive treatment program, as outlined above, is ineffective, surgery must be considered to strengthen the LES muscle. Successful surgery greatly relieves and can correct severe reflux and heartburn. This procedure is called fundoplication. Previously this surgery required a major operation, often through the chest. It is a difficult operation for the patient, with a long recovery. Fundoplication surgery is now usually done by laparoscopy, which is minimally invasive surgery performed with a tiny incision at the naval. The patient usually returns home 1 to 2 days after surgery, with few problems. There is a newer treatment called endoluminal gastroplication which is an outpatient procedure combining the use of endoscopes with a special suturing device to make plications or pleats in the wall of the esophagus just below the LES. Esophageal endoscopy and endoluminal gastroplication are done under sedation, with no incisions whatsoever. As an outpatient procedure, the patient returns home the same day and usually returns to normal daily activity the next day.
Heartburn occurs so commonly that it is normal for everyone to experience it sometime. However, when heartburn is persistent, it needs to be evaluated, and long-term follow up care is often required. Medical treatment is usually very effective and can prevent complications. For the few patients for whom medical treatment does not work, surgery offers a viable and usually successful alternative.