Burning it Up: How to Ease Heartburn

Soothing heartburnEarlier I wrote about the causes of heartburn, also called GERD (gastro-esophageal reflux disease). Now, let’s talk about how to make it better.

First scenario: You’re minding your own business, it’s late at night, you have an attack of heartburn, and you don’t have any medicine. What can you do? Well, you can go to the pantry, and make your own antacid by mixing up 1/2 teaspoon of baking soda in half a glass of water. It will neutralize the acid. But as with any antacid (see below), the effect won’t last forever. Some foods are soothing for the acid-inflamed stomach, as well. Soda crackers (like Saltines) have baking soda, and can help soak up the acid. Also, apples are your friend. Just eating a plain old apple can help disarm the stomach acid. Some people swear by apple cider vinegar:  A tablespoon, mixed with a tablespoon of honey in a cup of warm water can provide temporary relief, as well.

But this is just emergency stuff, best for the occasional flare-up.

The next scenario:  It’s not your first rodeo. You have noticed that you’ve been having heartburn lately, so you’ve bought some Tums. Well, okay. The problem here is that Tums contain calcium carbonate. They will buffer the acid and give you immediate relief. But the calcium actually causes the acid level to bounce back — higher than it was before you took the Tums. This is called rebound hyperacidity. “So an hour later, you are making more acid than you did before, and you’re taking another Tums,” says Prescott, Arizona, gastroenterologist Mark Worthington, M.D. (Disclaimer: I happen to be married to Mark, an excellent, caring physician who was on the faculty at the University of Virginia for 10 years and then on the faculty at Johns Hopkins for five. He’s in private practice now.)

You probably don’t want to live this way, with one surge of stomach acid following another in big, unpleasant waves. Tums are not a good long-term solution for chronic reflux, so let’s move on to drugs.

The next level up from Tums is other antacids:  Rolaids, Maalox, Mylanta, and Gaviscon. These are different from Tums in the chemicals they contain (the names for these compounds end in oxide and ate): Rolaids have calcium carbonate magnesium hydroxide. Maalox and Mylanta contain aluminum hydroxide and magnesium hydroxide, and Gaivscon has aluminum hydroxide and magnesium carbonate. You can get these kinds of antacids as chewable tablets, dissolving tablets, as chewing gum, and in a liquid form. Some of them have a bonus ingredient, like simethicone, which can subdue the gas bubbles percolating in your stomach; Gaviscon’s bonus ingredient is alginic acid, which foams and helps keep what’s in your stomach from creeping back up the esophagus.

“These work for people with heartburn that is occasional and not too severe,” says Worthington, “although the magnesium can cause loose stools (diarrhea).”

However, if you have more frequent bouts of heartburn, you need to move on to the next room in the acid-resisting bunker:  Acid Reducers, also called H2 Receptor Antagonists, or H2 Blockers. These drugs end in “idine.” Pepcid (famotidine), Zantac (ranitidine), Tagamet (cimetidine), Axid (nizatidine). Pepcid Complete combines an acid reducer with an antacid, so it gives immediate relief and then keeps the acid down. Interestingly, although they’re high on the ladder of heartburn remedies, doctors don’t even think of them as particularly high-powered. “These are okay reflux drugs,” says Worthington. “They don’t suppress acid as much as proton pump inhibitors do,” (see below), “which some people see as a benefit.” Why a benefit? Well, if you can get away with taking this level of drugs and having your symptoms controlled, you can still get some of the good out of stomach acid. Long-term lack of stomach acid can lead to bacterial overgrowth (an excess of bacteria) in the small intestine, and a deficiency of magnesium, iron, calcium, and other trace minerals — because it turns out that you need some acid to absorb them.

And that brings us to the big guns:  Proton Pump Inhibitors. These drugs are the “prazoles.” Prevacid (lansoprazole; note: this is different from the less powerful version of Pepcid discussed above), Prilosec (omeprazole), Protonix (pantoprazole), Nexium (esomeprazole), Dexilant (dexlansoprazole), Aciphex (rabeprazole). Some of these require a prescription. The good thing is, because they pretty much dry up all the acid in your stomach, they give your poor inflamed esophagus a chance to heal.

And this is really important because your esophagus can only take so much. So if your doctor thinks you need a proton pump inhibitor, you should take it. Because if you don’t treat GERD, it can damage your esophagus. Inflammation in the esophagus, called esophagitis, hurts, and makes it difficult to eat, because you’re in discomfort. Worse, long-term esophagitis can lead to a condition called Barrett’s esophagus — which, in turn, can lead to cancer. This is diagnosed with an upper endoscopy, and the good news is that there is treatment for it, called radiofrequency ablation. “We basically zap the lining of the esophagus with radio waves,” says Worthington. “This causes a very defined, superficial burn, and the Barrett’s tissue sloughs off. It’s like getting a sunburn in the esophagus, but it can save your life.”

There is also a condition called a Schatzki ring. “This is a shelf of scar tissue between the stomach and esophagus,” says Worthington, “and food can get hung up on that when you swallow. It’s called ‘steakhouse syndrome,’ because it’s usually a big piece of steak that gets stuck in there. You feel like you’re having a heart attack, but it’s really just the esophagus having a spasm around the food.” Long-term damage to the esophagus can also lead to development of a stricture — more scar tissue, but instead of a ring, it’s a progressive narrowing, so that food can’t go down very easily. This can be opened up during upper endoscopy, as a gastroenterologist makes tiny cuts in the scar tissue to relax its stranglehold on the esophagus.

Finally, there is surgery, a procedure called fundoplication:  taking the top of the stomach and wrapping it around the esophagus to create an artificial valve — so that what happens in the stomach stays in the stomach. “It works pretty well,” says Worthington, although with this procedure in place, “you can’t burp and you can’t vomit, because if you do, you could rip the stitches.” The fundoplication may not last forever. “They do tend to stretch a little over time, but for people with the most severe reflux, it is not an unreasonable thing to do.”

If you keep having heartburn more than twice a week, what should you do? Well, you can try the lifestyle and diet changes written about in the previous post. If those don’t make your symptoms better, you can start on the remedies here, but the best thing you could do would be to get an upper endoscopy (done by a gastroenterologist, so you’ll need a referral from your primary care doctor), to make sure you don’t have any damage to the esophagus that needs more serious treatment.

 

©Janet Farrar Worthington

Regular disclaimer:  This is a blog.  It is not an encyclopedia article or a research paper published in a peer-reviewed journal. If a relevant publication is involved in the story, I mention it. Otherwise, don’t look for a lot of citations, especially if I’m quoting from a medical professional. 

Feeling the Burn? What Causes Heartburn in Men?

soft drinks and chilisYou asked for it, and you got it!  A nice lady at church told me, “My husband has heartburn and keeps hoping it will go away. He won’t go to the doctor, and he doesn’t know anything about what he should do.  He needs very basic information.” 

So, this is part of an occasional series of very basic stuff that you should know about your body.  We’ll start with heartburn.  A lot of men have frequent heartburn, and either take something for the symptoms or tough it out, and neither approach is ideal.  If you are having a lot of heartburn, you should talk to a doctor, ideally a gastroenterologist, a doctor who specializes in the digestive tract.  You may be treating it the wrong way.  If you’re ignoring it, you should know that untreated heartburn can lead to a very bad situation called Barrett’s esophagus — which is treatable, but which can lead to cancer if it’s not addressed.

Heartburn 101

I hate heartburn.  It’s a burning in your esophagus, a fire in the chest, pain that, if it’s really bad, can make you think you’re having a heart attack.  It can affect the throat, too.  This is called throatburn (the medical name is “laryngopharyngeal reflux”), and it can make you cough and need to clear your throat a lot, can make your voice hoarse, even make it harder to swallow. 

Just about everybody gets heartburn sometimes.  But if you have it more than twice a week, then what you call this miserable condition should probably change to GERD — gastroesophageal reflux disease. 

What is it?

Basically, the problem is a leaky valve.  When you eat, food goes down your esophagus and into the stomach.  There is a stopper — a muscle that’s supposed to clench like a fist after food gets into the stomach — called the Lower Esophageal Sphincter (LES).  In a lot of us, it doesn’t always work right.  This is bad because stomach acid, also called gastric acid, is very powerful.  It’s made up of hydrochloric acid, potassium chloride, and sodium chloride, and its job is to activate digestive enzymes, so they can start breaking down the proteins in what you just ate.  Think of Coke taking the tarnish off a penny:  stomach acid just works away, breaking down hamburgers and pizza and biscuits and gravy and apples and beer and cereal and salad.  That’s usually not a problem in the stomach, because the stomach is equipped to handle all that acid.  But the esophagus and throat are not protected from that spillover — so it’s like holding a hot pan without an oven mitt.  Not pleasant.

Why doesn’t my dang valve work? 

“There are three major reasons why people reflux,” says Prescott gastroenterologist Mark Worthington, M.D.  (Disclaimer: I happen to be married to Mark, an excellent, caring physician who was on the faculty at the University of Virginia for 10 years and then on the faculty at Johns Hopkins for five.  He’s in private practice now.) 

One reason:  Transient (temporary) lower esophageal relaxations, “where the lower esophageal sphincter winks open,” just like it does when you burp, “and it bathes the lower esophagus in acid.”  The acid may never go all the way up to the throat; in fact, “some people don’t think they have reflux because they don’t taste acid,” Worthington says.  People with this problem have a normal valve; it just doesn’t function properly. 

Two: Hiatal hernia.  That’s where the junction between the stomach and esophagus is stretched, so that it no longer functions properly.  The valve itself is abnormal.  Have you ever heard of a dunlop?  As in, “my gut dunlopped over my belt?”  Well, in this case, there’s a tiny “dunlop” in which a little piece of your stomach pokes upward into the chest.  By itself, a hiatal hernia is not a worrisome thing; a lot of us have it.  But it can contribute to GERD.

The last big reason: Extra poundage:  Speaking of dunlops, if you want your heartburn to get better and you don’t want to take medicine forever, lose a few pounds.  It’s that darn belly fat again.  Using a few thousand patients from the Nurses’ Health Study, a massive long-term study of more than 238,000 nurses, Harvard physicians studied the link between Body Mass Index and symptoms of GERD; their work was published in the New England Journal of Medicine in 2006.  They found that women who gained just a few pounds had more frequent and severe symptoms of GERD.  The problem with excess weight around the gut — as opposed to extra weight elsewhere, as in thunder thighs or junk in the trunk — is that it pushes on the stomach, causing more pressure in there.  Very simply, this is a mechanical problem.  More pressure on the LES forces some of that stomach acid out and upward.  Now, there’s a flip side to every statistic, and the good news here is that even losing a little bit of weight is going to take some of that pressure off and make your symptoms better.  “You can make reflux better by losing weight, often as little as 10 pounds,” Worthington says.

Here are some other factors:

The luck of the genetic draw:  GERD has a genetic component.  It is known to run in families.  Now, you may say that in a lot of families, everybody eats the same food, so no wonder they all have it, and that’s a good point.  But there still seems to be an inherited tendency to GERD, so if a parent or sibling has it, you might have it, too.  A hiatal hernia can also be hereditary.

Tobacco: In addition to everything else bad that smoking does, it makes GERD worse.  When you smoke, your mouth produces less spit — and saliva helps buffer that awful acid from your stomach. Nicotine also seems to relax the Lower Esophageal Sphincter — it causes that fist to unclench.  And, if you cough a lot from smoking, that can cause acid to shoot upward, as well.  Chewing tobacco, because it has nicotine, is going to have that same effect of relaxing the LES.

 Stress:  Stress makes heartburn worse.  It’s not clear why; it may be that it makes you more sensitive to stomach acid, so even a little goes a long way to making you feel bad.  Also, when you’re stressed, you make fewer prostaglandins, chemicals that help protect against stomach acid.

Eating like a pig:  Yes, I could have put it more delicately.  But I don’t judge; we’ve all done it.  Two things here:  One, when you pig out, it causes more pressure on the stomach, which puts more pressure on that valve, which can open and send acid into the esophagus and throat.  Two, you know it, I know it: Chances are, when you’re scarfing down food, it’s not broccoli and kale. The kind of foods that people tend to overeat — comfort foods, high in fat or oils — are known to relax the valve.  Chili, cheesesteaks, pizza, burgers, lasagna, fried chicken, cheese puffs, onion rings, etc.  Also, garlic, chocolate, alcohol, coffee, citrus fruit, and tomatoes can trigger GERD.

 Tight clothing:  Loosen your belt, and you may feel better.  It takes the pressure off the belly — which, in turn, takes pressure off that pesky valve.

Don’t miss the next article on what you can do to make heartburn better!  Sign up below to get it in your mailbox. 

©Janet Farrar Worthington

Regular disclaimer:  This is a blog.  It is not an encyclopedia article or a research paper published in a peer-reviewed journal. If a relevant publication is involved in the story, I mention it. Otherwise, don’t look for a lot of citations, especially if I’m quoting from a medical professional. 

There is New Hope for Male Infertility

Dandelion seedThink infertility and the picture that comes to mind is usually some poor woman hopped up on a regimen of hormones, getting one or more rounds of expensive in-vitro fertilization (IVF), and hoping desperately that it will take.  But sometimes, when a couple wants to have a baby and can’t, the problem is not with the woman.  It’s the man, and this side of the story is just as heartbreaking and frustrating, but we don’t hear much about it.  Yet another item on the long list of depressing things men don’t want to talk about.

I think maybe we should be talking about it.  Maybe, if you’re in this painful situation — maybe you had an illness like the mumps, or testicular cancer – you have been told that there’s no hope that you could ever father a child of your own.   But that might not be the case.  There’s a lot more hope now.

Pravin Rao, M.D., is an expert at finding what was previously considered unfindable.  “A lot of my patients come in thinking that since there’s no sperm in the ejaculate, there’s no hope for having children,” he told me in an interview for the newsletter, Johns Hopkins Urology.   But just because there’s no sperm one place, doesn’t mean that there’s no sperm at all.  Often, there is.

“That used to be true.  But now we are able to achieve pregnancy with very few sperm,” using a process called intracytoplasmic sperm injection, says Rao, who is the director of Reproductive Medicine and Surgery at the Brady Urological Institute.   So there are several good things happening here: One, doctors can fertilize an egg with just a few sperm, and two, there are new methods for delving into the nooks and crannies of the testicles, finding sperm, and extracting it.  “With improving techniques of finding sperm, we’re able to help many of these families reach their goals.”

Some men who have azoospermia, the absence of sperm in the semen, still may be producing small amounts of sperm within the testes, or testacles.  Even though they don’t reach the semen, that doesn’t mean these little guys can’t still work and do their job of fertilizing an egg.  It’s just a logistics problem.  In about 55 to 60 percent of these men, Rao is successful at retrieving sperm from the testes with micro-dissection testicular sperm extraction (TESE).

This is microsurgery, and it’s extremely delicate.  “We look for areas within the testis that might be making sperm,” tiny pockets among the thin, tightly looped seminiferous tubules.  “In most men, every tubule is making large amounts of sperm,” Rao says, “but these men are making so little that you don’t see it in their ejaculate.  But in just one or a few healthy tubules, we often find sperm.”

How do they find it?  Well, there are no helpful imaging or other tests that can show or help predict where these little pockets might be hiding.  Thus, “the only way to know for sure is to go in there and find the tubules that look promising.

Once Rao finds some sperm, with the help of reproductive endocrinologists (from Johns Hopkins or other hospitals), the sperm are joined with an egg and implanted in the female partner’s womb through IVF.  “On average, it takes two to three cycles to produce pregnancy,” Rao says.  The sperm may be used that same day it is harvested, if the eggs are also being obtained then, or they can be frozen for future use. He also performs vasectomy reversal and other procedures to correct issues that can cause a very low to nonexistent sperm count, such as hormonal factors, varicocele, or blocked ejaculatory ducts.

Here is the take-home message from Rao, which I hope you will receive and pass on to someone who might need it:  “For many men who think there is no hope, there is actually a lot of hope.”

 

©Janet Farrar Worthington

Regular disclaimer:  This is a blog.  It is not an encyclopedia article or a research paper published in a peer-reviewed journal. If a relevant publication is involved in the story, I mention it. Otherwise, don’t look for a lot of citations, especially if I’m quoting from a medical professional.