Help for Heartburn

Heartburn, also called GERD (gastro-esophageal reflux disease), is miserable.  To review what causes it, see this post.  Now, let’s talk about how to make it better.  I know this subject better than I’d like to, and if you suffer from heartburn, I feel your pain:  I, too, am a reluctant member of the GERD herd.

So. what kind of heartburn do you have?  Let’s look at the whole spectrum, ranging from the occasional unwelcome guest to the toxic constant companion.

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 old-school: 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.  My go-to, if I’m feeling the burn and need help right away:  a shot of something carbonated.  Mexican Coca-Cola (with cane sugar, not high-fructose corn syrup) is my personal favorite, but any seltzer or soda water will provide temporary relief.  The bubbles are good.

But this is just emergency stuff, best for the occasional flare-up.  If you have severe or persistent GERD, you need to move into the realm of acid-fighting medicines.

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 – and some people do okay just taking an occasional Tums.  But for those of us with persistent GERD, 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 University of Virginia gastroenterologist Mark Worthington, M.D. (Disclaimer: I happen to be married to Mark, an excellent gastroenterologist and caring physician.)

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.

Other antacids include 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 may help 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 Mark, “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 level in the acid-resisting fortress:

Acid Reducers, also called H2 Receptor Antagonists, or H2 Blockers. These drugs end in “idine,” and include Pepcid (famotidine; there are many generic famotidine 20 mg brands available) and Tagamet (cimetidine), not often used because it has interactions with other medications).  (Personal note, Pepcid or its generic equivalent works for me.  My GERD is controlled with one 20 mg famotidine, twice a day.)  Dual-action Pepcid Complete (or generic equivalent, containing 10 mg famotidine plus calcium carbonate and magnesium hydroxide) combines an acid reducer with antacids.  This 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 acid reducers as particularly high-powered. “These are okay reflux drugs,” says Mark. “They don’t suppress acid as much as proton pump inhibitors or PCABs  (see below) do, 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, vitamin B12, and some trace minerals — because it turns out that you need some acid to absorb them.

The Big Guns

Now we move to the high-powered drugs:  Proton Pump Inhibitors (PPIs) and potassium channel acid blockers (PCABS).

PPIs are the “prazoles,” and include:  Prevacid (lansoprazole), Prilosec (omeprazole), Protonix (pantoprazole), Nexium (esomeprazole), Dexilant (dexlansoprazole), Aciphex (rabeprazole). The over-the-counter PPIs are at lower doses, and are meant to be taken for two to three weeks.  They can be taken for longer than that, but if you keep buying more of these 14-day packs, you should consider seeing a gastroenterologist.  PPIs don’t dry up all the acid in your stomach.  Instead, as Mark says, “In typical doses, they take the battery acid in your stomach and turn it into vinegar-strength acid,” and give your poor inflamed esophagus a chance to heal. More on this in a minute.  “If the reflux goes all the way to the airway (laryngopharyngeal reflux, where the acid bubbles up to your throat or even nose), we will give a higher dose of a PPI and block all the acid,” notes Mark, “but there are side effects,” including bacterial overgrowth, nutritional deficiency, kidney damage, and loss of bone strength.  In severe cases, the best option may be surgery (see below).

Note:  PPIs are not meant to be taken continuously over the long run.  The idea is to take a prescription PPI for two to three months when you have had a bad bout of GERD with a lot of esophagitis, get you through that, and then wean you off or move you to something less powerful like Pepcid – or to nothing at all.

What about the risk of dementia with PPIs?  “That really appears to be related to vitamin B12 deficiency,” says Mark, “which tends to occur after about two to five years on the drug.”  So if you are on a PPI for more than a year, make sure your doctor checks your level of vitamin B12, and to be on the safe side, take a vitamin B12 supplement.  “You need stomach acid to absorb B12,” Mark explains, “but if you take enough of it, using a vitamin supplement, your body will manage to absorb some. The good news is that this cognitive impairment is usually reversible when the vitamin B12 is repleted.”

Still, the idea is not to take a PPI forever, and if your symptoms don’t get better, one option is surgery (see below).  But wait!  Your pool of options just got bigger.  There is a brand-new category of drugs to treat GERD:  PCABs.

PCABs are “potassium-competitive acid blockers.”  For now, they are available only by prescription, and they’re expensive (several hundred dollars a month).  The first PCAB on the market is called Voquenza (vonoprazan).  “It blocks acid, but it works in a different way than a PPI,” says Mark.  “The nice thing is, there’s no strict association with taking it on an empty stomach – unlike a PPI, which you need to take when the stomach is empty and there’s acid present, so the drug has access to the acid pumps.  Voquenza doesn’t take days to work, either, compared to PPIs, which require a few days to get to their peak effect – so it may have potential in the future for intermittent dosing.”  Although there is only one PCAB on the market in the U.S., others are available in Japan, and may one day come to the U.S. market.  As Mark says, “Competition is good,” and maybe this will lower the cost of these drugs.

Protecting the Beleaguered Esophagus

“Your esophagus can only take so much,” as Mark explains.  “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.  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 Mark. “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.”

Long-term esophagitis can lead to a condition called a Schatzki ring. “This is a shelf of scar tissue between the stomach and esophagus,” says Mark, “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, too, is treatable: the stricture 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 Mark, 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 – reflux that is not controlled with medication, or when people can’t get off a PPI because their symptoms are so bad – 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 here. If those don’t make your symptoms better, you can start on the remedies discussed above, but if these don’t help, or if you are taking a PPI more than twice a week, 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.

In addition to the book, I have written about prostate cancer on the Prostate Cancer Foundation’s website, pcf.org.  The stories I’ve written are under the categories, “Understanding Prostate Cancer,” and “For Patients.”  I firmly believe that knowledge is power.  Saving your life may start with you going to the doctor and knowing the right questions to ask.  I hope all men will put prostate cancer on their radar. Get a baseline PSA blood test in your early 40s, and if you are of African descent, or if cancer and/or prostate cancer runs in your family, you need to be screened regularly for the disease.  Many doctors don’t do this, so it’s up to you to ask for it.

©Janet Farrar Worthington

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Making the Bowel Less Irritable

Got irritable bowel?  As many as 40 percent of people who go to the doctor with gastrointestinal problems suffer from irritable bowel syndrome (alternating diarrhea and constipation); dyspepsia (uncomfortable fullness or pain in the upper abdomen, heartburn, or other digestive problems); or gastroparesis (the stomach muscles or the nerves that drive them stop working, and food doesn’t move out of the stomach the way it should).

These conditions are motility disorders, and they involve the enteric nervous system, the massive highway of nerve cells lining the muscular walls of your esophagus, stomach, intestines, and rectum.  The enteric nerves control peristalis, the conveyor-belt series of muscle contractions — think of toothpaste being squeezed through a tube — essential for swallowing, for digestion, absorption of food, and for pooping (literally, movement of the bowels).

“The treatment of motility disorders really requires the art as well as the science of medicine, because every patient responds differently,” says Pankaj Jay Pasricha, M.D., gastroenterologist and neuroscientist, director of the Center for Digestive Diseases at Johns Hopkins Bayview.  Pasricha created the Johns Hopkins Center for Neurogastroenterology and Gastrointestinal Motility Disorders to explore this gut-brain axis, which I wrote about here.

Diagnosing and treating these disorders can take time, dedication, creativity, and patience.  My husband, Mark, an excellent gastroenterologist, was on the faculty at Johns Hopkins and the University of Virginia before he went into private practice here in his home state of Arizona.  Many of his patients have difficult diseases, and he works with them – sometimes for months or even years – to find the right treatment to improve their lives.  By the time they get to him, these patients may be feeling frustration or even despair because they haven’t gotten the help they need.  For years, irritable bowel was the fibromyalgia of GI disorders, misunderstood and misdiagnosed.  If you are suffering from irritable bowel symptoms, you probably already know this.  Maybe you’ve also had a doctor get frustrated or impatient with you when you didn’t get better – like it’s your fault, or it is all in your head!  Or maybe the doctor has done a colonoscopy or endoscopy and, not finding anything striking, has seemed to lose interest in your care.  You’re not alone.

Successful treatment starts with a meticulous history and careful physical exam.  “About 80 percent of the time,” says Mark, “the key to the diagnosis is right there in the history.”  But just knowing the underlying cause of a motility disorder doesn’t necessarily mean the problem can be fixed right away.  Everybody’s different, and there is no cookie-cutter approach to making this better; treatment that helps one person won’t necessarily help someone else with the same diagnosis.  “If we’re trying a new medicine, it can take four weeks, or longer, to see if it works,” says Mark. “And if it doesn’t, then it’s another several weeks with the next medicine, and the next.  There’s a lot of trial and error, but if the doctor and patient are determined, and if they have patience to keep trying, we can often make it better.  The art is managing the symptoms, such as diarrhea, without simply converting it to chronic constipation, which is just as miserable in its own way.”

Not all treatment requires a prescription:  There are some very good over-the-counter products that can help reduce symptoms.  (Note: Heartburn and gastro-esophageal reflux disease (GERD), and acid reducers and proton pump inhibitors, are discussed here.)  Here are four:  For dyspepsia, Mark often recommends FDgard, whose ingredients include peppermint oil and caraway oil.  For irritable bowel, IBgard is a similar product — except it works in the gut, instead of the stomach.  Iberogast, an herbal medicine from Germany, works on both the stomach and gut: just put 20 drops into a glass of water or tea.  Equalactin helps ease irritable bowel by evening things out:  it treats constipation by adding bulk and also increasing the amount of water in your poop, making it easier to pass; at the same time, the bulking agent treats diarrhea by making it less runny and more solid.

What else?  You may need to take a good, close look at your diet. “Foods can be a major issue,” says Mark. “Many people have food allergies and don’t know it, and the way we figure this out is to remove one type of food (like dairy products) from the diet at a time and see if it makes a difference.  Celiac disease is not an allergy but an immune reaction to gluten, and the treatment is a gluten-free diet, which is harder than you may think,” because many products, from soy sauce to shampoo, have wheat.  Shampoo??  Yes, and to people with celiac, or people who are very sensitive to gluten, even absorbing it through the skin can cause cramping, bloating, and diarrhea.  If you have a food allergy or celiac disease, “you need to change the diet permanently to get lasting relief.  This requires a commitment,” and vigilance to check every single label of every packaged food you buy.  It also requires discussions with the server at every single restaurant you go to.  This can get old – trust me; in my family, in addition to GERD and irritable bowel, we’ve got celiac disease, lactose intolerance, and an allergy to milk and butter (from cows, but not from goats; go figure!).  It’s a pain, but the consequence of not being vigilant about what my family members eat is sickness.  In the case of celiac disease, prolonged exposure can actually lead to cancer in the small bowel — but prolonged avoidance of gluten means a healthy life!  It’s a no-brainer.

“Many patients have a sensitivity to FODMAPs, which are fermentable things in foods we eat.”  Every time I hear the word, “FODMAP,” I think of the old song, “RaggMopp,” by the Treniers.  Just putting that out there.  FODMAP is an acronym for Fermentable Oligo-, Di-, Mono-saccharides And Polyols.  And what are these fine fellows, you may be wondering?  Basically, they’re carbs.  Notorious carbs that may not do villainous things to other people, but if you are sensitive to them, they trigger bloating, gas and stomach pain.

The key word here is fermentable: Sugars, sugar alcohols, high-fructose corn syrup, lactose, sugars in fruits, especially stone fruits (pears, plums, peaches, prunes, and probably some others that don’t start with the letter p). “All these foods tend to make everyone produce gas, but the effect is greater on people who have irritable bowel,” says Mark.  Basically, if you have irritable bowel, these foods are a fermentable toot fest.

So that’s the F in FODMAP; what about the other letters?  Oligosaccharides are foods including wheat, rye, legumes, garlic, onions, and some other fruits and vegetables.  Disaccharides are milk, yogurt, and soft cheese.  The sugar they contain is lactose.  Monosaccharides have a different type of sugar, fructose, and include fruits such as figs and mangoes, agave nectar and honey.  Polyols are found in other fruits and vegetables, including blackberries.  They’re also found in sugar-free gum.

The bottom line here, no pun intended, is this:  If you find that you have a lot of gas and discomfort after eating, if you are prone to diarrhea, constipation, or both, if you are feeling like food is not moving through your GI tract the way it ought to, well, it’s quite possible that you have a motility disorder such as irritable bowel.  The good news is that there is help out there — prescription medicine, over-the-counter treatment, and dietary changes.

©Janet Farrar Worthington

 

 

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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 University of Virginia gastroenterologist Mark Worthington, M.D.  (Disclaimer: I happen to be married to Mark, an excellent, caring physician.) 

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. 

In addition to the book, I have written about prostate cancer on the Prostate Cancer Foundation’s website, pcf.org.  The stories I’ve written are under the categories, “Understanding Prostate Cancer,” and “For Patients.”  I firmly believe that knowledge is power.  Saving your life may start with you going to the doctor and knowing the right questions to ask.  I hope all men will put prostate cancer on their radar. Get a baseline PSA blood test in your early 40s, and if you are of African descent, or if cancer and/or prostate cancer runs in your family, you need to be screened regularly for the disease.  Many doctors don’t do this, so it’s up to you to ask for it.

©Janet Farrar Worthington

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