The Burning Question
Is that searing pain just simple indigestion or a chronic disease?
When automotive journalist Markus Stier was in his 20s, he started experiencing burning pain in his chest about twice a month. For years, he suffered without seeking medical assistance. A girlfriend who worked in a pharmacy recommended antacids, and although they helped somewhat, Stier was initially doubtful that she’d pinpointed his problem.
“She suspected it was the stomach, which sounded weird to me, because the pain always came from a higher-located area,” says Stier, now 51. “Sometimes the cramps were so extreme that I had the feeling my chest would implode.”
About 15 years ago, Stier finally saw a doctor. He had accepted the idea that his pain might be stomach-related, so he was surprised to be diagnosed with gastroesophageal reflux disease (GERD), or inflammation of the esophagus, the tube that leads from the mouth to the stomach.
“I still have the doctor’s words in my head: “Your stomach is totally fine inside, but the lower part of your esophagus looks like flames climbing up the wall,’” Stier says.
His doctor prescribed medicine, which helped soothe his esophageal inflammation. At the same time, Stier modified his diet, eliminating chocolate, sweets, spirits, juices, and coffee.
A common problem
For many Europeans, the searing pain of heartburn is an unpleasant occasional fact of life. It’s often the sign of acid reflux: stomach acid backing up into the esophagus when the muscle that’s supposed to separate the esophagus and stomach doesn’t stay shut.
Heartburn tends to fade after a few hours, so many people don’t consider it a serious concern.
“It’s pretty acceptable to have once-a-month episodes of heartburn, particularly related to a heavy meal or alcohol,” says Daniel Sifrim, professor of GI physiology at Barts and The London School of Medicine and Dentistry at Queen Mary University. “It’s considered a disease when the symptoms are more than once a week, when it affects quality of life, or when there are complications.”
More frequent heartburn could indicate GERD, which sometimes causes damage to the delicate lining of the esophagus, due to the effects of stomach acid repeatedly spewing upward. GERD affects up to 25 percent of Europeans. Some people feel such intense pain, they worry that they’re having a heart attack.
“People say: ‘I woke up in the middle of the night with the most searing chest pain, and I rushed to the hospital thinking it was a heart attack, and they did all the tests, and they were normal,’” says Laurence Lovat, professor of gastroenterology at University College London. “They said maybe it was acid reflux.’”
Complications may arise
Although GERD isn’t as serious as a heart attack, it isn’t always benign, either. Left untreated, GERD may cause complications over time. Some people get a chronic cough. Others may experience a narrowing of the esophagus caused by scar tissue, which makes it difficult to swallow food comfortably. Years of damage may cause Barrett’s esophagus, a condition that sometimes precedes esophageal cancer.
“In 1 in 10 people with chronic acid reflux, the lining of the esophagus changes from being normal to being that of Barrett’s esophagus,” Lovat says. “Barrett’s esophagus itself has a 1 in 10 or less chance of becoming cancerous. If you don’t have Barrett’s esophagus, the likelihood of getting esophageal cancer is almost zero.”
To minimize the effects of chronic acid reflux or avoid it in the first place, try these ideas:
Visit your doctor GERD can be treated, which may keep your condition from progressing, so it’s wise to see your doctor if you have chronic reflux. “Those who ought to see a doctor are those whose symptoms are interfering with their lives, if they can’t sleep because of the symptoms, or because they’re having to take drugstore remedies very frequently,” says Amritpal Hungin, professor at Newcastle University’s Institute of Health and Society.
Your doctor may perform an endoscopy—a procedure that reveals the interior of your esophagus with the help of a camera attached to a long tube—to see if your esophagus is inflamed or damaged. If it is, your doctor can prescribe medication and offer lifestyle changes that may reduce your symptoms.
“If you are bad enough to come to the doctor in the first place, take the medicine the doctor prescribes and heal it all up,” Lovat says. “Then use that opportunity to improve your lifestyle. The top of my list would be: Do not eat or drink for a minimum of two to three hours before going to bed. Do not eat large amounts at any one time. And do not eat fatty foods.”
Manage your weight How much you weigh can influence whether or not you experience chronic reflux. Being overweight or obese makes it harder for the muscle that separates your stomach and esophagus to maintain a tight seal, which allows acid to leak into the esophagus.
“Especially, this is the case in male patients [with potbellies],” says Mark van Berge Henegouwen, professor of gastrointestinal surgery at the University of Amsterdam. “You have an increased pressure inside the abdomen, and therefore you have more reflux.”
GERD has become more prevalent in recent years, as waistbands across Europe have grown.
“The main reason for the increasing incidence of GERD is probably the increasing BMI [body mass index] in the population,” says Asle Medhus, head of the department of gastroenterology at Oslo University Hospital. “Although difficult, the ideal treatment is thus weight loss.”
Jayne Feld, 49, an education and lifestyle reporter, gets heartburn when she gains weight, but it disappears when she slims down.
“Every time I hit 75 kilos on the scale, I am more prone to it,” Feld says. “It’s my big wake-up call to lose weight.”
Small weight changes can help. “Even in non-obese individuals, the reduction of two points of the BMI is associated with a reduction in reflux,” Sifrim says.
Avoid diet triggers Some people get heartburn when they eat chocolate, citrus, or mint, or when they drink alcohol or coffee. If you’ve identified a pattern, steer clear of things that cause reflux.
“If you know that heartburn is going to happen if you eat certain foods, then you have a choice,” Sifrim says. “You don’t eat that food, or you take pills. It is your choice. My perspective is ideally you try to refrain from taking that particular food as much as you can.”
Take medication People with infrequent heartburn may find relief from over-the-counter antacids or alginates, a heartburn remedy derived from seaweed. But those with GERD often need prescription-strength relief. Some people feel better after an eight-week course of medication. Others need to continue for years to keep symptoms at bay. The two most commonly prescribed classes of drugs for GERD are known as H2 blockers and proton pump inhibitors (PPIs). Both reduce the amount of acid your stomach produces.
“The evidence overwhelmingly shows that proton pump inhibitors are much better than H2 receptor antagonists at healing gastroesophageal reflux,” Lovat says. The esophagus will heal in 50 percent of people who take H2 blockers for an eight-week course. But it will heal in 80 percent of people who take PPIs for the same amount of time. “That’s really significantly better,” he says.
Because PPIs are more effective, doctors prescribe them more often, even long-term. Occasionally, research is released that tries to link long-term PPI use to an increased risk of heart attack, dementia, kidney damage, or stomach cancer, but experts say that the evidence for risk remains weak. PPIs are safe and people shouldn’t stop taking them if they need them.
“The side effect of long-term treatment with PPI has been debated for many years,” Medhus says. “These drugs have now been available for about 30 years, and millions of patients have now used this drug for prolonged periods. Many of the previous concerns about side effects have thus turned out to be needless.”
“The problem with those studies is that they are all based on large-scale data collection,” Hungin says. “They’re not cause-and-effect studies.”
Find the right medication schedule
Yoga instructor Miriam Pilgrim, 45, controls GERD with H2 blockers. In 2009, her gastroenterologist prescribed PPIs, but when she got pregnant later that year, her doctor switched her to H2 blockers. Pilgrim never switched back. Healthy lifestyle choices also influence her symptoms.
“Yoga definitely helps,” Pilgrim says. “Chocolate aggravates it.”
Claude Barruyer, 84, a retired dental assistant, uses PPIs as needed when reflux symptoms flare. After decades of stoically dealing with pain, Barruyer saw a doctor five years ago.
“I usually prefer to heal without any medication, but my son-in-law convinced me to ask the doctor for proton pump inhibitors,” says Barruyer, who took the medication, then stopped when her symptoms disappeared.
For attorney Ian Sirota, 52, taking PPIs indefinitely is the only way he can find relief. He has taken PPIs since 2007, after a brief, unsuccessful hiatus. “Within days, the acid reflux returned, so I was immediately put back on the medication,” Sirota says. “Before I went on it, at least once or twice a week, I would be woken up by a severe attack, where stomach acid would go up my throat. It would leave my throat burning for days. That doesn’t happen anymore.”
If you’ve been on reflux medication for awhile, ask your doctor if he recommends a PPI-free trial period, because not everyone needs to be on medication indefinitely. Because there are always risks of side effects when you take any drug long-term, weaning off unnecessary medication can reduce your risk of possible problems.
Some doctors worry that a percentage of people who take PPIs may not even have acid reflux, because long-term use of the drugs doesn’t always improve symptoms.
“Not everything that sounds like heartburn, indigestion, regurgitation is due to gastroesophageal reflux,” Hungin says. “Although we doctors do prescribe proton pump inhibitors, our success rate with people who have these symptoms is not quite what it’s cracked up to be. And I suspect that around half the people we see, we can’t help with medications alone.”
Although Stier, the automotive journalist, doesn’t take medication daily, he still relies upon PPIs when his symptoms flare. “I don’t like to take pills frequently—it makes me feel like an old-timer,” Stier says. “But I know that [PPIs] will be my companion for the rest of my life. To be fair, since I’ve had them, a new life started for me. Instead of hours of torture, I gain peace and quiet within a half hour by swallowing one pill.”