GERD

Heartburn: Causes and Treatment

Heartburn is defined as burning pain in the chest behind the breast bone and sometimes into the throat. It often occurs after eating or at night. Heartburn is caused by acid in the stomach (where it belongs) coming up into the esophagus (where it does not belong). Normally there is a one way valve that lets food go into the stomach, but keeps acid from coming back up into the esophagus. This valve is called the gastroesophageal sphincter. When that sphincter doesn’t work well, it allows acid from the stomach to come back up into the esophagus. The medical term for back up of acid from the stomach into the esophagus is gastroesophageal reflux disease often abbreviated as GERD. GERD has become increasingly common in western countries. One in five people in the US suffer from some form of GERD!

In this post I will talk about the causes of dysfunction of the gastroesophageal sphincter that lead to GERD and the symptoms of heartburn. I will focus first on foods and lifestyles that increase your population risk of GERD and also foods and lifestyle changes that reduce your population risk of GERD.

Finally, I will talk about medicines for GERD and the risks of side effects from these medicines.

Things that Increase the Population Risk of GERD

Smoking

Smoking cigarettes has been shown to decrease the pressure of the gastroesophageal sphincter. That means that anything that increases the abdominal pressure, such as coughing or bending over overcomes the weak sphincter and leads to GERD. The population of people who smoke has almost twice the risk of GERD of people who do not smoke.

Foods that relax the gastroesophageal sphincter

Decreased muscle tone in the gastroesophageal sphincter can lead to GERD. The following foods decrease the muscle tone of the gastroesophageal sphincter.

  • Fried (greasy) foods
  • High-fat meats
  • Butter and margarine
  • Mayonnaise
  • Creamy sauces
  • Salad dressings
  • Whole-milk dairy products
  • Chocolate
  • Peppermint
  • High salt intake

Obesity

Obesity increases intra-abdominal pressure, which can cause GERD even with a well functioning gastroesophageal sphincter. Obesity also increases the risk of developing a hiatal hernia. This is when part of the stomach comes up through the diaphragm in the same opening the esophagus goes through. Small hiatal hernias usually cause no symptoms, but large ones can lead to GERD.

Sedentary Lifestyle

Studies have shown that couch potatoes have a higher risk of GERD even if they are not over fat.

Medicines

The Mayo Clinic has a list of medicines that either can irritate the esophagus (causing heartburn) or can cause GERD. Here is the Mayo Clinic list:

Medications and dietary supplements that can irritate your esophagus and cause heartburn pain include:

  • Antibiotics, such as tetracycline and clindamycin
  • Bisphosphonates taken orally, such as alendronate (Fosamax), ibandronate (Boniva) and risedronate (Actonel, Atelvia)
  • Iron supplements
  • Quinidine
  • Pain relievers, such as ibuprofen (Advil, Motrin IB, others) and aspirin
  • Potassium supplements

Medications and dietary supplements that can increase acid reflux and worsen GERD include:

  • Anticholinergics, such as oxybutynin (Ditropan XL), prescribed for overactive bladder and irritable bowel syndrome
  • Tricyclic antidepressants (amitriptyline, doxepin, others)
  • Calcium channel blockers, statins, angiotensin-converting enzyme (ACE) inhibitors and nitrates used for high blood pressure and heart disease
  • Narcotics (opioids), such as codeine, and those containing hydrocodone and acetaminophen (Norco, Vicodin, others)
  • Progesterone
  • Sedatives or tranquilizers, including benzodiazepines such as diazepam (Valium) and temazepam (Restoril)
  • Theophylline (Elixophyllin, Theochron)

Microbiome

It turns out that we have bacteria living in our mouth and esophagus as well as our colon (see my previous post on the microbiome: The Microbiome: How Our Own Bacteria Affect Our Lives). There is increasing evidence that when unhealthy bacteria (gram negative bacteria) replace healthy bacteria (gram positive bacteria) in the esophagus we are more likely to have GERD and a precancerous change called Barrett’s Esophagus. Unhealthy bacteria replacing healthy bacteria is called dysbiosis. It can be cause by eating too much fat, sugar, processed food and a low fiber diet.

Things that decrease population risk of GERD

Never smoking or quitting if you smoke

That’s pretty obvious. Enough said.

Maintaining normal body fat

BMI is not a very accurate measure of percent body fat. A better measure is waist to hip ratio. A healthy waist to hip ratio is .75 for women and .85 for men. A ratio of .85 or more for women and .90 or more for men is defined as obesity. It is a very easy measurement for you to do at home. Use a cloth tape measure and measure the circumference of your waist at the level of the belly button. Write that measurement down. Then measure the circumference of your hips at the widest part and write that measurement down. Use a calculator to divide the waist circumference by the hip circumference. If you fall into the over fat range, review my post The Psychology of Eating and How to Use It to Your Advantage.

Eat a high fiber diet low in fat, sugar and processed foods

Not only does this kind of diet increase the tone of the gastroesophageal sphincter, but it also leads to a healthy microbiome in the mouth and the esophagus, which further decreases the population risk of GERD and Barrett’s Esophagus. Here is a link to the Cleveland Clinic web page that lists 11 high fiber foods: 11 High Fiber Foods You Should be Eating.

Minimize the number of medicines you take

Certain prescription medicines may be necessary and unavoidable, but you can certainly minimize the over the counter medicines you take. Whenever your doctor recommends a prescription medicine, you should almost always ask if there are any non-medicine ways to treat the condition. There may not be, but you will never know if you don’t ask.

Medicines for GERD

Even if you do all the things to put yourself in a low risk population for GERD you still may suffer from GERD. Remember that risk is calculated for populations and has no meaning for an individual. You will either get GERD or you won’t. In other words individual risk is either zero percent or 100 percent.

If you do have GERD despite doing everything you can to put yourself in a lower risk population, you may need to take medicine to alleviate the symptoms and prevent precancerous changes of Barrett’s Esophagus.

H2 Blockers

These medicines block a histamine receptor called the histamine 2, abbreviated H2. They work by decreasing acid production in the stomach. These are the medicines with the least side effects including on the microbiome. They include:

  • Famotidine (Pepcid AC, Pepcid Oral, Zantac 360)
  • Cimetidine (Tagamet, Tagamet HB)
  • Nizatidine Capsules (Axid AR, Axid Capsules, Nizatidine Capsules)

Most people with GERD get symptom relief from these medicines. They used to be prescription only, but almost all of them are now available over the counter. A small percentage of people with GERD will not respond to H2 blockers.

Proton Pump Inhibitors (PPI’s)

PPI’s are the most potent inhibitors of production of stomach acid. PPI’s essentially block the production of all stomach acid. They include:

  • lansoprazole (Prevacid)
  • omeprazole (Prilosec)
  • pantoprazole (Protonix)
  • rabeprazole (AcipHex)
  • esomeprazole (Nexium).

Prevacid and Prilosec are available over the counter. The others are prescription only.

Remember that stomach acid is there for a reason. The hydrochloric acid in the stomach breaks down the food and the digestive enzymes split up the proteins. The acidic gastric juice also kills bacteria.

Because PPI’s are such potent inhibitors of stomach acid production, they increase the risk of certain intestinal infections, especially clostridium difficile infections. They also promote less healthy bacteria in the colon, even more so than antibiotics. Over the long term they can also cause osteoporosis (thinning of bones) and low magnesium levels.

Once started, they are difficult to stop. Stopping PPI’s causes a rebound production of stomach acid, much more than the normal amount. This leads to rebound symptoms of GERD. They have to be stopped gradually with H2 blockers used to slowly replace them. This regimen helps prevent rebound excess acid production.

Most people have no symptoms from short term use of PPI’s and some people have such severe GERD and/or Barrett’s esophagus that they must take PPI’s to get any relief. For this relatively small number of people, the benefit is much greater than the risk. People with symptoms of GERD should only use PPI’s as a last resort, when diet, lifestyle changes and H2 blockers fail to relieve symptoms.

Bottom Line

The symptom of heartburn is almost always due to stomach acid back-flowing into the esophagus where it does not belong. The medical term is GERD. Anything that tends to decrease the muscle tone of the valve between the esophagus and the stomach (gastroesophageal sphincter) increases the risk of GERD. Such things include smoking cigarettes, obesity, high sugar high fat foods with low fiber, certain medicines and a sedentary life style. Things that decrease the risk of GERD include not smoking, maintaining a normal body weight, eating a high fiber diet, regular exercise and minimizing taking over the counter medicines.

For people that have to take medicines for GERD symptoms, H2 blockers have fewer side effects and little effect on the microbiome. For the few people with GERD that don’t get relief from diet, lifestyle changes of H2 blockers, PPI’s may be necessary but have more severe short term and long term side effects including increased intestinal infections, promoting a less healthy microbiome and long term risk of osteoporosis and low magnesium levels.