Heartburn is one of the most common reasons that Canadians see their doctor. Most often, the condition can be managed with lifestyle changes and medication.
"Dr. Q., you gotta help me. I've been burning and belching like crazy."
"How long has this been going on?"
"More than a year," my 52-year-old patient replies, cradling his stomach.
"A year? Why'd you wait so long?"
"I thought it would go away… that I could fight it," he says, clearly uncomfortable. "But it's getting worse."
Acid reflux – better known as heartburn – was causing his symptoms. Formally, doctors call it GERD, gastroesophageal reflux disease. It's common: Almost 15 per cent of Canadians experience acid reflux daily. So a busy family doctor might see 100 people a month with this condition.
Yet, it's surprising how long people suffer before seeking medical care. ("It started in 1994," says my record-holder.) People buy time, nursing their symptoms with chewable antacids, over-the-counter medications, herbals, potions from the Internet and home concoctions. Often, it's only when all these manoeuvres fail to bring relief that they see a physician.
Usually, the diagnosis can be made on history. We ask targeted questions: Do you feel stomach burning and pain after a meal? Does it flow back up the food pipe? Do you have excessive burping and bloating, especially with oily, greasy foods? Do you frequently get an acid, sour taste in the back of your throat – which is one of the most troubling symptoms? Answering yes to such questions can alert a doctor to a probable diagnosis of GERD.
For some patients, the main symptoms are not burning and pain but bloating and gas. One female patient told me, "I just puff up like I'm pregnant." Such bloated patients may also have lactose intolerance, an allergy to one of the sugars in milk. For others, even their sleep suffers. This is especially true for obese people. Lying down, they soon find stomach acid flowing upward to their throat. This wakes them, causing coughing, discomfort, nausea – and can even provoke asthma. (Patients tend to suck the regurgitated stomach fluids back into the lungs.)
What's the prime cause of reflux? Stomach acid is meant to stay in the stomach, digesting food in a kind of controlled corrosion. But if the gate between the esophagus and stomach – known as the LES, the lower esophageal sphincter, becomes weak, it lets acid leak back up. And the tissue in the esophagus is much more delicate than the acid-resistant stomach lining. That's when patients start experiencing the burning, pain, even ulcers.
To help patients deal with heartburn, the first approach is to encourage a healthier lifestyle – which is easier said than done. Our favoured modern stimulants – caffeine, nicotine, alcohol – all trigger acid release. So patients must reduce their intake of these acidogenic substances. But most patients can't or won't follow this advice for long. "You want me to give all that up?" one man protested. "What am I supposed to live for?"
Also, in our diverse society, there are many cultures whose food is so hot and spicy that you're expected to burn – it's part of the flavour and experience. Such households find it difficult to adopt a blander diet, especially if it's only for one person with acid reflux.
Sometimes, a simple manoeuvre such as taking time to eat can help. As a nation, we always seem to be on the go – drinking, chewing and eating in our vehicles, digesting food between text messaging and commitments.
Frequently, doctors themselves may unwittingly induce acid disease. Many Canadians, especially the elderly, take a whole pharmacy of medications – sometimes 10 or more pills per day. Widely prescribed pain medications – the NSAIDs or non-steroidal anti-inflammatories – are known to irritate the stomach. Many patients are happily taking these tablets for arthritis, yet all the while slowly burning their gut.
When lifestyle management isn't enough, we offer prescription medications. To control acid production, the best medicines are the well-known PPIs, the proton-pump inhibitors. These pills reduce stomach acid by 90 per cent, thus promoting tissue healing. One recommendation: I notice that most doctors prescribe PPIs once a day, which is the standard. But GERD patients with more severe disease will likely benefit from taking these medications twice a day.
When symptoms persist despite lifestyle changes and medication, we may need to do X-rays such as an upper GI series, "the drinking test." For this test, you drink a milky liquid, and the X-rays reveal the background landscape – if there's reflux, ulcers or any traffic jam caused by scarring or growths. This test also picks up hiatal hernias, which are extra pouches in the chest, like a bonus stomach. Such patients may need surgery. "Nothing helped … none of the pills," says Rita C., 49. "And this burning foam kept coming up, like climbing a ladder."
Everyone gets occasional heartburn, perhaps from overeating at a celebration. But if the problem persists for weeks – even years – see your doctor. It's important to extinguish the stomach fire and interrupt the burning. Left untreated for years, burned gut tissue can lead to bleeding, ulcers and even cancer.