What Your Doctor May Not Tell You about Heartburn
DOUSE YOUR HEARTBURN BY TREATING THE CAUSE
Lack of treatment can lead to more serious problems.
By John R. Lee, M.D. and Virginia Hopkins
Heartburn is big business these days. TV is full of ads for antacids and histamine H2-receptor antagonists (Pepcid, Tagamet, and Zantac) to relieve it, and the July 13 issue of the National Enquirer tabloid lists "10 Natural Cures" for it. There's a lot of money in heartburn. The funny thing is that, while all these treatments are being sold, no one seems to address the cause or prevention.
Heartburn generally refers to a sour taste and a burning sub-sternal discomfort (under the breastbone) arising (no pun intended) from reflux of highly acidic gastric juices up to the esophagus and even into the mouth. Symptoms occur especially after meals, when bending over, and when reclining. Their intensity varies from mild (sour taste) to severe, discomforting upper abdominal and chest pain. Most people find that certain foods are more likely to cause their heartburn. Mainstream medical approaches emphasize treating either hyperacidity (abnormally high production of caustic stomach acid) or some sort of dysfunction of the "valve" at the esophageal-gastric at the upper end of the stomach to prevent reflux.
It Can Begin with Difficulty Swallowing
In truth, it is a little more complicated than that. The act of swallowing involves fairly complex synchronized involuntary muscle contractions from your throat through the esophagus. We swallow food and liquids when eating, of course, but also we swallow saliva thousands of times every day without thinking about it. (We make several quarts of saliva a day.) Sometimes we swallow air, especially when we hastily gulp our meals, or are agitated or talking while we eat. Swallowing air (aerophagia) builds up pressure in the stomach that makes reflux more likely. Stress is the greatest cause of these swallowing abnormalities.
This notion of a "valve" at the esophageal-gastric junction is not quite accurate. There is no valve, per se, only a set of muscles surrounding the bottom end of the esophagus, which can constrict to diminish the passage of esophageal contents at the point where the esophagus passes through the diaphragm into the stomach. Over-dilation (loosening) of this set of muscles--which occurs in people who eat large meals, or have aerophagia, or women in late term pregnancy--increases the risk of reflux.
Treat Your Esophagus with TLC and Avoid a Hiatus Hernia
Over-dilation can be caused by fizzy carbonated beverages which increase stomach gas. Calcium channel blockers (Adalat, Calan, Procardia) prescribed to treat high blood pressure, cause dilation of the smooth muscles, including the muscles of the distal esophagus, and taking them often leads to esophageal reflux. The dilated or lax muscles allow the upper end of the stomach to slide up through the diaphragm. This is called hiatus hernia. It can result in severe heartburn, with sub-sternal pain identical to cardiac-related angina pectoris.
If the diagnosis is uncertain, the presence of hiatus hernia can sometimes be clearly demonstrated by X-ray of the stomach area after swallowing contrast material (barium or gastrographin) while the patient is lying on the X-ray table tilted so that the patient's head is lower than his/her legs. Usually, the diagnosis of esophageal reflux is clear from symptoms alone.
Serious Side Effects of Chronic Heartburn
Besides the discomfort and sour taste, there are other good reasons to treat acid reflux. The repeated surges of acids from the stomach rising to the mouth can cause dental decay. I have a patient who ended up with thousands of dollars in dental bills because she ignored her reflux until it was severe. Reflux when sleeping can result in some of the acid entering the bronchial tubes, leading to chronic cough. This, in turn, leads to unnecessary X-rays and other tests, as well as useless rounds of antibiotics. Heartburn can disrupt sleep, leading to fatigue and emotional problems. It can lead to chronic bad breath (halitosis). The constant up-wash of corrosive acid can also cause very painful ulcers in the lining of the esophagus.
People with chronic esophageal reflux also have a much-increased risk of esophageal cancer. The repeated acid surges up the esophagus destroy its inner lining. Often, the body replaces those damaged cells with a different type of cell exactly like those in lower parts of the intestinal tract. This substitution of one type of cell for another is a precancerous condition known as Barrett's Esophagus. Everyone who develops esophageal cancer first develops Barnett's Esophagus. Esophageal cancer is a dangerous form of cancer which progresses quickly and generally does not have a good prognosis.
Why Antacids and Drugs Aren't a Good Long-Term Treatment Plan
Treatment is, to say the least, diverse. Most people start with simple antacids and find their relief is weak and temporary. They often progress to the histamine-H2 receptor blockers, which were previously available only by prescription but which are now, thanks to drug companies' aggressive search for more profits, available over the counter. These drugs effectively block gastric acid production and can effectively relieve heartburn, but their numerous side effects must be considered.
For example, they reduce calcium absorption. We need sufficient gastric hydrochloric acid to absorb calcium, and we need good calcium intake for strong bones. These drugs can also block specific enzyme systems in the liver, which, in turn, prevent normal excretion of many other drugs including tricyclic antidepressants, erythromycin, digoxin, phenytoin (Dilantin), Coumadin (anticoagulant), beta-blockers, estrogen, theophylline (anti-asthmatic). This leads to unexpectedly high blood levels of these drugs, which may cause serious problems. Headache, diarrhea, and gynecomastia (enlarged breasts in males) are also well-known side effects.
Mainstream medicine often gives little thought to the notion that heartburn is Mother Nature's way of telling you not to eat certain foods. If fried, greasy, or spicy foods cause heartburn, why not simply avoid them? Milk commonly causes acid rebound in adults. Since there is no need for adults to drink milk, my advice is to not drink it. Listen to your body; avoid the foods that cause your dyspepsia or heartburn.
On the other hand, some alternative health practitioners put a great deal of emphasis on digestive enzymes as a treatment. In my experience, these expensive concoctions have very little benefit.
However, supplementing with hydrochloric acid (HCl), frequently works wonders. Most people initially feel reluctant to take hydrochloric acid since the common wisdom is that heartburn is the result of excessive gastric acid. In fact, heartburn and peptic ulcers are not correlated with excessive acid. It is more often that a lack of HCl causes food to sit in the stomach for extended periods of time, leading to poor digestion and more surges of stomach contents up the esophagus.
You can find hydrochloric acid at your health food store. It's ideal to take it just before a meal, but you can also take it up to 20 minutes or so after a meal. Follow the directions on the bottle for dosage. Start with a lower dose at first, and gradually build it up. If you feel burning in your stomach after you take it, reduce the dosage.
Even if the HCl doesn't work, if you tackle the other causes listed below, and follow the treatment program, chronic heartburn should clear up within a few months.
If you have a hiatus hernia, most chiropractors can show you an easy maneuver that will put it back in. If you are persistent in putting it back in whenever you have trouble swallowing or feel heartburn, it will tend to stay in for longer and longer periods of time, especially if you also get at the causes listed in the sidebar on page 3.
The chances of getting chronic heartburn increase greatly as we age. This is not a health problem to take lightly, or to be treated only by suppressing symptoms with over-the-counter-drugs. The causes should be treated as soon as it begins - before it becomes more serious.
Causes of Heartburn
- Excess weight
- Food intolerance (e.g. greasy fried foods)
- Eating too fast
- Dysfunctional swallowing, usually secondary to stress
- Hiatus Hernia
- Insufficient gastric hydrochloric acid
- Eating too much at any one time
- Constipation (slow transit time)
- Drinking cows' milk
- Lying down after eating
- Fluoridated water and/or toothpaste
- Calcium channel blocking drugs
- Learn to avoid foods -- including fatty or greasy foods, peppermint and chocolate--and drugs, that cause heartburn.
- Eat four or five small meals a day instead of any big meals.
- Chew food slowly and thoroughly before you swallow.
- Avoid stress and agitation while eating meals.
- Eat fresh, relatively unprocessed organic food rather than refined or processed food.
- Avoid fluoridated water and fluoridated toothpaste
- Drink plenty of good water while eating.
- Do not lie down or recline for at least an hour after eating.
- A good walk every day is good for the bowels.
- Raise the headposts of your bed by 4" to 6".
- Do not drink cows' milk. (Cheese or yogurt--both bacterially cultured--are OK)
- Avoid carbonated sodas.
- Tea is better for the stomach than coffee is, regardless of caffeine content.
This article was originally published in the John R. Lee, M.D. Medical Letter