Heartburn / GERD / Acid Reflux

Heartburn / GERD / Acid Reflux: Overview

Alternative Names: Gastroesophageal Reflux Disease (GERD), Gastro-Oesophageal Reflux Disease (GORD), Gastric Reflux Disease, Acid Reflux Disease

Heartburn is a symptom of gastroesophageal reflux disease (GERD), which is a digestive disorder that affects the lower esophageal sphincter (LES) – the muscle connecting the esophagus with the stomach.  Many people, often pregnant women, suffer from heartburn or acid indigestion caused by GERD.

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Incidence; Causes and Development

Up to 15 million Americans experience heartburn daily.  Some studies have reported that 36% to 44% of adults experience heartburn at least once per month, 14% every week, and 7% once a day.  Gastroesophageal reflux disease itself is common.  One study reported that 20% of people had frequent symptoms of GERD but that very few of them sought help for the condition.  People at all ages are susceptible to GERD.

During the course of normal digestion, the LES opens to allow food to pass into the stomach and closes to prevent food and acidic stomach juices from flowing back into the esophagusGastroesophageal reflux occurs when the LES is weak or relaxes inappropriately allowing the stomach's contents to flow up into the esophagus.

Unlike the lining of the stomach, which has a thin layer of protective mucus, the lining of the esophagus offers only a weak defense against stomach acid and other harmful substances.  The most important structure in protecting the esophagus is the LES but if, in spite of LES pressure, there is some acid back-up (reflux), an additional defense mechanism, the peristaltic action of the esophagus, pushes the residue back down into the stomach.

If the LES or the peristaltic action is impaired, stomach tone is increased or other protective mechanisms fail, then acid and other substances back up into the esophagus from the stomach, causing GERD.

Some doctors believe a hiatal hernia may weaken the LES and cause reflux.  Recent studies show that the opening in the diaphragm acts as an additional sphincter around the lower end of the esophagus.  Studies also show that hiatal hernia results in retention of acid and other contents above this opening.  These substances can reflux easily into the esophagus.

Dietary and lifestyle choices may contribute to GERD.  Certain foods and beverages, including chocolate, peppermint, spearmint, fried or fatty foods, coffee, garlic, onions or alcoholic beverages, may weaken the LES or increase stomach tone causing reflux and heartburnCaffeinated drinks and decaffeinated coffee increase acid content in the stomach.  Other acidic foods include citrus and tomato products.  All carbonated beverages increase the risk for symptoms of GERD by bloating the abdomen and causing pressure that forces acid up into the esophagus.  Food allergies may be responsible for some cases of gastroesophageal reflux disease in children.  Studies show that cigarette smoking relaxes the LES and that obesity and pregnancy can also cause GERD.

Persistent GERD may be due to abnormal biologic or structural factors which, as well as malfunction of the LES muscles, include defects or injuries in the lining of the esophagus, peristalsis problems, over-acidic stomach contents, amongst others.  Some people may be sensitive to digestive factors other than acid; such substances can cause GERD symptoms, but are likely to be missed during a medical examination.

Indigestion might be caused by a disease or an ulcer in the digestive tract, but for most people it is simply a result of eating too much, eating too quickly, eating high-fat foods, or eating during stressful situations.  Smoking, drinking too much alcohol, using medications that irritate the stomach lining, being tired, or having ongoing stress can also cause indigestion or make it worse.

In one study, over half of GERD patients showed abnormal nerve or muscle function in the stomach, which caused impaired motility – an inability of the muscles to contract normally.  This causes delays in stomach emptying, increasing the risk of acid reflux.

Drugs That Increase the Risk for GERD
A number of drugs can cause the LES to relax and function poorly including calcium channel blockers, anti-cholinergics, beta- and alpha-adrenergic agonists, dopamine, sedatives, and common pain relievers.  Calcium channel blockers and anti-cholinergics also weaken the peristaltic action of the esophagus and slow stomach emptying.  The anti-osteoporosis drug alendronate (Fosamax) can cause damage to the esophagus.  Patients should take this drug with six to eight ounces of water (not juice or carbonated or mineral water) on an empty stomach in the morning and should remain upright for 30 minutes afterward.

Antibiotics can also affect the mucous membrane, making it more vulnerable to acids.  Potassium and iron pills are corrosive and can cause ulcers (erosions) in the esophagus.

Nonsteroidal anti-inflammatory drugs (NSAIDs) are common culprits in causing ulcers in the stomach.  Until recently there was no strong evidence that they harmed the esophagus.  A 1997 study reported however, that elderly people who took NSAIDs and also had GERD appeared to be at higher risk for complications, particularly strictures, abnormal narrowing of the esophagus, and also chest pain and Barrett's esophagus.  There are dozens of NSAIDs including aspirin, ibuprofen (Motrin, Advil, Nuprin, Rufen), naproxen (Aleve), piroxicam (Feldene), diflunisal (Dolobid), indomethacin (Indocin), flurbiprofen (Ansaid), ketorolac (Toradol), ketoprofen (Actron, Orudis KT), and diclofenac (Voltaren).  Most likely, taking an occasional aspirin or other NSAID will not harm someone who has GERD and no other risk factors for or indications of ulcers.  Tylenol (acetaminophen) is usually a good alternative for those who want to avoid NSAIDs.

Signs and Symptoms

Elderly people with GERD tend to have a more serious condition than younger people with the problem.

The most common symptoms of GERD are heartburn (a burning sensation in the chest and throat) and regurgitation (a sensation of acid backed up in the esophagus).  In most people, the symptoms are short-lived and occur infrequently.  In about 20% of cases, however, the condition becomes chronic.  In such cases, the acid can cause irritation, inflammation, and even erosion of the esophagus (a condition called esophagitis).  Although acid is a primary factor in damage caused by GERD, other products of the digestive tract, including pepsin and bile, can also be harmful.

In some cases the esophagus may be hypersensitive.  When irritants are introduced into the esophagus, the immune system reacts with an exaggerated (hyperreactive) response to them, triggering the release of agents that cause inflammation and possibly injury.  This event is similar to the asthmatic response to irritants in the airways.

The severity of GERD depends on tissue sensitivity, LES dysfunction, the type and amount of fluid brought up from the stomach and the neutralizing effect of saliva.

It should be noted that symptoms of GERD may be present without any signs of injury to the esophagus.

Treatment and Prevention

In order to decrease heartburn symptoms, the patient should try to decrease consumption of fat, chocolate, peppermint, onions, coffee, decaffeinated coffee, as these are all believed to cause heartburn by decreasing the pressure of the lower esophageal sphincter and increasing the number of relaxations of this sphincter.  Overeating and straining associated with constipation may also compromise the sphincter's ability to keep the acid where it belongs in the stomach.

Many people believe that beverages quickly flow through our stomachs without affecting acid production.  Surprisingly, a lot of beverages – such as beer, wine and sodas – do stimulate acid secretion.  Beer is worst of all, potentially doubling stomach acid within an hour.

Complications

In a small percentage of chronic patients, a serious form of GERD called Barrett's esophagus may eventually develop, in which the erosion can lead to cancerous changes in the tissue lining of the esophagus.

Signs, symptoms & indicators of Heartburn / GERD / Acid Reflux:

Symptoms - Abdomen

Meals worsen epigastric pain

The pain often starts in the upper abdomen and spreads up into the neck.  It usually begins about 30-60 minutes after a meal and can last for up to 2 hours.  Lying down or bending over can bring on heartburn or make it worse.

Symptoms - Gas-Int - General

Counter-indicators

Symptoms - Head - Mouth/Oral

(Recent onset/long-term) hoarse voice

Irritation caused by stomach acid refluxed into the throat can lead to hoarseness.

(Slight/significant) bitter taste in mouth

Reflux of acid, bile and/or gastric juices into the esophagus may cause a sour or bitter taste.

Symptoms - Respiratory

Symptoms - Sleep

Conditions that suggest Heartburn / GERD / Acid Reflux:

Digestion

Gastric/Peptic/Duodenal Ulcers

There is a relatively high prevalence of GERD amongst patients with duodenal or gastric ulcers.  Persistent dyspepsia/heartburn symptoms after eradication of H.  pylori and ulcer resolution might suggest the treatment of GERD as a separate entity.  [Am J Gastroenterol 2000;95: pp.101-105]

Organ Health

Barrett's Esophagus

Chronic GERD can result in Barrett's esophagus.  In Barrett's esophagus, the lining of the esophagus is so badly damaged that a new lining is formed.

Respiratory

Asthma

About half of asthmatic patients also have GERD, of which heartburn is a symptom.  It is not entirely clear, however, whether asthma is a cause or effect of GERD.  Some experts speculate that the coughing and sneezing accompanying asthmatic attacks cause changes in pressure in the chest that can trigger reflux.  Exercise-induced asthma does not appear to be related to GERD.  Certain asthmatic drugs that dilate the airways may relax the LES and contribute to GERD.

Risk factors for Heartburn / GERD / Acid Reflux:

Allergy

Autoimmune

Crohn's Disease

Crohn's disease is a chronic ailment that causes inflammation and injury in the colon and other parts of the gastrointestinal tract, including the esophagus.

Diet

Overconsumption

Overeating is the most common cause of heartburn.

Dehydration

Dr. Batmanghelidj, author of Your Bodies Many Cries for Water, believes that in the same way we have a "hunger pain" signal, we also have a "thirst pain" signal in the body, and that it is called dyspepsia (heartburn).

Digestion

Hiatal Hernia

Some doctors believe that some people suffer from GERD due to a condition called hiatal hernia.  Hiatal hernia causes burning and difficulty in swallowing.  Hiatal hernia and GERD can both cause heartburn.

Hydrochloric Acid Deficiency

Based on the clinical experience of doctors such as Dr. Jonathon Wright, MD, supplementing with hydrochloric acid sometimes relieves the symptoms of heartburn and improves digestion in individuals who have hypochlorhydria.  Unexplained bloating, belching and heartburn are frequently diagnosed as symptoms of hyperacidity and sometimes wrongly treated with antacids, when in fact the underlying problem is insufficient acid production.

Hormones

Hypothyroidism

Gastrointestinal manifestations of hypothyroidism include GERD as a result of delayed emptying of the stomach.

Metabolic

Organ Health

Respiratory

Supplements and Medications

Symptoms - Food - Beverages

(High) coffee consumption

Coffee affects the lower esophageal sphincter and thus contributes to the reflux of stomach acid into the throat (heartburn).

Symptoms - Reproductive - General

Being in late pregnancy

Pregnant women are particularly vulnerable to GERD in their third trimester as the growing uterus puts increasing pressure on the stomach.  Heartburn in such cases is often resistant to dietary interventions and even antacids.

Symptoms - Respiratory

History of asthma

About half of asthmatic patients also have GERD, of which heartburn is a symptom.  It is not entirely clear, however, whether asthma is a cause or effect of GERD.  Some experts speculate that the coughing and sneezing accompanying asthmatic attacks cause changes in pressure in the chest that can trigger reflux.  Exercise-induced asthma does not appear to be related to GERD.  Certain asthmatic drugs that dilate the airways may relax the LES and contribute to GERD.

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Heartburn / GERD / Acid Reflux suggests the following may be present:

Metabolic

Heartburn / GERD / Acid Reflux can lead to:

Organ Health

Barrett's Esophagus

Chronic GERD can result in Barrett's esophagus.  In Barrett's esophagus, the lining of the esophagus is so badly damaged that a new lining is formed.

Recommendations for Heartburn / GERD / Acid Reflux:

Botanical

Orange Peel (Extract)

Products containing orange peel extract deliver relief from occasional heartburn, acid indigestion, and upset stomach.  They will not reduce mineral absorption or inhibit protein digestion, and do not shut down acid production nor adversely affect acid-producing cells, as many antacids do.

Orange peel extract should be standardized to contain a minimum of 98% of d-limonene.  Upon first experiencing symptoms, take one softgel capsule (1,000mg) every other day for 20 days, and one softgel capsule as needed for occasional relief thereafter.

Almost 90% of participants reported resolution of heartburn symptoms 2 weeks after starting orange peel extract.  Almost one-third experienced resolution of heartburn symptoms as early as day 2 of the study.  In addition, even though participants stopped taking the orange peel extract, they still reported symptom resolution on days 21, 28 and 35.  In other words, orange peel extract remained effective against heartburn for 2 weeks after they stopped taking it.  Occasionally, after completing the 20-day treatment period, some people may experience mild heartburn after eating foods they had previously avoided.  The study scientists concluded these individuals overindulged on these "forbidden" foods.  Taking a single orange peel extract capsule as needed usually solves this problem.

Picrorhiza

The bitter rhizomes of picrorhiza have been used for thousands of years in India for people with indigestion and were considered a substitute for gentian.  [Krishnamurthy A.  The Wealth of India vol VIII.  New Delhi, Publication and Information Directorate, Council of Scientific and Industrial Research, 1969, p.49]

Bladderwrack

An over-the-counter antacid, Gaviscon®, containing magnesium carbonate and sodium alginate (the sodium salt of alginic acid, an active component of bladderwrack), has been shown to effectively relieve the symptoms of heartburn compared to other antacids in a double-blind study.  [Chevrel B.  A comparative crossover study on the treatment of heartburn and epigastric pain: Liquid Gaviscon® and a magnesium-aluminum antacid gel.  J Int Med Res 1980;8: pp300-3]

However, bladderwrack has at the time of writing not been studied for use in people with heartburn.  Bladderwrack might also help indigestion, though again clinical trials have not been conducted.

Diet

Dairy Products Avoidance

Whilst drinking milk can be a 'quick fix' by neutralizing some of the acid, it also has a rebound action that eventually will encourage the secretion of more stomach acid, which causes the acid reflux.

Alcohol Avoidance

Avoid or limit alcohol.

High/Increased Carbohydrate Diet

Make sure to include foods that are high in complex carbohydrates in each meal.  These foods, such as rice, breads and pasta, are able to tie up excess stomach acid and are often easy on the stomach.

Increased Water Consumption

Additional water intake can help resolve heartburn symptoms.

Digestion

Digestive Habit Changes

Although there are many types of antacids and other medications you can take to help relieve symptoms of acid reflux, the right posture can have a positive impact on the way you digest food, thus preventing acid reflux from occurring.

Chewing Gum

Gum chewing can increase saliva quantity by 130%.  Saliva is rich in esophageal protective factors including epidermal growth factor, mucin, proteins and prostaglandin E2.

Drug

Conventional Drug Use

If nothing else seems to work, it may be necessary to start using proton pump inhibitor drugs.

Habits

Posture Improvement

Maintain an upright position during and at least 45 minutes after eating.

When you put excess pressure on your stomach, it takes longer for your stomach to digest food.  The longer it takes for your stomach to digest food, the higher your chances of developing indigestion and/or acid reflux.  Therefore, improving posture during and after meals may help or prevent symptoms of heartburn.

The postures that you adopt while you ingest food and directly after you eat are important, because they can either make food digestion an easy or difficult process for your body.  For instance, sitting in a hunched forward position while you eat, and lying down directly after a meal, places additional stress on the stomach and can promote indigestion or heartburn.

Furthermore, wearing anything tight around your waist (belts, tight pants, corset, etc.) while you're eating places pressure on your stomach.  Taut clothing prevents your stomach from expanding and moving freely, which is a natural process during eating and digestion.

Mineral

MSM (Methyl Sulfonyl Methane)

Doctors using MSM agree that patients who have used antacids and histamine receptor antagonists to control hyperacidity can employ MSM with good results.

Physical Medicine

Incline Board

A May, 2006 study published in the Archives of Internal Medicine showed that the two most important behavioral changes that can reduce acid reflux are eating less and elevating your head while sleeping.

It has long been known that stomach acid tends to reflux more when one is lying flat.  Based on this knowledge, a natural treatment was developed long ago for heartburn that occurs at night.  By slipping a 4- to 8-inch high block beneath each of the legs at the head of the bed a slight incline is produced.  Gravity may pull the stomach downward and minimize the amount of stomach acid that refluxes into the esophagus.  Many people find that this technique provides the additional relief they are looking for and prevents further esophageal erosion.

Another solution may be the use of a special pillow, such as the Prop Up Pillow.  These pillows are specially designed to create an incline and relieve the heartburn discomfort found in several disorders.  Pillows are useful when one's partner does not wish to sleep on an inclined bed.

Surgery/Invasive

Surgery

In most cases, heartburn can be relieved through diet and lifestyle changes alone, but some people may require medication or surgery.

Preventive measures against Heartburn / GERD / Acid Reflux:

Diet

Low/Decreased Fat Diet

Fats are the most difficult component of the diet to digest, remaining in the stomach longer and thus causing the need for more stomach acid in order to digest them.  Fatty foods cause more indigestion than proteins or starches.

Plant-Based Nutrition

Eating a low-fat plant-based diet in small frequent meals is one of the best ways to reduce heartburn.

Smaller, More Frequent Meals

Try to eat small, frequent meals instead of three big meals each day.  Small amounts of food each time will exert less workload on the stomach and therefore require less acid secretion for digestion.

Weight Loss

Obesity is known to be a cause of GERD.

Not recommended
Eating Nearer to Bedtime

Anyone who eats a heavy meal (which causes excess stomach acid production), particularly if one subsequently lies on the back or bends over from the waist, is at risk of an attack of heartburn.  Anyone who snacks at bedtime is at high risk of GERD.  For those who experience heartburn made worse by lying down, eating before bed may not be a good idea; eating the last meal of the day at least 3 hours before bed should reduce the likelihood of reflux at bedtime.  Try adjusting your diet by eating a small meal at dinner time and, if necessary, having a small snack, such as crackers, before sleep.

There is a myth that drinking milk before bedtime will ease acid reflux.  In fact, milk often ends up causing acid reflux during sleep.

Habits

Tobacco Avoidance

Studies show that cigarette smoking relaxes the lower esophageal sphincter (LES).

Not recommended
Aerobic Exercise

Heartburn is more frequent when exercising within 2 hours of eating.

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