“I look out the window and I see the lights and the skyline and the people on the street rushing around looking for action, love, and the world’s greatest chocolate chip cookie, and my heart does a little dance.” …
– Heartburn by Nora Ephron
Read time: 15 minutes
TL;DR Key Points:
- Not all heartburn deals with acid
- Not all heartburn comes from the gut
- Lifestyle changes can make a big difference but you have to committ
- PPI’s are not going to harm you in standard doses
A Word about Words
FYI: Truth be told, the above quote has nothing directly to do with this post but it’s lyrical and it makes me look more erudite than I actually am.
Heartburn, or the older term pyrosis, is a symptom. It’s that burning and stinging feeling you get in the back of your throat, say after eating a large slice of New Yaahk pizza.
And now “You got that burnin’ feeling. Oh Ohh that burnin’ feeling…”
Acid reflux is the most common cause of heartburn. It is when acid inappropriately moves upward into the esophagus from the stomach. It may (or may not) surprise you that there can be non-acid reflux or basic reflux because we can have more than just acid in our upper gi tract.
However, acid reflux is NOT the ONLY cause of heartburn. In fact, as its name suggests heartburn can often have a cardiac cause (such as atherosclerosis), and the two etiologies (stomach and heart) can be hard to differentiate it.
GERD is the name of the disease state when acid reflux becomes “troublesome,” which admittedly is somewhat subjective. The other formal criterion is x2- 3 per week.
What is GERD?
GERD stands for gastro-esophageal reflux disease. The cardinal complaints of GERD involve the following:
- Trouble or painful swallowing
Some other complaints that can be associated with GERD include:
- Recurrent (dry) coughing
- Hoarse voice
- Non cardiac chest pain
- Chronic sore throat
- Dental Erosions
- Recurrent ear infections
- Lung fibrosis (scarring)
GERD can be a systemic problem
As you can see above, GERD can sometimes present with non-intestinal symptoms. I have had patients with low libido, insomnia, coughing, fatigue, and poor singing voice (a lot of entertainers here in Los Angeles) who ultimately had GERD at the heart of their problem (pun intended).
At the same time, some of these links are still unclear. We know from some retrospective population data that asthma appears to be linked to GERD. This makes sense (i.e. it is bio-plausible). Aspirated stomach acid can be quite irritating to the airways and can trigger bronchoconstriction, one of the primary mechanisms of asthma. However, antacid therapy for acid reflux does not consistently improve asthma in patients who suffer from both.
If you are older, have a family history of cardiovascular disease or have a history of obesity, smoking, high blood pressure or other conditions then realize it is important to work with your primary care provider to evaluate for these conditions.
So we need a high index of suspicion for GERD, but we have to avoid making it a wastebasket diagnosis.
GERD is not simply too much acid
GERD is primarily a motility disorder. That is medical-ese for the fact that GERD is more an issue of how your intestines handles stomach contents, usually acid, as opposed too much acid creation (although that can happen at times also).
Much like water, things in the GI tract tend to flow downhill, from mouth towards anus. An intricate series of neuro-muscular contractions helps propel forward internal items like food, digestive enzymes, and yes acid. GERD is when this pattern is disrupted and stomach acid moves retrograde, up into the esophagus and towards the mouth.
photo cred: Dr SN Prasad
The Nexus of Eating, Burping, and Reflux-ing
The central actor in this process is the Lower Esophageal Sphincter (LES), the most important muscle you didn’t know you had. No, it’s not like the flux capacitor from Back To the Future.
The LES creates the control of flow of food from the esophagus (food pipe) into the stomach. The diaphragm, the top bookend of the abdominal cavity, buttresses it. Together they create an area of high pressure that helps us eat food and prevent acid from spilling upward like a cauldron. Imagine a belt that can be loosened or tightened as needed and you start to get the picture.
When digestive contents of the upper intestinal tract (usually but not always acid) travel upward into the esophagus past the LES, GERD symptoms occur. Dysfunction with the LES often (but not always) triggers GERD complaints. Some GERD patients have frequent inappropriate relaxations of this sphincter. Others have normal sphincter functioning but appear to have more sensitivity to even normal amount of acid exposure in the stomach.
photo cred: Google
Why all this Talk about Acid and Acid Blockers?
Simply put, we don’t have a good non-surgical remedy for improving the stomach’s ability to process contents that pass through the LES. We’ve tried: baclofen, erythromycin, lesogaberan – none of these really work well and the latter is not formally available. It’s unfortunate but decades of research and numerous scientists dedicating their entire careers to this one area of work hasn’t yet yielded significant treatment options- yet. Since acid is the most commonly refluxed agent, we do the next best thing – we lower the amount of stomach acid through the use of lifestyle changes and medications.
And they work. These medications can help a significant number of people get major relief of heartburn, bring pleasure back to eating, improve their sleep and overall quality of life. And in the hospital, I’ve seen many patients who’ve actually had upper intestinal bleeding due to erosive esophagitis, or acid induced chemical burns of their throat, heal and get better! We’ve seen rates of scar tissue development in the esophagus drop dramatically, so called peptic strictures, allowing people to not choke when they eat.They also are part of the regimen for treating H Pylori, which is the source of stomach ulcers and a known carcinogen. Learn more here . I could go on but the point is that for many Americans and people around the world, these pills when used appropriately are truly remarkable.
Erosive esophagitis is no one’s friend
Photo cred: Endoscopy Campus
This is why the alternative health message that “they (meaning “Western doc’s”) don’t fix your reflux they just mask the symptoms” is so off base. First of all, the only definitive way to truly fix the underlying problem would be to do a surgery to tighten the LES (and even then it doesn’t always work, more on that later). Taking baking soda, drinking ginger tea, probiotics, enzymes, and activated charcoal – all popular “natural” approaches to healing GERD – don’t treat the underlying problem either! Moreso, even if we are only treating symptoms since when is that a bad thing? As long as patients feel supported and an honest fair dialogue takes place and a full evaluation has been done, this seems appropriate to me.
Listen, I’m the last one to defend Big Pharma. They have a lot to account for, especially with serious problems like the opiate epidemic. Their drug prices are unconscionable. But we need a fair, evidence based, and contextualized discussion about how to use medications for reflux.
I know for some of you this is controversial topic, for which I’ll address in more detail in future posts.
Your Words Matter: Treatment can be Diagnostic
How do we actually diagnose GERD? As a practical matter, it is clinical. The symptoms you describe in the right clinical setting can make the diagnosis in the absence of any significant testing.
One way to confirm the diagnosis is to empirically treat, in other words, without any structured objective testing. If I place someone on anti-reflux lifestyle or start a low dose ant-acid therapy and they do well and I have no reason to suspect any other diagnosis, then my work is done. This is an example of a therapeutic trial.
Empirical treatments are often done in medicine, and there’s nothing wrong with that. The clinical narrative (what we call the History of Present Illness) is the most under appreciated intervention we perform. This is ironic because it is the most powerful tool we have in all of medicine.
Researchers are even circling back to this timeless if neglected element of medicine and incorporating it formally into research studies as outcome measures (so called PRO’s or patient reported outcomes). It is sad that formally measuring what patients think and feel have taken so long to be fully legitimized in medical research.
But your Words are Not the Only thing: Heartburn Redux
Why did your friend’s reflux get better but yours hasn’t? Aww now that is the crux of the question and get’s into the new science of the brain-gut axis, which I’ve addressed before in the context of small bowel and colonic health. Read more here.
New data is supporting what physicians have suspected for a while. A study published in CGH earlier this year prospectively followed some individuals with typical GERD complaints and had some interesting insights The objective difference, as measured by formal pressure and pH tests, between people who respond to traditional therapy and those who don’t are actually minimal. In other words, patients descriptions of their symptoms, while valuable, is not often a trustworthy descriptor of acid physiology in their guts.
The other thing that resulted from this study is that the vast majority (75%) of non-responders had so-called functional heartburn or reflux hypersensitivity. For reasons that we are still struggling to determine, some people are more sensitive to acid than others. Even people who have normal, physiologic amounts of reflux or don’t have a lot of contact time of acid in their throat (the DeMeester score) can experience intense discomfort. Their endoscopies are normal, PPI’s don’t help, and even lifestyle changes (see below) are sometimes of little use.
So what gives? We’re not sure yet, but it is an example of neuroplasticity gone wrong. Local nerves in the esophagus pick up signals of acid even when little to no acid is to be found. The brain processes these signals and produces a symptom of heartburn even when acid is not the problem. However, since they can have physical complaints like their “true” GERD brethen, they are often put on escalating doses of PPI’s in an attempt to get relief – a path that can have it’s own problems.
So Not all Heartburn is GERD
Everyone experiences intermittent heartburn at times. It’s part of living. However, this alone does not mandate a diagnosis of GERD. It is only when these and other symptoms become recurrent or chronic and troubling is a diagnosis of GERD considered.
But what is troublesome for one person may not be much of a problem for another. Awareness and internal self-talk can shape perception of hurtful symptoms. This is a reality that athletes use to their advantage (I can do it! Just another a mile) and can actually influence neuroplasticity, or how the brain re-wires.
The Zen truth behind this is that pain and pleasure are, to a certain degree, a matter of focus. It is for this reason that perhaps we are starting to see studies suggest that controlled breathing and mindfulness strategies can help patients cope with this problem, especially for those whose nerves are especially primed to pick up on signals of acid (called visceral hypersensitivity)
So before you reflexively reach for Tums or bottle of the some pink stuff, trying getting right between the ears. Take a page from athletes: they learn to down-regulate effectively in order to perform better the next time. That’s why so many recovery techniques first started or take root in their world.
Lifestyle has a big role to play in GERD complaints
The current American College of Gastroenterology (ACG) doesn’t rate behavioral changes as very valuable in the fight against reflux. Truth be told, not a tremendous number of studies have been done on this topic (one reason is lack of funding, partly because there is not “Big Lifestyle Counseling” to counterbalance the studies by “Big Pharma”). The studies are generally short in nature and small in size. For these and other reasons, the strength of recommendation for improving diet and such is relatively weak. Like the US Gymnastics Team , the ACG isn’t impressed.
In my experience, food and behavioral choices do matter and they can help. But it is not a cure-all and this is a long-term play. That can be hard news for people in the midst of a burn to accept, but it is the truth.
Dietary intake (what you eat) as well as eating patterns (how/when you eat) both have a role to play. One of my strategies is to have patients use lifestyle therapies to eventually minimize medication use (when possible). In general:
- Eat smaller, frequent meals throughout the day as opposed to 1 or 2 large meals
- Avoiding lying flat immediately after eating (acid and gravity and food are not your gut’s friend).
- For this reason, dinner should be your smallest meal of the day
- Minimize caffeine, greasy/fatty food, alcohol
- Tomato, Chocolate, Peppermint, Citrus foods are common triggers
- Very spicy or processed foods
- Highly carbonated drinks
Lifestyle factors that are relevant to GERD:
- Lack of sleep (it is a bi-directional association between suboptimal sleep and GERD)
- Laying flat immediately after eating
- Aging (not really a lifestyle factor per se, but the LES tends to loosen with time)
- Rapid eating (as opposed to taking your time eating)
- Stress – typically major life stressors can increase perception of GERD complaints. Some data suggest it may possibly increase actual esophageal acid exposure, but this is not proven
Eating nutrient rich foods, losing a small amount of weight and sleeping with a pillow (or two) can go a long way to relieving GERD complaints.
photo cred: Hindustan Times
Diaries can be insightful
I mean, it might tell you that all that resentment at your boss is actually coming from unresolved childhood trauma. Face it : it’s time to deal with your mother issues.
Whoops, sorry for that stream of consciousness. I actually meant food diaries (or food journals for those of you so inclined. Does anyone have food scrolls? Is that what the Royals at Buckingham have?). Whatever their name, their purpose is to help you with pattern recognition.
Food triggers are often unique so keeping a food and symptom diary can be valuable. Some helpful suggestions:
- Include an average week of eating (eg not while on vacation)
- Include at least one weekend day (people eat differently on Sat/Sun)
- Be honest (lying to yourself or your MD/RD/NP/PA etc about your intake is not helpful)
- Note when you tend to have symptoms and which ones
But I know all this already doc!
I hear this comment quite frequently from my patients. One even gave me this response with a large Kit Kat bar sticking out of his backpack in the exam room. True story!
There’s a big difference between knowing and doing, and in this gap most of us fall. That’s not a criticism (heck, it often includes me too!) but it is a point worth repeating: consistent positive behaviors will have long-term benefits.
As with finances the name of the game is compound interest.
And for some of us, even if we are already healthy (doc, I workout a few times a week and don’t have a sweet tooth) we may unfortunately need to do even more in order to help fight the battle against stomach acid.
- The Battle over PPI’s : Harm or Hype?
- Pills, Potions, and Paradigms: Western Medicine v. “Holistic” Care
- Burn Notice: FAQs about GERD
 ACG Clinical Guideline: Diagnosis and Management of Gastroesophageal Reflux Disease. Am J Gastroenterol 2013; 108:308–328; doi: 10.1038/ajg.2012.444
 J Abdallah, N George, T Yamasaki, S Ganocy, R Fass. Most Patients With Gastroesophageal Reflux Disease Who Failed Proton Pump Inhibitor Therapy Also Have Functional Esophageal Disorders. Clin. Gastroenterol. Hepatol. 2018 Jun 15