Don't take acid reflux problem lying down

Medical Matters

Medicine & Science

May 03, 2004|By Judy Foreman | Judy Foreman,SPECIAL TO THE SUN

You get home from work, late as usual, a pepperoni pizza in your arms. You sit down, shake some chili pepper flakes onto the pizza and sit down to indulge, washing a few slices down with a beer, maybe two. You top it off with a cup of coffee and head straight to bed.

Bad move.

You might pay for your late-night indulgence, waking up in the wee hours with heartburn, the hallmark of acid reflux, or what doctors call GERD, or gastroesophageal reflux disease.

Your biggest mistake? Lying down so soon after eating, which makes it easy for nasty stomach acid still churning around your pizza to burn its way up your esophagus. But the spicy chili wasn't such a hot idea, either; nor was the beer and certainly not the coffee.

Everybody gets a little heartburn. But millions of Americans - estimates vary from the 18.6 million mentioned on the American Gastroenterological Association Web site to the 60 million noted by other sources - get reflux from once a month to several times a week.

The problem lies in a circular muscle called the lower esophageal sphincter, which opens to let food slide down to the stomach but is supposed to close afterward.

In older people, and those who have an anatomical problem called hiatal hernia (in which part of the stomach sticks up into the chest through the diaphragm), the sphincter works poorly, allowing acid and sometimes partially digested food to back up.

Symptoms include post-prandial belching, asthma, hoarseness, sore throats and heartburn so bad it sends people to the emergency room, fearing a heart attack. Sometimes, GERD can cause damage to vocal cords without obvious symptoms such as heartburn.

In bad cases, reflux can lead to ulceration and strictures, or scarring, in esophageal tissue, which is more easily injured by acid than the tougher stuff the stomach is made of.

Reflux can also lead to "Barrett's esophagus," in which the lining of the injured esophagus tries to heal itself with cells from the stomach or intestine, raising the risk of esophageal cancer.

For unclear reasons, Barrett's esophagus often strikes middle-aged white males. It can't be diagnosed only by symptoms; doctors must look down the esophagus with a tube called an endoscope.

The diagnosis and treatment of GERD costs Americans $9.3 billion a year, says Dr. Frank Hamilton, chief of the digestive diseases program at the National Institute of Diabetes and Digestive and Kidney Diseases, part of the National Institutes of Health.

A good chunk of that spending goes for medications, including over-the-counter antacids such as Tums, Mylanta and Maalox. These drugs neutralize acid, providing immediate relief, but they don't stop acid production.

Often a more effective solution is a class of drugs called H-2 blockers, including Zantac, Tagamet, Pepcid and Axid. These are available over the counter in lower doses than are available by prescription. They block receptors on stomach cells for histamine, one of the major chemical signals telling cells to secrete acids.

But the biggest guns in the war on GERD are the proton pump inhibitors, or PPIs - drugs such as Prilosec, Prevacid, Nexium, Protonix and Aciphex. Prilosec is available over the counter for more than $1 per pill, but the others are still only available by prescription.

Unlike H-2 blockers, which stop only the acid production triggered by histamines, these drugs also block acid triggered by other mechanisms, according to Dr. William Ravich, an associate professor of medicine in the division of gastroenterology at the Johns Hopkins University School of Medicine.

For people who don't mind taking pills daily - and the side effects are generally minimal - this can be a simple way to ward off GERD. But for those who don't like pills, other solutions are obtainable.

The best, or "gold standard," is surgery, specifically a procedure called laparoscopic fundoplication - surgery done through small incisions in the stomach wall to wrap part of the stomach around the bottom of the esophagus to tighten the opening.

"This is the most effective way to treat reflux," says Dr. David Rattner, chief of general and gastrointestinal surgery at Massachusetts General Hospital. It involves general anesthesia and an overnight stay in the hospital, but it solves the problem for 80 to 90 percent of patients.

Less invasive, but probably less effective in the long term, are four procedures done through an endoscope placed in the esophagus. They're widely available, but some doctors say they're "not ready for prime time."

In one, a system called Enteryx developed by the Boston Scientific Corp., doctors inject a polymer at the base of the esophagus to bulk up the sphincter, making it tighter.

Dr. Douglas Pleskow, co-director of endoscopy at Beth Israel Deaconess Medical Center in Boston, says studies suggest that about 70 percent of patients having this procedure can get off medications for at least a year.

A different procedure with similar effectiveness was developed by NDO Surgical Inc. Doctors tighten the opening by using one stitch to sew a full-thickness pleat, or plication, in the wall of the stomach, just below the junction with the esophagus.

A similar approach uses the Bard EndoCinch device, which enables doctors to suture a pleat into the lower esophageal sphincter. Yet another approach is the Stretta system developed by Curdon Medical Inc., in which doctors use radio frequency waves to tighten the sagging esophageal sphincter.

The bottom line?

If reflux is becoming a habitual problem, see your doctor. And don't forget the simple stuff: Elevate the head of your bed to make it harder for acid to seep up your esophagus. And go easy on spicy food, alcohol and caffeine if they make your symptoms worse.

Judy Foreman is a lecturer on medicine at Harvard Medical School.

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