Q: I’ve suffered from bad heartburn for years, and nothing seems to control my symptoms. What can I do?
Poorly controlled heartburn that is caused by acid reflux can increase the risk of dental cavities, inflammation in the esophagus and even esophageal cancer.
When nothing seems to be working, it’s often a problem with how you are taking the medication. But it also could be that acid reflux is not the real issue.
Reflux, regurgitation and GERD: What do they mean?
There is a lot of confusion and misuse regarding the terms associated with heartburn, despite its being a common ailment. These terms include acid and nonacid reflux, regurgitation, gastroesophageal reflux disease (GERD) and non-erosive reflux disease (somewhat amusingly dubbed NERD).
Your stomach naturally produces acid to break down food. Acid reflux is that acid splashing upward from the stomach into the esophagus; however, not all reflux is acidic, and not all reflux is “bad.” Nonacidic reflux, or contents in your gut that have been neutralized, frequently sloshes around and hits your esophagus, too.
Reflux happens multiple times a day to everyone, typically without our even knowing. Sometimes, though, we do notice it, especially when it is acidic and irritating our esophagus.
Acid reflux can cause two classic symptoms: heartburn and regurgitation, which is when stomach contents travel all the way up the esophagus and into our mouths, leaving us with a sour taste.
GERD is acid reflux causing heartburn symptoms as well as inflammation in the esophagus.
With NERD, some people have typical heartburn symptoms, but there’s no sign of damage to the esophagus. The issue is still acid reflux, and it responds to medications that suppress acid — hence “non-erosive reflux disease.”
How is each condition diagnosed?
Diagnosing these different conditions is important because each requires a different approach to treatment.
If you have typical heartburn symptoms — a burning sensation in the chest, usually after eating, that may be worse when lying down — that’s often enough for a physician to say you probably have a problem with acidic reflux.
On the basis of symptoms alone, your doctor may even tell you that you have GERD. But, officially, GERD is diagnosed only after someone undergoes a procedure called an esophagogastroduodenoscopy (or an upper endoscopy) that confirms inflammation in the esophagus resulting from problematic acid reflux.
NERD is diagnosed in some patients with a normal upper endoscopy (no signs of inflammation in the esophagus) whose symptoms are still the result of acid reflux. To make that diagnosis, gastroenterologists can do a test called a pH impedance study. Most gastroenterologists consider this the gold standard for reflux testing, but it’s not always available everywhere, so you may need to discuss a referral with your primary care physician to a special center that performs the procedure.
This test measures the presence and acidity of reflux throughout your esophagus — and then correlates it with the precise moments when you report experiencing symptoms. With NERD, we find that heartburn symptoms occur when the esophagus is exposed to increased acid levels.
When the problem isn’t acid reflux
Some people may have disorders called reflux hypersensitivity or functional heartburn.
With reflux hypersensitivity, you may have heartburn symptoms even though the reflux is not particularly acidic or, in the case of functional heartburn, it occurs regardless of reflux. In these disorders — which make up 90 percent of patients whose heartburn symptoms do not respond to high-dose PPI therapy — we think the nerves of the esophagus have become overly reactive.
Treatments and common pitfalls of heartburn medications
For people with rare heartburn that occurs once or twice a month, medications such as TUMS or Pepcid might be enough to alleviate symptoms. These can be taken when you’re feeling symptoms or preemptively if you’re about to order some Nashville hot chicken and want to be prepared for the consequences.
But if you experience heartburn several times a week, it helps to try a heavier hitter, a proton pump inhibitor (PPI) such as omeprazole (or Prilosec) or pantoprazole (or Protonix), which blocks the release of acid in the stomach for about 48 hours.
Up to 45 percent of people who take PPIs (approximately 2 percent of Americans), however, still do not get relief, and incorrect use may be one reason.
PPIs should be taken consistently every day, 30 minutes before a meal for them to work. But that crucial piece of advice is frequently overlooked (it’s omitted by 70 percent of primary care physicians — and even 20 percent of gastroenterologists), leading to roughly half of heartburn sufferers taking PPIs at the wrong time.
I always ask my patients when they take their PPIs. I am amazed at how many take a dose once a week, instead of daily, or take it after meals — even right before bed — instead of 30 minutes before eating. They won’t work that way. Proper timing is often the easiest fix.
Furthermore, if you have heartburn predominantly at nighttime, taking your PPI 30 minutes before breakfast won’t be as helpful as taking it 30 minutes before dinner. Have symptoms during the day as well as at night? You probably should take a PPI twice a day.
Often, we prescribe higher-dose PPIs for just a few weeks and then taper it down to the lowest daily dose (if at all) you need to control your symptoms in the long term.
For GERD, the first recommendation for treatment is lifestyle modifications. These include weight loss, smoking cessation, avoiding late night meals and propping your head up with two or three pillows while sleeping (which makes reflux less likely as it would have to work against gravity).
Many people are interested in natural remedies for heartburn, and you’ll probably hear lots of anecdotes from friends and family about what worked for them. Although remedies such as ginger-containing supplements or probiotic yogurt show some promise in relieving heartburn symptoms, we unfortunately don’t have strong enough data to make broad recommendations about these or similar potential remedies.
For NERD, we would recommend similar treatment to GERD, but people with NERD often respond less well to PPIs. Fortunately, because inflammation does not seem to play a big role, NERD patients may have a lower risk of precancerous changes in the esophagus than patients with GERD.
Patients with reflux hypersensitivity or functional heartburn may respond better to medications, such as gabapentin and trazodone, that moderate pain signaling.
Then there are people whose acid reflux is severe, as measured by the pH impedance study, and despite taking PPIs correctly, still experience painful, breakthrough heartburn. They may need surgery to fix the problem.
When heartburn is a heart attack
Perhaps you’ve tried it all. You quit smoking, you time your PPI correctly, and you’re still popping TUMS around-the-clock. It’s time to talk to your doctor again.
The scariest symptom that can be mistaken for heartburn is chest pain caused by insufficient blood flow to the heart that can turn into a heart attack. Women especially often have atypical symptoms of a heart attack, such as nausea or back pain, so it’s very important to not dismiss symptoms as “heartburn” when they’re not responding to standard treatments. If you’re not sure, it’s always better to seek immediate medical attention.
Heartburn is so common, you may think of it as no big deal compared with other medical issues. But the consequences of inadequately treated heartburn as well as of a mistaken diagnosis can be serious. If you’ve had long-standing heartburn symptoms, get the right treatment, and you don’t have to suffer endlessly.
Meet the doctor: Trisha S. Pasricha is a gastroenterologist at the Massachusetts General Hospital Center for Neurointestinal Health and a medical journalist.
