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Everyone has heartburn occasionally. This occurs when stomach
acid flows backward (regurgitates) into the esophagus. The
esophagus is the tube that carries food to the stomach. People
usually feel heartburn as a burning sensation or pain behind the
breastbone. Often, regurgitation of bitter-tasting stomach acid
accompanies heartburn. An antacid or milk temporarily relieves
heartburn for most people.
Why Does Heartburn Occur?
To understand heartburn, let's look at the body's
anatomy.- The esophagus carries food and liquid to the stomach. A
sphincter (specialized muscle) is located at the end of the
esophagus. It is known as the lower esophageal sphincter (LES).
This muscle contracts much the same as the anus does to close the
opening of the rectum to the outside of the body. The LES muscle
should only open when food or liquid is passed into the
stomach.
However, the LES muscle does not always work perfectly.
Sometimes it is too weak to stay completely closed, and stomach
juices seep back into the esophagus. This is known as reflux.
There are certain factors that contribute to reflux. The most
common is eating a large meal. Along with swallowed air, a large
meal causes pressure in the stomach to rise, and overpowers the
LES muscle. The following are other factors that reduce the LES
pressure and allow reflux:
- Nicotine (cigarettes)
- Fried or fatty foods
- Chocolate
- Coffee
- Citrus fruits and juices
- Peppermint
- Pregnancy
- Lying flat
- Hiatus hernia
- Certain prescription medicines
Is Heartburn Serious?
Heartburn and reflux are extremely common, with 10 percent of
the population experiencing them daily. Twenty-five percent of
pregnant women have heartburn. Even though heartburn is common,
it is rarely life-threatening. Severe cases, however, can result
in injury to the lower esophagus that requires treatment.
What Is a Hiatus Hernia?
The diaphragm is a flat horizontal muscle that separates the
lungs from the stomach and the rest of the digestive tract. The
esophagus passes through an opening in the diaphragm. If the
opening enlarges, a portion of the stomach can protrude
(herniate) through it into the chest. This is called a hiatus
hernia. A persistent hiatus hernia may produce significant
heartburn. However, many people who experience heartburn do not
have a hiatus hernia. Likewise, many people with a hiatus hernia
do not experience heartburn.
Diagnosis of Reflux
There are various tests used to diagnose reflux-
Upper GI Series - The patient drinks liquid barium, and x-rays
are taken of the esophagus and stomach to see how they
function.
Upper GI Endoscopy - The patient is given a mild sedative. Then,
a thin, lighted, flexible tube, called an endoscope, is inserted
into the esophagus to visually inspect it and the stomach.
Esophageal Manometry - This test measures the pressures within
the esophagus, especially the LES pressure.
Complications of Reflux
In some people, acid in the lower esophagus actually causes
tissue damage. Certain complications can then result:
-- Chronic bleeding and anemia.
-- Barrett's esophagus can occur when reflux irritates the
lower esophagus over a long period of time. The stomach lining
then actually grows into the esophagus. In these cases, there is
a slight, but definite, risk of cancer developing.
-- Lung problems can develop when reflux results in stomach fluid
trickling into the breathing tubes. It often occurs at night when
a patient is lying down. This causes wheezing, bronchitis, and
even pneumonia.
Treatment of Reflux
There are general measures the patient can take to reduce
reflux:
- Eat smaller and more frequent meals
- Do not lie down immediately after eating, and avoid eating
for several hours before going to bed
- Excessive bending, lifting, abdominal exercises, girdles, and
tight belts all increase abdominal pressure and provoke
reflux
- If overweight, lose weight. Being overweight promotes
reflux
- Stop using all tobacco; nicotine weakens the LES
- Avoid fatty foods, alcohol, coffee, chocolate, and
peppermint
- Elevate the head of the bed 8" to 10" so gravity
keeps stomach juices out of the esophagus while the patient
sleeps. Extra pillows, by themselves, are usually not
helpful
- Certain prescription or over-the-counter medications can
weaken the LES or aggravate reflux. Review all medications you
are taking with the physician.
Other treatments include:
Antacids - These can and should be used often. Generally,
antacids should be taken 30 to 60 minutes after eating and at
bedtime. Liquids are preferred to tablets, with the strongest
being Maalox ll, Mylanta ll, Gelusil ll and Extra Strength
Riopan.
Drugs - Medicines are now available that effectively reduce
and even eliminate the secretion of stomach acid and increase the
strength of the LES muscle. The most potent of these are called
proton pump inhibitors. These remarkable drugs are often
dramatically effective in severe cases of reflux. The most
popular of these is omeprazole (trade name: Prilosec).
Surgery - Surgery is rarely required in treating reflux.
However, when the treatment programs outlined above are
ineffective, surgery must be considered to strengthen the LES
muscle. A newer method of performing anti-reflux surgery is by
laparoscopic technique. This surgery is accomplished through tiny
holes in the belly button and upper abdomen. Recovery is far
quicker with this technique. This operation should only be
performed by surgeons thoroughly familiar with it. Surgery,
however, is not always permanently successful and there can be
complications.
Summary
Heartburn occurs so commonly that it is normal for everyone to
experience it at some time. However, when heartburn is
persistent, it needs to be evaluated, and long-term follow-up
care is often required. Medical treatment is usually very
effective and can prevent complications. For the few patients who
are not helped by medical treatment, surgery offers a viable and
usually successful alternative.
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