Is It Heartburn or Acid Reflux?
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Is It Heartburn or Acid Reflux?

Holiday bingeing worsens acid reflux, but if you are having repeated bouts, you may have a far more serious condition. Learn the signs of gastroesophageal reflux disease (GERD).

Could You Have GERD?

As anyone who has ever gobbled down a Thanksgiving feast knows, you're as likely to have a little post-meal indigestion as you are to be served pumpkin pie for dessert. Certainly, after my all-the-trimmings meal last year, I was prepared for some stomach upset. What actually happened was a lot more dramatic and much scarier. Hours after going to bed, I woke up violently coughing and choking on what felt like something lodged in my throat. My husband and I were terrified: I was even having trouble taking a breath. As an asthma sufferer, I thought at first I was having an asthma attack, but my symptoms were unlike any I had ever experienced. Thankfully, within 20 minutes, the episode subsided and I went back to sleep, shaken and worried.

First thing the next morning, I called my internist and was soon on my way to an ear, nose, and throat specialist who put a scope down my throat and quickly made a diagnosis: gastroesophageal reflux disease (GERD). I was surprised to find out that I had most likely had this potentially dangerous problem, also known as acid reflux, for a very long time.

The nagging cough that I had for years attributed to my asthma was actually caused by stomach acid that, over time, had corroded the tissues in my esophagus. But I'm far from the only person to have misread the initial symptoms. GERD is mistaken by the majority of sufferers -- and there may be as many as 14 to 20 million of them in the United States -- for garden-variety heartburn or indigestion and is often misdiagnosed by physicians as well. The confusion is understandable, since GERD often presents itself as chronic indigestion, with the all-too-familiar litany of symptoms: a burning sensation behind the breastbone, chest pressure, and a sour taste in the mouth sometimes accompanied by embarrassing belching.

Signs of Acid Reflux

The red-flag signs of reflux have to do with frequency and severity: If heartburn occurs more than twice a week, keeps you from falling asleep or wakes you in the middle of the night, or if there is a persistent lump in your throat, you sometimes have trouble swallowing or have a chronic cough or throat pain that does not respond to antibiotics or other treatments, you may have GERD.

Fortunately, awareness of GERD is growing, at least partly spurred by direct-to-consumer marketing campaigns by drug manufacturers. In the past year, over-the-counter antacid tablet sales (excluding sales at Wal-Mart) chalked up more than $900 million, representing about 5 percent of all over-the-counter U.S. drug sales.

Make no mistake, however: Though GERD is common, the dangers of brushing it off as only heartburn can be serious. For one thing, it can cause a lot of unnecessary anxiety: One and a half million people went to the emergency room last year thinking they were having a heart attack when in fact acid reflux caused their chest pain. Left untreated, GERD can have dire consequences, including narrowing of the esophagus that may lead to food getting lodged there, and throat lesions called "Barrett's esophagus" that can lead to esophageal cancer.

Are You at Risk for GERD?

GERD often happens because the sphincter muscles that separate the stomach from the esophagus don't close properly, for reasons that are unclear, allowing caustic stomach acid to flow back up into the esophagus, sometimes traveling as far up as the nasal passages, possibly causing a sinus infection or asthma. Although GERD affects people of every ethnicity, age, and economic and geographic group, pregnant women especially are at high risk: Two-thirds of them will experience reflux at some point in their pregnancies, usually during the third trimester. But by and large, GERD is a condition of the middle-aged.

Common Triggers of Reflux

Eating too much fat or too little, eating too close to bedtime, drinking carbonated beverages or alcohol, and smoking can all worsen reflux, as can being overweight and sedentary. In addition, some people find that stress can worsen already-existing reflux symptoms, although scientists have not found a definite link.

When people are under stress, they are more likely to eat poorly, exercise less, drink alcohol, and smoke -- all of which can aggravate GERD, according to gastroenterologist Paulo Pacheco, MD, clinical assistant professor of medicine at New York University School of Medicine, in New York City, and coauthor of Living with Chronic Heartburn: The Complete Health Guide to Acid Reflux and Gastroesophageal Reflux Disease.

Spicy foods and citrus fruits contribute to the acidic sensation that is common to heartburn. Other foods, such as coffee, peppermints, and chocolate, may cause the esophageal sphincter to slacken and open, allowing stomach acid to flow upward. A family history of reflux may also increase your chances of developing it, although this has not been proved.

Health conditions such as celiac disease (commonly known as wheat intolerance) can trigger reflux. The gas that comes up from the intestine with some wheat-intolerant patients may cause bloating, which pushes stomach acid back up into the esophagus. Some over-the-counter and prescription drugs can worsen reflux, either by diminishing lower esophageal sphincter pressure, which prevents the valve from staying closed, or by causing the muscles that line the esophagus to slacken, allowing stomach contents to flow upward. Speak to your doctor, however, before stopping or changing any medication. The major offenders are fever reducers and anti-inflammatory drugs containing ibuprofen or aspirin; calcium channel blockers; theophylline, an ingredient in many asthma medications; tricyclic antidepressants; anti-spasmodics; and sleeping pills containing benzodiazepines.

Tips for Calming Your Gut Reaction

Whether you get a bout of heartburn or indigestion once a month or several times a week, you can use these tips to ease or eliminate your discomfort.

  • Lose Weight: Although you can be average-size and have acid reflux, being overweight puts pressure on the lower esophageal sphincter, causing reflux.
  • Control Portions: Eating too much at one time causes the stomach to overexpand, sending excess food and acid the wrong way. Eat smaller and more frequent meals during the day.
  • Don't Lie Down Right After a Meal: Eat at least three to four hours before bedtime. Lying down too soon after a heavy meal causes a change in stomach pressure that triggers backflow of acids.
  • Bulk Up on Fiber: Boost your intake of vegetables, fruits, and multigrain breads and cereals. Not only will this help you lose weight, it also will minimize reflux. Foods that are higher in fiber produce less stomach acid and speed digestion.
  • Quit Smoking and Drink Less: Nicotine makes the lower esophagus slacken, causing reflux; alcohol is also a muscle relaxant. In addition, many wines and spirits are acidic.
  • Exercise: Any regular cardiovascular activity, such as walking, will help keep indigestion at bay by speeding weight loss and improving circulation. Milder exercise, such as yoga, can reduce stress, which has been linked to reflux.
  • Use Gravity at Bedtime: Minimize reflux by elevating your head with extra pillows or by placing phone books under your mattress to keep you in a more upright position during sleep.
  • Wear Comfortable Clothing: Too-tight belts, panty hose, and waistbands compress the stomach, sending food contents, including acid, upward into the esophagus.

Is It Reflux or an Ulcer?

The typical symptoms of a stomach ulcer (also called a peptic or gastric ulcer) are similar to those of reflux disease. Fortunately, you're unlikely to have both conditions at the same time. And contrary to conventional wisdom, ulcers are not caused by stress or overindulging in spicy foods, though both ulcers and reflux disease can be aggravated by them. But because they're "gut" related, it's easy to confuse one with the other. Here's how to distinguish between the two.

Acid Reflux Cause:

  • Backflow of stomach acid into the esophagus, caused by weakening of the muscles that separate the stomach from the esophagus

Symptoms:

  • a burning sensation in or near the chest or near or just under the breastbone
  • heartburn or indigestion that begins soon after eating

Triggers:

  • lying down immediately after a meal
  • eating spicy or acidic foods or drinking carbonated beverages
  • smoking and drinking alcohol
  • taking aspirin or anti-inflammatories more than two or three times a week
  • being overweight

Ulcer Cause:

  • Helicobacter pylori, a bacterium that erodes the lining of the stomach or upper intestine, causing a sore or hole to develop

Symptoms:

  • a burning sensation or pain in the area just below the chest
  • symptoms that go away or lessen after eating
  • weight loss and vomiting

Triggers:

  • eating spicy or acidic foods
  • smoking and drinking alcohol
  • taking aspirin or anti-inflammatories more than two or three times a week

Typical treatments for both ulcers and reflux are proton pump inhibitors (PPIs) or histamine receptor blockers, which block or reduce acid. But to eliminate the bacterium that causes ulcers, doctors will likely also prescribe a course of antibiotics in addition to PPIs. This allows the ulcer to heal and also prevents it from recurring.

New Treatments for Reflux

If you get heartburn only once or twice a month, you may not need anything stronger than an over-the-counter antacid. If GERD is diagnosed, however, often by an ear, nose, and throat specialist or a gastroenterologist, you will likely be advised to make lifestyle changes in addition to taking medication. The good news is that non-drug treatments can be so successful that some people eventually don't need medication at all, or if they do, only sporadically.

It's helpful to monitor your particular reflux triggers by keeping a diary of food and beverages consumed and medications taken, as well as the times of the onset of your symptoms. Forty-four to 79 percent of Americans suffer from nighttime reflux, which can cause more damage to the esophagus than daytime reflux and wake you up at night.

Common Medication for Treating GERD

If you are diagnosed with GERD, you will most likely be prescribed either histamine receptor blockers (H2 blockers) such as Pepcid, Tagamet, and Zantac, or a newer class of drugs known as proton pump inhibitors (PPIs), such as Prevacid or Nexium. H2 blockers work by decreasing the production of histamine, which stimulates gastric acid. (Histamine also causes the itching and swelling of insect bites and hives. H2 blockers affect histamine in the stomach only. They do not work for hay fever, bee stings, or hives.)

PPIs home in on a specific target: By jamming a "pump" in acid-secreting stomach cells, PPIs block acid production before it starts. They are usually used for patients with severe GERD.

People who take H2 blockers and PPIs for a long time or in high doses may also have an increased risk of pneumonia, since H2 blockers and PPIs suppress stomach acid, making the stomach more hospitable to pneumonia-causing bacteria. Yet experts say that the risk is slight.

Typically most people will be on medication until their symptoms improve, after which they might take their medication only occasionally. To prevent reflux or reduce its severity when indulging in a "forbidden" food like tomato sauce or hot peppers, doctors recommend taking a medication an hour or two before sitting down to eat. Yet doctors urge caution: Antacid overuse can be dangerous for people with kidney disease and can cause other side effects. Those with severe reflux may need to be on medication long-term.

Surgical Alternatives

For those who don't want to take medication for the rest of their lives, there are new surgical alternatives. One method uses radio-frequency currents to scar the esophagus, thereby strengthening the lower esophageal sphincter and preventing backflow. Another involves implanting synthetic materials to reinforce the sphincter. Afterward, many people are able to reduce or completely eliminate their need for medication.

As for me, getting rid of the coughing spasms was difficult. Two full months on a reflux medication and a strict low-acid diet finally did the trick. Saying good-bye to citrus fruits and late-night snacking wasn't easy, but gradually I've been able to reintroduce some of my favorite treats in limited quantities. And I certainly sleep better having eliminated this major pain in the neck.

Originally published in Ladies' Home Journal magazine, December 2005.

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