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New Updates To The Management Of Heartburn?

Heartburn, also known in the medical world as “gastroesophageal reflux” or “GERD,” is caused by irritation of the esophagus due to stomach acid.  Most commonly this leads to a burning discomfort in your upper abdomen below your breastbone or up into your chest.  Other symptoms can include nausea, finding it difficult to swallow, or a hot, acidic, bitter taste in the back of the throat.  Occasionally untreated GERD can lead to chronic cough.

Normally, with the help of gravity, a muscular valve called the lower esophageal sphincter (LES), located where the esophagus meets the stomach (generally just inferior to your sternum), helps keep stomach acid in your stomach.  If the LES opens too often or doesn’t close tightly enough, stomach acid can reflux into the esophagus and cause irritation.

Things that can worsen this include:

  • Overeating: too much food in your stomach causes pressure on the LES to reflux
  • Pressure on the stomach: for example, from obesity, pregnancy or constipation
  • Foods that can relax the LES or increase stomach acid:
    • Tomatoes
    • Citrus fruits
    • Garlic and onions
    • Chocolate
    • Coffee or caffeinated products
    • Alcohol
    • Peppermint
    • Meals high in fats and oils
  • Lack of sleep and stress can increase acid production in the stomach
  • Progesterone, when you’re pregnant, can relax your LES and lead to heartburn
  • Smoking relaxes the LES and increases stomach acid

Earlier this year the American College of Gastroenterology (ACG) published updated guidelines on the management of GERD, the first such updates since 2013.  The guidelines include 30 pages and 39 recommendations covering all aspects of diagnosis and treatment.

A few key highlights from the guidelines include:

  • For patients with classic symptoms and no worrisome symptoms (such as weight loss, difficulty swallowing, bleeding or anemia), an 8-week trial of a proton-pump inhibitor (PPI) such as omeprazole (Prilosec) is recommended. A good clinical response to PPIs is considered an adequate diagnostic test for gastroesophageal reflux disease (GERD). The authors emphasize that many nonresponders to PPIs have not taken the drugs correctly: PPIs should be taken 30 to 60 minutes before a meal, because they bind to proton pumps that have been stimulated by meals.
  • PPI nonresponders, and PPI responders whose symptoms return after an 8-week PPI course, should be evaluated for objective evidence of GERD. Endoscopy should be done after 2 to 4 weeks off PPIs (to maximize the chance to document esophagitis). If endoscopy is normal, ambulatory pH monitoring (off treatment) is the next step.
  • The authors encourage intermittent or “on-demand” (rather than indefinite) PPI therapy in patients with no history of high-grade esophagitis or Barrett esophagus. A patient who requires ongoing PPI therapy for symptom control should use the lowest effective dose. Although there are statistical associations between long-term PPI therapy and various purported “complications,” a causal relation is doubtful for most of them.
  • Although scientific evidence to support favorable effects of diet and lifestyle modification on GERD generally is weak, the authors recommend several — in particular, weight loss, smoking cessation, and avoiding eating before bedtime. Elevating the head of the bed or sleeping on a wedge, and sleeping preferentially on the left side, also are recommended.
  • GERD is thought to contribute to various extraesophageal symptoms, including chronic cough, hoarseness, and laryngitis; however, a causal relation often is unclear in any given patient. For patients with extraesophageal symptoms — but no heartburn or regurgitation — the authors argue against empirical PPI therapy unless reflux is documented by objective testing.
  • For refractory GERD, recommendations vary depending on the extent of previous diagnostic evaluation. Some patients will respond to twice-daily PPIs or as-needed addition of a histamine-2 (H2)-receptor antagonist at bedtime. However, clinicians should be vigilant for alternative conditions with symptoms that might be mistaken for GERD (e.g., achalasia). Pros and cons of surgical approaches to GERD also are discussed.

Please always feel free to call your friendly Village Doctor to explore any symptoms you feel might be heartburn, particularly if you’ve never had it before.  As you can see above, if we do believe your symptoms are from heartburn, there is a long list of possible interventions, including diet/lifestyle changes, over-the-counter and prescription medications, as well as a role for endoscopy if symptoms are worrisome or do not abate with typical interventions.

Katz PO et al. ACG clinical guideline for the diagnosis and management of gastroesophageal reflux disease. Am J Gastroenterol 2022 Jan; 117:27.

Jennifer Abrams, MD, April, 2022