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June 10, 2013 at 9:56 AMComments: 0 Faves: 0

New Developments in the Treatment of Chronic Heartburn

By Jeffrey VanWingen M.D. More Blogs by This Author

A Minor Incident

In a previous chapter of my life, I taught chemistry in the lab setting to college freshmen.  Though safety was stressed time and again, accidents did occasionally happen. I was working with hydrochloric acid at a pH of 2 (relatively acidic) when I knocked over a beaker, and it spilled off the edge of the table and on to my foot. My first thought was, "You idiot!  Why did you wear sandals to lab?" I then set to work wiping up the mess and cleaning my foot. After a few minutes, things were tidy once more. The next day, however, I had a nice burn on my foot and the sandals looked moth-eaten where the acid splashed. Overall, it took about a week for the foot to heal completely.

A few years later, I began thinking about this minor incident as I sat in a medical school lecture on the workings of the stomach. I learned that the same potency hydrochloric acid that I had spilled on my foot was made by cells in the stomach and pumped into its cavern to help digest food. I was amazed recalling how it had scorched my foot. A special lining, I learned, protects the stomach from damaging itself. Things neutralize as the acid works through the digestive tract. If it goes the opposite way into the esophagus, however, watch out.  Burning of the esophagus can cause all sorts of problems.

This problem, known as gastroesophageal reflux disease (GERD) is common, affecting 1 in 12 chronically, but there are preventative and home remedies for the condition.  Many times, however, further therapy is needed. Here's a brief detailing of a few different treatment options.

H2 Blockers

H2 blockers (Zantac and Tagamet) are actually antihistamines, like the allergy tablets widely available. Each of these two types of antihistamine, however, hits a different target. While the H1 targets activate typical allergy symptoms in our respiratory passages, the H2 targets cause acid production in the stomach. The H2 blockers, antihistamines, reduce the amount of acid in the stomach by reducing the histamine response, helping with heartburn and reflux symptoms. These medicines are readily available over the counter and are relatively inexpensive.

Proton Pump Inhibitors (PPI's)

PPI's, like Prilosec, Prevacid, Aciphex, Nexium and Protonix, also reduce acid production in the stomach. These medicines block the acid making mechanism in certain cells that line the stomach. They're a bit more effective than the H2 blockers and are taken only once per day (as opposed to twice per day with the H2 blockers). Prilosec and Prevacid are available over-the-counter, but the others are prescription medications. While they work for a full 24 hours, it is important that they are taken first thing in the morning - at least 30 minutes before any food is consumed. Also, the PPI's are more expensive than the H2 blockers.

Surgical Options

Surgery

For some, severity of symptoms and the notion of taking a pill every day outweighs the physical and financial costs of surgery. In years past, a surgical option for GERD called fundoplication involved cutting into the abdomen and wrapping the muscle of the stomach around the valve of the stomach-esophagus junction. The ultimate goal was to firm up and restore the acid barrier between the the stomach and the esophagus. The weight of suffering from GERD despite medication was obviously quite significant to undergo this procedure given pain, healing time, and inconvenience. Eventually, the endoscope made the procedure much easier - still a surgery but done through tiny incisions. The weight further lessened with the introduction of this laproscopic fundoplication. Most recently, however, the procedure is being done "incisionless" from inside the esophagus.  

Comparative Analysis

A recent study comparing incisionless fundoplication vs. maximum dose PPI use favored the procedure over the pill. The study took 63 patients who had suffered for a median of 10 years with GERD symptoms and had been on PPI medication for a median of 8 years. The procedure was performed, and the subjects were observed for 6 months. Most reported more significant improvement in their heartburn symptoms post procedure compared to life on daily PPI medication. All but 8 of the individuals were completely off medication to treat heartburn.

The number of subjects in the study was limited, leaving open the possibility that the relatively small sample size may have yielded ambiguous results. Further, the procedure is not widely available yet. Still, the study results are encouraging that this simple procedure can prevent a lifetime of annoying reflux symptoms and dependency on a daily pill as treatment.

Conclusion

Gastroesophageal reflux disease (GERD) is a common and chronic condition, affecting 12% of Americans. Many home remedies, medications, and even surgical procedures are available to combat symptoms. However, if home remedies, preventative measures, and over-the-counter medications fail to give adequate relief, talk to your doctor about further options.

Reference:

Digestive Disease Week (DDW) 2013. Abstract 925h. Presented May 21, 2013.

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