By JANE E. BRODY
Published: September 25, 1996
THE acronym GERD may be unfamiliar to most people, but chances are that they know the symptoms of this common condition all too well. GERD stands for gastroesophageal reflux disease, better known as acid indigestion or heartburn.
Nearly every adult has experienced the disconcerting rise of stomach acid at least once, and surveys indicate that 44 percent of Americans suffer heartburn at least monthly. But for about 10 percent of the population, heartburn is a chronic, daily affair that impinges on their quality of life and could ultimately seriously threaten their health.
The flurry of new medications, both over-the-counter and prescription, to treat or suppress heartburn has done much to improve both public and medical recognition of this condition. But widespread misunderstanding of its potential seriousness and confusion about appropriate treatment still prevail.
Many people, for example, assume that since highly effective medications are now available, there is no need to follow the practical nondrug methods for reducing heartburn. They fail to consider the high cost of chronic drug therapy, possible side effects and hidden complications that could result from taking a drug every day that masks the symptoms of heartburn.
What Is Heartburn?
In a well-tuned digestive tract, when food or drink is swallowed, the tightly closed muscular ring at the base of the esophagus opens momentarily to let what was swallowed pass into the stomach. The ring, called the lower esophageal sphincter, then closes immediately to prevent the acid contents of the stomach from backing up into the esophagus.
When heartburn, or acid reflux, occurs, this barrier to stomach contents fails to function properly and some of the acidic material swirls back up into the esophagus and may cause that familiar burning sensation beneath the sternum, or chest bone. Acid reflux may even rise to the mouth, producing a sour taste. When this happens during sleep, some of the regurgitated acidic material may be inhaled into the respiratory tract, causing coughing, asthmatic symptoms or even pneumonia.
Other possible symptoms of chronic heartburn include unexplained chest pain (sometimes mistaken for a heart attack), a sore throat, hoarseness, eroded tooth enamel, a sensation of having something stuck in the throat and difficulty swallowing.
Certain foods and circumstances increase the likelihood of heartburn and its symptoms. In addition to resulting from acidic foods like citrus fruits and juices and tomatoes, heartburn may follow the consumption of spicy or fatty foods, coffee, tea, cola drinks, alcohol, chocolate and peppermint. People who drink alcohol or smoke as well as those who are overweight or older than 65 are at greater than average risk.
Exercising soon after eating, lying down or going to sleep after eating a main meal, bending over to pick something up after eating and wearing clothing that constricts the waist or abdomen all increase the upward pressure on the esophageal sphincter and the chances of heartburn.
But while the typical symptoms of occasional heartburn are momentarily discomforting, the underlying damage done by chronic acid reflux can result in serious illness. The esophagus can become chronically inflamed, eroded or even ulcerated, scar tissue can form that reduces the opening through which food must pass and the cells lining the esophagus can eventually become cancerous. This is why simply squelching the symptoms of heartburn is not adequate therapy. The goal of therapy should be to stop or greatly reduce acid reflux.
The occasional heartburn sufferer can rely on antacids like Tums, Rolaids, Maalox and Mylanta for fast relief. Those who know which foods are likely to cause symptoms can avoid those foods or try a newly marketed product, Prelief, that is swallowed before eating them or sprinkled on them. Prelief, developed by the same company that invented Lactaid and Beano, is a calcium-based dietary supplement (not a drug) that lowers the acidity of foods and beverages, including coffee. It is available in some drugstores; a free sample can be obtained by calling 1-888-PRELIEF (773-5433).
If heartburn is a frequent problem, before resorting to medication, it would be wise to make changes that can bring significant and perhaps even total relief. Avoid troublesome foods like those listed above; eat smaller amounts at one time; wait two to three hours after eating a main meal to exercise vigorously or to lie down or go to sleep; wear loose-fitting clothing; learn to bend from the knees instead of the waist; sleep in a more upright position by placing a foam-rubber wedge under the pillow or six-to-eight-inch blocks beneath the head of the bed or, if your bedmate objects, by sleeping on several pillows; lose weight if you are overweight, quit the habit if you smoke and avoid alcohol or at least reduce the amount normally consumed.
Your problem may also be touched off by medications you take for other conditions, so be sure to tell your doctor about them, since alternative treatments that do not cause acid reflux may be available.
Activities that stimulate salivation like chewing gum, sucking on lozenges and eating sweet pickles may help to relieve symptoms by bathing the esophagus with alkaline saliva.
If such measures do not bring adequate relief, in addition to antacids there are now over-the-counter drugs that reduce the amount of acid the stomach produces. These include Tagamet HB (cimetidine), Pepcid AC (famotidine), Zantac 75 (ranitidine hydrochloride) and Axid AR (nizatidine). These are called H2 blockers because they interfere with the substance that sets off the release of acid. Be sure to follow package directions, including how often and how long to use such drugs before consulting a doctor.
Doctors may recommend prescription-strength H2 blockers (the same products without the suffixed letters or numbers) either alone or in combination with other drugs. One substance, sucralfate (marketed as Carafate), when taken before eating, coats the esophagus to prevent acid irritation. Drugs that promote digstestive tract motility, called promotility agents -- bethanechol (Duvoid and Urecholine), cisapride (Propulsid) and metoclopramide hydrochloride (Reglan) -- are taken on an empty stomach to speed the passage of foods through the digestive tract, thereby reducing the pressure of stomach contents on the esophageal sphincter. Finally, there are even more potent acid suppressors than H2 blockers, called proton pump inhibitors. These drugs, lansoprazole (Prevacid) and omeprazole (Prilosec), can cut stomach acid by 90 percent.
If all else fails, surgery to tighten the esophageal sphincter has long been the treatment of last resort. But recently perfected laparoscopic surgery for chronic, severe acid reflux can bring permanent relief and may be preferable to decades of costly drug therapy for some patients.
Diagram: ''Roots of Heartburn'' Normally, swallowed food goes through the lower esophageal sphincter into the stomach. The sphincter momentarily opens, then closes to keep the food and digestive juices in the stomach. In heartburn, the sphincter fails to close, and some stomach contents flow back, or reflux, into the esophagus. (Adapted from Patient Care)