Heartburn and Reflux Treatment: The Truth Be Told

I have already written about heartburn and reflux. There are many treatment options available. Initial therapy consists of over-the-counter medications –ranitidine, omeprazole and others. These medications can be quite effective when taken correctly.

To understand the basics of treatment, let's discuss how the medications work.  There are two primary categories of drugs used for acid suppression: H2 blockers (Tagamet, Pepcid, Zantac and their generic formulations), and the Proton Pump Inhibitors (Prilosec, Nexium, Aciphex, Protonix and Prevacid). Many of these are now available over the counter, meaning you don't need a prescription.

H2 blockers work by blocking the H2 receptor on the parietal cells in the stomach that actually produce acid. This can be quite effective, and these medications can be taken anytime and they work. They are strong suppressors of acid secretion, but can't help with acid already in your stomach or that you may eat, such as oranges, tomatoes, etc.

Proton Pump Inhibitors work by killing the pump in the parietal cell that actually makes the acid. This is an irreversible inhibiting of the proton pump. The body takes about 24 hours to make new pumps. The trick is, only active pumps are blocked by the PPI medications, and the medications only last for two to three hours in the blood stream, except for the newest version of Prevacid called Dexilant which is slowly released over many hours. 

The most potent stimulation of the proton pump is food in the stomach.  Therefore, the recommendation is to take these medications 30-60 minutes before a meal, usually once per day. By combining omeprazole, a PPI, with sodium bicarbonate (known as Zegerid) to stimulate acid secretion in the stomach, the PPI can be taken at anytime.

Medication alone often is not sufficient to adequately suppress acid in the stomach. There are a series of recommendations to follow, including not eating within two hours of laying down, avoiding acidic foods such as citrus and tomatoes, elevating the head of your bed at night, not chewing gum, avoiding mint and chocolate, not drinking caffeine, not stomaching cigarettes and many others.

If the reflux and heartburn are long standing, a further evaluation should be considered to look for a precancerous condition called Barrett's Esophagus. If medications, weight loss, dietary changes, etc are not adequately controlling your symptoms, surgery might be an answer.

Surgery is only found to be significantly effective in patients with either a poorly functioning lower esophageal sphincter, meaning the bottom of the esophagus doesn't function to close properly and keep stomach contents down, or, there is a significant hiatal hernia.  A hiatal hernia occurs when the top part of the stomach herniates up through the diaphragm into the chest. This dislocation of the esophagus upward impairs normal lower esophageal sphincter function.

Patients with normal anatomy and normally functioning esophagus do not benefit from surgery. Surgery has its downsides even when it is beneficial. By tightening the bottom of the esophagus, it is often difficult to impossible to belch, burp or vomit; this is by design, the procedure is designed to stop anything from refluxing back up.

There have been several forms of endoscopic anti-reflux procedures that are billed as incisionless. They have all come and gone over the years. These procedures are not considered a preferred surgery despite their appeal of leaving no scars. While they may seem to be simpler and easier, they are also far less effective.

A patient with severe reflux that is not responding to standard medical therapy with medication, lifestyle and dietary changes is at risk of developing Barrett's Esophagus and possibly esophageal cancer. 

The best approach is to be fully evaluated by a gastroenterologist with endoscopy, esophogram and esophageal manometry to assess the functioning of the esophagus. Only after this evaluation can a recommendation for surgery be properly made. 

If a surgical intervention is required, I only recommend Laparoscopic Nissen fundoplication with repair of hiatal hernia if needed. It is important to work with your gastroenterologist to find the right surgeon for this specialized procedure. 

If you feel you have significant heartburn and reflux, please call our office to schedule a consultation and evaluation with one of our board-certified gastroenterologists at 678-475-1606, www.advgastro.com.

Brian K. Hudes, MD