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Are Heartburn, Acid Reflux Disease, and GERD the Same?
The terms heartburn, acid reflux, and GERD (gastroesophageal reflux disease) are often confused by people and used interchangeably. However, they have different meanings, and their symptoms manifest differently.
Heartburn is a burning feeling in the chest that often occurs after eating. It is a symptom of acid reflux or Gastroesophageal Reflux Disease (GERD).
It is caused by hydrochloric acid coming up from the stomach (reflux) and irritating the esophagus (the tube that carries food from the mouth to the stomach).
The pain can be so severe in some people that it resembles a heart attack.
Heartburn can be accompanied by a sour taste in the mouth, a hoarse voice, and trouble swallowing.
It is usually caused by certain trigger foods, such as spicy, acidic, or greasy food.
Heartburn is very common, affecting more than 60 million people in the United States.
Heartburn can be managed by weight loss, avoiding trigger foods, and stopping smoking. The symptoms can be easily managed if needed by prescription and over-the-counter medications.
I will detail these drug classes and specific medications later in this post.
The lower esophageal sphincter (LES) is a muscle that connects the esophagus to the stomach.
The LES’ primary function is to keep food or fluids from refluxing back into the esophagus after food passes through into the stomach.
If this critical muscle gets weak or doesn’t close off properly, acid from the stomach can back up into the esophagus, where the damage begins.
Almost anyone experiences it intermittently. Symptoms can range from mild to severe, with some seeking medical attention.
Gastroesophageal Reflux Disease (GERD)
In many people, acid reflux becomes a chronic problem. This more severe form is called Gastroesophageal Reflux Disease (GERD).
Symptoms are similar to heartburn and can also include hoarseness, chest pain, a dry, persistent cough, and a feeling of a “lump” in your throat.
What Happens If You Don’t Treat Acid Reflux or GERD?
Because the mucosal tissue in the esophagus is much more delicate than the lining of the stomach, the esophagus is much more prone to damage from the stomach acid.
The constant exposure to the acid can damage the esophageal lining and lead to more severe outcomes such as bleeding, stomach ulcers, respiratory problems, and scarring or fibrosis of the tissue.
Sometimes, patients can progress to a precancerous condition called Barrett’s esophagus.
This is a perilous time in the disease process, and if left untreated, erosive esophagitis can result, and the damaged tissue can become cancerous.
People with untreated GERD have a fivefold higher risk of developing esophageal adenocarcinoma.
This problem is compounded in elderly patients because their stomach lining is already thinned due to aging.
How is GERD diagnosed?
There are two ways by which medical providers diagnose GERD:
The 24-hour pH-impedance-probe testing: This is a process where the doctor inserts a flexible tube, called a catheter, into your nose and advances it through your esophagus and into your stomach opening. Small sensors on the tube measure the amount of acid refluxing up from your stomach.
Upper endoscopy: Your Gastroenterologist uses a scope with a light and a small video camera at the end to visually inspect your esophagus, stomach, and duodenum, which is the upper part of the small intestine.
This procedure is also called an esophagogastroduodenoscopy, or EGD. Your GI specialist can also use the EGD to treat any digestive issues you may have, such as removal of polyps or tumors, stopping upper digestive tract bleeding, or stretching your digestive tract if it has become narrowed.
GERD Treatment Options
Diet and Lifestyle Management of GERD
GERD can be managed with diet and lifestyle changes. Certain foods can worsen symptoms of acid reflux and GERD by increasing the production of stomach acid. It is possible that you can reduce these symptoms by avoiding:
- Alcoholic drinks
- Coffee or drinks containing caffeine
- Spicy, high fat, and salty food items
- Tomatoes or products containing this food
- Tight-fitting clothing
- Large meals instead of spreading out food intake with smaller meals
- Lying down for at least 3 hours after meals
- Lying flat on your bed instead of at an incline (A sleep wedge works very well to resolve this issue)
Medication Management of GERD
Prescription and over-the-counter medications are available for treating the symptoms of acid reflux and GERD:
Cheap and first-line treatment option for acid reflux. These medicines react quickly when they encounter the stomach’s acid.
A chemical reaction happens, which results in the release of bubbles and water. This layer sits on top of the acid in the stomach and effectively becomes a barrier against the acid.
However, this is only a temporary solution as the bubbly layer dissipates over 30 – 60 minutes, upon which the acid reflux symptoms reappear. Examples of antacids are Tums and Rolaids. These agents are best for occasional heartburn.
A more effective treatment option is the heartburn drugs called the H2 receptor antagonists or simply the “H2 blockers.”
These agents bind to specific specialized cells in the stomach lining responsible for gastric acid secretion.
In so doing, these medications effectively prevent the stomach from producing acid. Medical providers prescribe these medications, which can also be acquired over-the-counter, to heal duodenal ulcers and manage Zollinger-Ellison disease, a rare condition in which the stomach produces too much acid. Typically, higher doses of heartburn medication are necessary to manage this condition.
Sometimes taking these medicines with antacids can help.
Notably, unacceptable levels of a cancer-linked chemical known as N-nitrosodimethylamine (NDMA) were found in certain formulations of the commonly bought medication Zantac (ranitidine).
Because of this information, the FDA requested all manufacturers of Zantac to cease production, marketing, and distribution of the drug effective April 1, 2020. If you have any old medication bottles, throw them away immediately.
Proton Pump Inhibitors (PPIs)
Proton pump inhibitors (PPIs) are a class of medications that suppress gastric acid secretion. They are among the most commonly prescribed drugs in the United States and are best for treating frequent heartburn or GERD symptoms.
These medications work by stopping the production of stomach acid at its source.
Specifically, proton-pump inhibitors irreversibly bind to and inhibit the hydrogen-potassium ATPase pump that is found on the surface of the stomach lining.
As such, since acid production is drastically reduced at the proton pumps, PPIs are very effective at managing GERD symptoms. However, they need time to achieve full therapeutic effect because of how they work.
It can take 1-4 days for most patients to take full effect. On average, PPIs increase the pH of the stomach to greater than 4, making it less acidic (the higher the pH, the less acidic the environment, and vice versa).
This is the numerical threshold at which healing begins to occur in the esophagus.
This is why PPIs are superior at reversing the effects of acid-induced esophageal erosion. If you think you need to start PPI treatment, I highly recommend you seek medical advice first.
You should weigh the benefits vs. risks of starting on a PPI and then agree on a consistent follow-up and monitoring schedule with your doctor.
Ask whether you should be appropriately screened first with the 24-hour pH impedance probe or an upper endoscopy (EGD).
The most common PPIs are:
- esomeprazole (Nexium)
- omeprazole (Prilosec OTC and prescription)
- lansoprazole (Prevacid)
- pantoprazole (Protonix)
- rabeprazole (Aciphex)
The little purple pill (Nexium)
Of the above, esomeprazole, also known as the “purple pill,” is one of the most widely prescribed and largest-selling PPIs in the United States. OTC availability of Nexium 24hr adds to the popularity of this medication. It is used to treat:
- Peptic Ulcer Disease (PUD)
- NSAID-associated stomach ulcers
- Ulcers in the duodenum (first part of the small intestine) caused by Helicobacter pylori bacteria
- Conditions that cause excessive secretion of stomach acid (Zollinger-Ellison syndrome)
Esomeprazole dosage formulations
- 20 mg capsule
- 40 mg capsule
- 10 mg powder
- 20 mg powder
- 40 mg powder
The table below details specific doses used to treat various conditions:
|Gastroesophageal reflux disease (GERD)
|20 mg or 40 mg by mouth once a day for 4 to 8 weeks
|Risk reduction of NSAID-associated stomach ulcer
|20 mg or 40 mg by mouth once a day for up to 6 months
|H. pylori eradication to reduce risk of duodenal ulcer - triple therapy
|40 mg by mouth once a day for 10 days in combination with amoxicillin and clarithromycin
|Other rare conditions that cause excessive stomach acid secretion (i.e., Zollinger-Ellison syndrome)
|40 mg by mouth twice a day
|Heartburn (over-the-counter formula)
|20 mg by mouth once daily for 14 days
Risks of Long-Term Use of PPIs and Side Effects:
Clinical trials indicate that 25% and 70% of PPIs are inappropriately prescribed without any medical indication in the United States.
This is of significant concern because long-term use or higher dose use of PPIs is associated with several severe adverse effects such as hypomagnesemia (low magnesium levels), community-acquired pneumonia, osteoporosis, increased risk of bone fractures, malabsorption of essential vitamins and minerals such as Vitamin B12 and Iron, heart disease, kidney damage, and Clostridium difficile (C. diff) colitis.
Drug Interactions with Esomeprazole
Do not take the following medications and OTC drugs with esomeprazole:
- clopidogrel (blood thinner, brand name Plavix)
- methotrexate (anti-cancer, rheumatoid arthritis, psoriasis treatment)
- rifampin (antibiotic)
- St. John’s Wort (OTC agent to manage depression)
- Warfarin (anticoagulant – to manage atrial fibrillation/prevent clots)
- diazepam (anti-anxiety, brand name Valium)
- tacrolimus (to prevent post-transplant organ rejection)
- phenytoin (anti-seizure drug)
- atazanavir (HIV)
- drugs containing iron
- ketoconazole (antifungal medication)
Esomeprazole is more effective than other proton pump inhibitors in treating these conditions. In addition, it has also been shown to be safe and well-tolerated.
Side effects of Esomeprazole
Most of the side effects listed below will disappear after a while as your body becomes tolerant to the medication. If the symptoms worsen over time, seek medical help immediately.
Common side effects of Nexium include:
- Severe Diarrhea
- Flatulence (Gas)
Less common side effects:
- High blood pressure
- Tachycardia (fast heart rate)
- Skin flushing
- GI upset
My personal opinion on the use of the purple pill and other PPIs:
While long term PPI use can cause serious side effects such as osteoporosis, C. diff infection, iron, and vitamin B12 deficiency, etc., I firmly believe that the possibility of having these adverse effects should not deter you from taking a PPI; if you have a clear medical need and diagnosis of GERD.
I encourage you to talk to your doctor to discuss the benefits vs. risks of long-term prescription PPI therapy.
Because the alternative is that you may develop esophageal cancer from untreated acid erosion.
This type of cancer sneaks up on you, and by the time you start experiencing symptoms and receive a diagnosis, it may be too late, and you may only have months to live (this happened to the mother of one of my former students).
Some health care professionals think they can avoid the PPI-specific side effects by putting their patients on long-term H2 blocker therapy instead.
It is important to note that H2 blockers were never meant for long-term use. There is evidence to suggest that H2 blockers desensitize your esophagus so that you do not feel the familiar burning as the acid slowly continues to destroy the delicate mucosal tissue in your esophagus.
Evidence also suggests that you may develop tachyphylaxis or build a tolerance to the H2 blocker with repeated use, meaning that symptom relief is reduced.
If you decide to stop your PPI therapy, under no circumstances should you stop it “cold turkey.”
Doing so can result in a rebound effect, meaning that you may experience acid hypersecretion if PPI therapy is abruptly stopped.
A slow taper to discontinuation of the PPI must be done with close monitoring and oversight by your healthcare provider.
- Heartburn is a symptom of acid reflux and GERD
- Chronic acid reflux results in GERD
- Untreated GERD can lead to esophageal cancer
- Acid reflux can be managed with antacids, H2 blockers, or PPIs
- PPIs are very effective at managing the symptoms of GERD
- PPIs prevent and heal acid erosion of the esophagus, thereby lowering the risk of the development of esophageal cancer
- Long-term use of PPIs can lead to low magnesium, malabsorption of Vitamin B12 and Iron, osteoporosis, heart disease, kidney disease, Clostridium difficile (C. diff) colitis, and community-acquired pneumonia
- H2 blockers are best for people needing a short term course of therapy.
- Long-term use of H2 blockers instead of PPIs to manage GERD also comes with risks such as tolerance and esophageal desensitization to acid erosion
- NEVER stop PPI therapy abruptly – this must be done under the supervision of your physician to prevent the dreaded acid rebound