Gut check for reflux

Special to The Times

It WAS 1972 when a visibly uncomfortable man leaned over the side of his bed bemoaning his indulgence with the phrase, “I can’t believe I ate the whole thing.” This Alka-Seltzer commercial was an early and memorable marketing effort to show how a simple pill could ease the pain of gluttons everywhere. And it was just a hint of what was to come.

More than 35 years of plop, plops and fizz, fizzes later, Americans have hardly learned their lesson.

Today, approximately 60% experience occasional episodes of acid reflux, and about 25% deal with the problem on a weekly basis. The prevalence of the condition in North America is increasing by about 5% a year, according to a 2007 study in the journal Clinical Gastroenterology and Hepatology.


A report in January from the Agency for Healthcare Research and Quality found that more than 95,000 people in the U.S. were hospitalized with acid reflux as a primary diagnosis in 2005, up 4.5% from 1998. But the number of people hospitalized with reflux as either a primary or secondary diagnosis reached 3 million in 2005 -- an increase of 216% from 1998.

Gastroesophageal reflux disease, GERD or acid reflux, occurs when the small ring of muscle at the bottom of the esophagus weakens and allows stomach acid and food to back up, or reflux, into the esophagus after a meal. Common symptoms include heartburn, difficulty swallowing, an acidic taste in the mouth and nausea or vomiting.

The increase in obesity is speculated to be one cause of its growing prevalence. Excess fat in the abdominal area pushes on the stomach’s contents; stomach fat causes distention and relaxes the lower esophagus; and fat-laden foods slow down the stomach’s emptying process. Other factors include Americans’ notoriously poor nutritional habits and a heightened awareness of the condition induced by pharmaceutical advertising.

Medications also may be contributing to the problem.

“If people didn’t have good medications to treat it and something they ate made them sick, they would avoid it -- but it’s human nature to pop a pill and continue eating,” said Dr. Prateek Sharma, a professor of medicine and director of the GI Fellowship Training at the University of Kansas School of Medicine.


Medical therapy

Although medication is not a cure for acid reflux, a majority of patients find relief through prescription and over-the-counter drugs. Aside from traditional antacids, including Alka-Seltzer and Tums, there are now two main medications used to treat reflux.

H2 blockers reduce the amount of histamine-2, which produces acid in the stomach. They are recommended for people with less frequent and severe bouts of reflux. Zantac 75, Pepcid AC, Tagamet HB and Axid AR are some of the products available without a prescription.

A second medication is the proton pump inhibitor, which shuts down proton pumps in the stomach that produce acid. These are stronger than H2 blockers and recommended for people with more persistent, acute symptoms. Products such as Prilosec, Prevacid and Nexium are available only by prescription; Prilosec OTC is the only proton pump inhibitor available over the counter.

Even though there are a number of brands, Sharma said they all work similarly. He recommends patients use them for periodic acid reflux problems -- once a week or twice a month.

There are some side effects associated with the medications, though most physicians say they are rare. Dr. Nicholas Shaheen, an associate professor of medicine and epidemiology and director of the Center for Esophageal Diseases and Swallowing at the University of North Carolina School of Medicine, said acid-suppressive medications are among the safest drugs he prescribes.

One potential issue is that stomach acid helps fight infection, so reducing acid could make individuals more prone to infections like pneumonia, said Dr. Stuart Spechler, chief of gastroenterology at the Dallas Veterans Affairs Medical Center and professor of medicine at the University of Texas Southwestern Medical Center at Dallas.

The medications also may block the absorption of vitamins and minerals such as B-12 and calcium, which could lead to hip fractures.


Surgical options

For people who have responded to medication but continue to experience symptoms such as heartburn or regurgitation, surgery is an option. Only about 5% of reflux patients undergo the minimally invasive procedure in which the upper part of the stomach is wrapped around the lower esophagus to re-create the weakened valve.

Some doctors are skeptics of the surgery, Spechler included. He said the procedure tends to “break down” over time, and though many of his surgical patients tell him their symptoms are improved afterward, few are completely cured.

In the late 1980s, Spechler and his colleagues performed a study comparing the results of patients on medication and those receiving surgery. A follow-up study in 2001 found that almost two-thirds of the surgical patients were back on medication.

Dr. David Rattner, professor of surgery at Harvard Medical School and chief of gastroenterology and general surgery at Massachusetts General Hospital, said the surgery is relatively simple; most people go home after 24 hours and are “100%” after about two weeks. Side effects of surgery are rare. They include difficulty swallowing, excessive gas or return of symptoms, particularly among obese patients. Spechler said deaths occur in about one in every 1,000 operations.

One final way to treat reflux is through various endoscopic procedures, including stitching or using radio-frequency waves to restore the lower esophageal muscles. Studies have shown that these procedures can reduce medication usage, are relatively safe and can improve quality of life.

But they are not time-tested and not commonly used. In 2002, the American Gastroenterological Assn. said endoscopic treatment is not a recommended therapy for reflux sufferers.




Prevention will do your body good

To avoid medications and surgery altogether, patients should change their lifestyle -- sooner rather than later. Some tips:

Eat nothing three hours before bed so the stomach is empty upon reclining.

Avoid fatty foods as well as alcohol, coffee, caffeine and chocolate.

If you are overweight, shed some of those excess pounds.

Eat smaller meals to reduce the stomach’s content.

When symptoms are mild and infrequent, such changes can potentially get rid of reflux for good. But they must be done early. “In my practice, I recommend a combination of lifestyle changes and medications,” said Dr. Prateek Sharma, a professor of medicine and director of the GI Fellowship Training at the University of Kansas School of Medicine. “By the time they [patients] see us, their symptoms are frequent or so severe that, by themselves, lifestyle changes are not effective.”

-- Tammy Worth