Heartburn Health Article

Diagnosis

Gastroenterologists and internists are best equipped to diagnose and treat gastroesophageal reflux. Diagnosis is usually based solely on patient histories that report heartburn and other related symptoms. Additional diagnostic procedures can confirm the diagnosis and assess

damage to the esophagus, as well as monitor healing progress. The following diagnostic procedures are appropriate for anyone who has frequent, chronic, or difficult-to-treat heartburn or any of the complicating symptoms noted in the previous paragraph.

X rays taken after a patient swallows a barium suspension can reveal esophageal narrowing, ulcerations or a reflux episode as it occurs. However, this procedure cannot detect the structural changes associated with different degrees of esophagitis. This diagnostic procedure has traditionally been called the "upper GI series" or "barium swallow" and costs about $250.00.

Esophagoscopy is a newer procedure that uses a thin flexible tube to view the inside of the esophagus directly. It should be done by a gastroenterologist or gastrointestinal endoscopist and costs about $700. It gives an accurate picture of any damage present and gives the physician the ability to distinguish between different degrees of esophagitis.

Other tests may also be used. They include pressure measurements of the LES; measurements of esophageal acidity (pH), usually throughout a 24-hour period; and microscopic examination of biopsied tissue from the esophageal wall (to inspect esophageal cell structure for Barrett's syndrome and malignancies).

Note: A burning sensation in the chest is usually heartburn and is not associated with the heart. However, chest pain that radiates into the arms and is not accompanied by regurgitation is a warning of a possible serious heart problem. Anyone with these symptoms should contact a doctor immediately.

Drugs

Occasional heartburn is probably best treated with over-the-counter antacids. These products go straight to the esophagus and immediately begin to decrease acidity. However, they should not be used as the sole treatment for heartburn sufferers who either have two or more episodes per week or who suffer for periods of over three weeks. There is a risk of kidney damage and other metabolic changes.

H2 blockers (histamine receptor blockers, such as Pepsid AC, Zantac, Tagamet) decrease stomach acid production and are effective against heartburn. H2 blocker treatment also allows healing of esophageal damage but is not very effective when there is a high degree of damage. It takes 30–45 minutes for these drugs to take effect, so they must be taken prior to an episode. Thus, they should be taken daily, usually two to four times per day for several weeks. Six to twelve weeks of standard-dose treatment relieves symptoms in about half the patients. Higher doses relieve symptoms in a greater fraction of the population, but at least 25% of heartburn sufferers are not helped by H2 blockers.

Proton-pump inhibitors also inhibit acid production by the stomach, but are much more effective than H2 blockers for some people. They are also more effective in aiding the healing process. Esophagitis is healed in about 90% of the patients undergoing proton-pump inhibitor treatment.

The long-term effects of inhibiting stomach acid production are unknown. Without the antiseptic effects of a consistently very acidic stomach environment, users of H2 blockers or proton-pump inhibitors may become more susceptible to bacterial and viral infection. Absorption of some drugs is also lowered by this less-acidic environment.

Prokinetic agents (also known as motility drugs) act on the LES, stimulating it to close more tightly, thereby keeping stomach contents out of the esophagus. It is not known how effectively these drugs promote healing. Some of the early motility drugs had serious neurological side effects, but a new drug, cisapride, seems to act only on digestive system nerve connections.

Surgery

Fundoplication, a surgical procedure to increase pressure on the LES by stretching and wrapping the upper part of the stomach around the sphincter, is a treatment of last resort. About 10% of heartburn sufferers undergo this procedure. It is not always effective and its effectiveness may decrease over time, especially several years after surgery. Dr. Robert Marks and his colleagues at the University of Alabama reported in 1997 on the long-term outcome of this procedure. They found that 64% of the patients in their study who had fundoplication between 1992 and 1995 still suffered from heartburn and reported an impaired quality of life after the surgery.

However, laparoscopy (an examination of the interior of the abdomen by means of the laparoscope) now provides hope for better outcomes. Fundoplication performed with a laparoscope is less invasive. Five small incisions are required instead of one large incision. Patients recover faster, and it is likely that studies will show they suffer from fewer surgical complications.