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Heartburn: What's Going On Down There?

Posted Aug 24 2008 1:49pm
DAVID R. MARKS, MD: Hi, and welcome to our webcast. I'm Dr. David Marks.

Now, most of us know what heartburn is like. In fact, 60 million Americans feel that sharp, burning sensation in their chest at least once a month. But fewer people know what causes heartburn or that it can be a symptom of a much more serious condition.

Joining me today to discuss what you should know about heartburn is Dr. Jim Freston from the University of Connecticut, welcome. And next to him is Dr. Michael Wolfe, he's here from Boston University School of Medicine. Welcome.

We use this term "heartburn" all the time, but what exactly is it?

JAMES FRESTON, MD, PhD: Heartburn is a sensation of burning, typically behind the breastbone. It migrates up toward the throat. Classically.

What it is is a manifestation of acid coming up from the stomach into the esophagus, where it doesn't belong. And actually causing irritation there. It's one end of the spectrum of a whole bunch of conditions that we call GERD, for gastroesophageal reflux disease. Ranging from simple heartburn clear to cancer of the esophagus.

DAVID R. MARKS, MD: What exactly is it? How does it differ from just regular old heartburn?

MICHAEL WOLFE, MD: Okay, heartburn is a symptom. That is, the burning sensation Jim described behind the breastbone that goes up into the throat. But GERD is actually what's happening. GER, actually. Gastroesophageal reflux. Meaning, you're getting flow of acid from the stomach into the esophagus. So the process is reflux. The end result, most commonly, is heartburn.

DAVID R. MARKS, MD: Can a person's lifestyle affect heartburn?

JAMES FRESTON, MD, PhD: Absolutely. People who overeat. People who are overweight. People who eat large meals before going to bed, leaving no gap between the meal and bedtime or very little. They're all predisposed to getting heartburn.

DAVID R. MARKS, MD: Any other factors?

MICHAEL WOLFE, MD: Well, certain foods are notorious for causing heartburn. But -- then again, causing reflux, I should say. But there are -- we should really recognize that everybody has their own individual trigger. Certain foods relax that valve -- that so-called "sphincter" between the esophagus and stomach, allowing acid to flow backwards, or reflux. Such as coffee of any type, fatty foods, chocolate, peppermint, alcohol. Those are the notorious foods that cause the problems of reflux.

JAMES FRESTON, MD, PhD: We should mention, and a host of medications.

DAVID R. MARKS, MD: What about stress?

JAMES FRESTON, MD, PhD: I think stress is overrated as a cause of heartburn. It can contribute indirectly. For example, uptight people who are rushing through meals and overeating they're so anxious, which is common. Drinking ten cups of coffee, that can contribute. But stress itself, I doubt is directly a cause.

MICHAEL WOLFE, MD: I agree. If you look at just stress by itself, it's very difficult. It's what people do in response to their stress.

DAVID R. MARKS, MD: A lot of people also have heartburn specifically at night. Why is that? What are they doing wrong?

MICHAEL WOLFE, MD: Well, they get heartburn at night because sometimes they're going to bed too soon after eating a meal. Not having given the food a chance to empty the stomach. But additionally, we no longer have gravity on our side. We're lying flat. We don't have the gravity of allowing food to empty the stomach.

Additionally, we're not swallowing as much. Saliva has a natural antiacid bicarbonate within it. So the defense mechanisms just aren't there to help us from getting the reflux, or getting the heartburn to occur.

DAVID R. MARKS, MD: Most people think of heartburn as just being kind of a minor problem. But there are some serious potential manifestations down the road from heartburn.

JAMES FRESTON, MD, PhD: Absolutely. Heartburn's not trivial. An interesting study was done of factory workers who were taking lots of over-the-counter medications. And they were studied. And about 40% of them had severe disease. That should have been handled better. It's not a trivial condition.

I mentioned earlier that some people have simple heartburn, other people have chronic cough, laryngitis, even asthma symptoms. And then some -- a small percent, but a growing percent -- get cancer of the esophagus.

DAVID R. MARKS, MD: You say "a growing percent," why is that? With all the medications out there, that are even available over the counter, why would more people be having cancer from this problem?

JAMES FRESTON, MD, PhD: We're having an epidemic of GERD. And it's dragging cancer with it. Cancer of the esophagus related to heartburn and GERD is the most rapidly increasing cancer in western countries. We're not sure why there's such an epidemic of GERD and bringing cancer with it.

Being overweight, as a society. Probably eating more fatty foods. And, undoubtedly, other factors are playing a role.

MICHAEL WOLFE, MD: I agree. There are many factors that are implicated in this so-called epidemic, but we shouldn't alarm people. It's still a small number.

DAVID R. MARKS, MD: Small number. Some people may think they're even having a heart attack with these symptoms. That's a common complaint in emergency rooms. So the symptoms can be very severe.

MICHAEL WOLFE, MD: And similar. But remember, we have to first exclude the more serious disorder. So, if someone thinks, "Well, I'm just having a little bit of heartburn, and I'm not going to worry about it." That's a serious mistake. Because the first thing we must do is exclude the possibility that this is, indeed, a heart attack. Or angina.

So, first rule out the more life-threatening condition before just saying, "Yes, this is reflux." Yes, reflux is bad. But it will not kill you instantly. Whereas a heart attack may.

DAVID R. MARKS, MD: And, of course, that entails a doctor's evaluation. So when should a patient with heartburn see a doctor.

JAMES FRESTON, MD, PhD: I think if you've had heartburn for a minimum -of four or five years or more. And if you're having it three times a week, you certainly should see a doctor.

MICHAEL WOLFE, MD: I agree completely. And I think if you've had heartburn for five years, I think it's incumbent upon your primary physician to refer you to a gastroenterologist for an endoscopy in order to obtain a tissue sample to make sure you don't have a pre-malignant condition. Which tends to occur the longer you've had heartburn.

DAVID R. MARKS, MD: You mean something that can turn into cancer down the road.


JAMES FRESTON, MD, PhD: I would add another thing. If a person is taking a lot of antacids, that's reason enough to come in, because there's a better way. And that can be explained to people.

DAVID R. MARKS, MD: Thank you very much for being here. Thank you for joining our webcast. I'm Dr. David Marks, goodbye.

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