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Heartburn, Hiatal Hernia, and Reflux

Heartburn is a burning pain in the middle of the chest. The pain may go up into the throat or into the back between the shoulder blades. Heartburn is caused by the stomach acid rising up into the esophagus, the swallowing tube in the chest. At times the stomach juices which taste sour or bitter, may come up into the mouth. The regurgitation occurs because the valve which normally keeps acid down in the stomach does not work properly.Heartburn is therefore caused by two problems:

  • acid
  • weakened valve which does not keep
    acid out of the esophagus

Treatment is often but not always associated with a hiatal hernia, a bulging up of the stomach into the chest. About 20% of middle aged people have hiatal hernias so they are very common and rarely require anything except medical therapy to keep them under control.

Dietary measures are aimed at lessening the amount and frequency of regurgitation.

Avoid eating large meals. It is better to eat several smaller meals than one large one.

Avoid foods which are known to promote heartburn:

  • fatty foods: butter, mayonnaise, fried foods, gravy.
  • spicy foods: hot peppers, onions, garlic
  • tart foods: tomato pastes such as spaghetti or pizza sauce. Pickles or pickled smoked fish or meats. Citrus juices often cause heartburn.
  • Chocolate: Pound for pound, the worst thing you can eat, unfortunately.
  • Coffee: Both caffeinated and decaffeinated seem to be bad.
  • Aspirin, AlkaSeltzer, Arthritis medications. Tylenol is O.K.
  1. When you lie down, do so on an empty stomach.
  2. Do not eat for at least three hours before bed time
  3. Do not lie down after a snack during the day

Weight reduction
Lose weight if you are above the ideal weight for your height and age. The heaviness of the abdomen squeezes acid back out of the stomach in heavy and even slightly overweight people.

Long term success in the treatment of heartburn seems to be most related to weight reduction if the patient is obese.

Avoid constriction of the abdomen
Garments such as tight belts or girdles will increase abdominal pressure and increase regurgitation. Wear loose fitting garments. Men may do better during the day with suspenders.

Head elevation
If you are bothered by heartburn or sour water coming back into your mouth at night, put blocks of wood or old books under the head of the bed. An elevation of 6 to 8 inches is ideal. A foam wedge (Available at medical supply stores or through mail order as “Bedge”) helps a lot of people and may be easier on your bed and your spouse. Simple head elevation on a pillow does not raise the chest enough.

There are three types of medications which can be used:

  • Medications which reduce acid production
  • Medications which reduce acid regurgitation
  • Medications which protect the lining of the esophagus

Acid reducing agents
Antacids )Tums, Maalox, etc.) and H2 Blockers (Axid, Ciinetidine, Tagamet, Pepcid, Zantac) are the most commonly used medications at present. H2 blockers are much more effective than antacids because their effect lasts for many hours instead of for minutes. They cost more than antacids but if you had to take enough antacid to equal the effect of the H2 blocker, you would pay about as much money.

Prilosec is a new type of drug, a Proton Pump Inhibitor. It is the most effective drug we have at present. Its long term side effects are unknown and it is expensive so it is prescribed only for difficult cases. This drug can cure people who have had no results with any other drug patients on this drug have to be closely monitored at present.

Reglan, Propulsid, Gaviscon lessen the amount of acid getting back into the esophagus. They may be used in addition to the above drugs if you are still having a lot of heartburn.

Protectors of the lining of the esophagus
Carafate and Cytotec may work by making the lining of the esophagus more resistant to acid. These drugs may be especially useful in patients who have to take irritating medicines because of another condition that they have, like arthritis.

In summary, we have various ways of treating heartburn which differ in effectiveness, side effects, and cost. Patient and doctor must make a choice of approach depending on such factors as the severity of the illness, cost, and the response to previous medications.

Surgery to correct heartburn and regurgitation is also available. Unfortunately, surgery is associated with a high rate of recurrent symptoms and is therefore not recommended unless all other approaches have failed. Fortunately, we don’t often run into this situation.