Dr. Dvora
An ER doc with heart and soul

Digesting our world: the whole view on stomach reflux

Welcome to my new medical blog. The daunting task of addressing the myriad medical and health issues that abound in our society make it difficult to know where to begin. I’ve settled on the topic of digestion, specifically what is generally known in lay terms as heartburn, and medically as gastroesophageal reflux disease (GERD).

GERD is one of the most common maladies in the Western world. Nearly a third of the adult population is self-treating every month. Risk factors include pregnancy, obesity, alcohol, caffeine, hormone therapy, and chronic use of certain prescribed medications such as calcium channel blockers. People are generally reticent to address most of these issues (we are too attached to our wine, coffee, and “spare tires”) and therefore must resort to other helpful measures to counter the discomfort. There’s evidence that tilting the bed, propping up the head, and sleeping on the left side can all be helpful.

The only behavioural approach that’s really proven is substantial weight loss — but treatment shouldn’t wait on that.

A trip to the GI specialist for endoscopy isn’t necessary to make the diagnosis, nor do you need to check for H. pylori (a stomach bacteria that can cause ulcers). Simple heartburn that affects quality of life is enough for your physician to treat. There are, however, “red flag” symptoms that necessitate an immediate visit to a doctor and, in most cases, further investigation; these include weight loss, vomiting, and painful swallowing. Discomfort brought on by swallowing hot liquids is widely considered a sign of esophagitis, a GERD-related condition that needs GI attention.

There are new endoscopic “bullets” (you swallow little endoscopic camera capsules) have been developed, notably by Given Images here in Israel, for example, and known as the PillCam. A less invasive alternative to a scope, these miniature camcorders can be swallowed and later analyzed to show the lining of the esophagus and stomach.

First-line and immediate over-the-counter treatment for GERD includes calcium carbonate (eg. “Tums”) or a liquid antacid (Mylanta, Maalox and equivalents). Symptoms that persist for more than a week or two, or those which are becoming increasingly severe, will require medication. Proton pump inhibitors (“PPI’s”) such as esomeprazole, lansoprazole, omeprazole, pantoprazole, and rabeprazole offer better acid suppression than H2 blockers like ranitidine. PPIs have been linked to weight gain and osteoporosis, so long-term use should be carefully assessed. A common mistake is to stop treatment too soon. Initial therapy should last at least a month, preferably two. Up to 10% of patients will respond only between weeks 4 and 8.

Surgery can work well in GERD, especially with volume reflux (such as hiatus hernia). But relapse rates can rise to about 30% by 10 years post-op.

So, what is the bottom line to all of this? You can make a big difference to the quality of your GI distress by taking a look at your lifestyle (always harder than popping a pill but a better option overall!). Get out for half an hour of exercise a day (even a brisk walk will help), watch the intake, quantity (remember portion control?), and quality of your food, avoid heavy meals before bed and generally avoid spicy and fatty foods. Turmeric is, however, a helpful spice and overall a healthy choice for the immune system. Keep a food diary and see which foods and/or drinks tip your stomach to the unhappy side. Typically, these include red wine, tomatoes and sauces, chocolate, peppermint, and citrus. Carbonated beverages can also bring gas and acids to the surface. Instead, choose camomile tea or, if there is some nausea, ginger tea. Avoid tight-fitting clothes or belts around your waist. Don’t smoke; nicotine affects the sphincter leading into the stomach.

Other holistic alternatives include exploring the mind-body connection. Try to see the positive in your life, and don’t sweat the small stuff. Anxiety and stress directly affect the gastroesophageal junction (where your eating tube meets with your stomach) and the likelihood that the highly acidic environment in your stomach will come back to haunt you. Regular meditation is a panacea for all ills in that it relaxes you (think “anal” personality) and decreases your heart rate and blood pressure. Stress, and specifically cortisol and adrenalin which are two of our stress hormones, directly affects digestion and gut motility. Finally, disease and illness are often metaphors for our life problems, so if your gut gives you grief, think seriously about how you digest the issues in your life and adjust your reactions accordingly.

About the Author
Debra Kiez is an ER physician in Toronto, Canada (where she spends some of her time) and teaches at the Technion American Medical School in Haifa when she's in Israel. She has a special interest in mind-body medicine, mindfulness, and narrative medicine. She has five children, one grandchild, two on the way, and an amazing husband who recently shared the aliyah experience.