Questions & Answers About GERD

Q: I was recently diagnosed with GERD and reflux problems. I understand everything I should be doing to try and alleviate these symptoms and problems. There is one problem, however, that I don't know what to do about. Every time I have a big flare-up from this GERD, my esophagus starts doing spasms that are very painful. It feels like it happens in my upper esophageal area and in my lower LES area.

It feels like a heart attack and the first time it happened, I actually went to the emergency room thinking that's what it was, but my EKG was normal. Is there anything I can do to relieve this pain when it hits? I want to try a heating pad but I don't want to aggravate it and make it worse. Please help! f

A: Chest pain secondary to esophageal spasm is commonly confused with cardiac (heart) chest pain. You mentioned that you were familiar with gastroesophageal reflux disease (GERD) but you didn't mention whether you tried any medications for that condition. H2 blockers such as cimetidine (Tagamet), ranitidine (Zantac) or famotidine (Pepcid) can help relieve the pain of GERD and non-cardiac chest pain due to esophageal spasm. Stronger acid suppression with omeprazole (Prilosec) or lansoprazole (Prevacid) may sometimes be required.

Other types of medications have been used to relieve the pain of esophageal spasm with variable results. Those include nitroglycerin and nifedipine (Procardia). Obviously, the medications should be complemented by anti-reflux measures. Anti-reflux measures are lifestyle and dietary modifications, which are important in the management of gastroesophageal reflux. You can ask your doctor for a list of these. Finally, there have been some recent reports using low dose anti-depressant medications in the treatment of non-cardiac chest pain. Good luck to you.

Q: I need to know whether people with GERD hav coughs or not and how bad it is. I'm really worried about mine and wonder if it relates to cancer. Please share your experiences, thoughts and suggestions for controlling the cough.

A: Many people with GERD can have a cough. There are a number of possible explanations for the cough. Acid may reflux into the mouth and even be aspirated into the lungs, initiating a spasm of coughing.

A second explanation is a nerve reflex initiated by acid merely refluxing into the esophagus. The acid causes spasm of the air tubes, which can lead to a dry cough. If you have had chronic reflux, you may develop a stricture. Food may regurgitate and be aspirated causing coughing and a choking sensation.

Finally, if you smoke, your reflux would be worse and the cigarettes could be responsible for the cough. If you are concerned that you may have a lung cancer, you should have a chest X-ray for peace of mind.

Q: I've had two really bad GERD attacks in the last fou months. Each time, it was so bad, I didn't sleep for seven nights straight! I was in such pain and agony, and nothing I did would help. I tried raising the bed and/or elevating my head and the acid traveled right up into my throat.

I had to wait until Prilosec started to do its job (about 6 to 7 days) before the symptoms improved enough for me to sleep. I was exhausted and depressed and missed time from work. I don't really like taking medications and didn't want to make a bad situation worse by taking sleeping aids. Do you have any suggestions so that I can be prepared if another attack like this hits?

A: Symptomatic esophageal reflux is an intermittent problem. Once the symptoms recur, there is nothing to do but wait for the antacid drugs to inhibit acid production so that the esophagus can heal. Obviously, there are lifestyle modifications that will reduce your probability of developing symptoms. Eating three meals a day, avoiding coffee, alcohol, cigarettes, fatty foods, etc., will reduce the likelihood of symptomatic reflux. Do not lie down for three hours after eating. These lifestyle modifications should be continued indefinitely because we know that reflux is a chronic problem.

When you have symptoms, you can obtain relief with antacids or over the counter H2 receptor antagonists e.g. Tagamet, Pepcid AC etc. Prevention of attacks often requires pharmacologic doses of H2 antagonists or proton pump inhibitors such as Prevacid or Prilosec. Prokinetic agents such as Propulsid are often used to prevent reflux symptoms.

The only definitive way to prevent reflux symptoms, but not take medications, is surgery. Your symptoms, however, are not severe enough to justify consideration of surgery.

Q: I've always heard of a correlation between coughing and many types of cancer. I have a constant hacking cough with my GERD, and I'm afraid I may have esophageal cancer. Is cough more of a symptom of Barrett's, cancer or just plain reflux or all three?

Are there any symptoms of cancer that are not present with ordinary GERD? I'm really scared to death and need a little reassurance. I've only been treated for five to six weeks, but I feel like some of this hacking would have eased up by now. I suspect I've had it a long time, but it was misdiagnosed as bronchitis. I'm taking 30 mg. of Prevacid once a day.

A: Cough is an atypical manifestation of gastroesophageal reflux. It may be associated with hoarseness or dental problems if due to gastroesophageal reflux. Having a cough does not necessary imply that you have Barrett's esophagus (change of the lining of the lower esophagus) or esophageal cancer.

The fact that your cough is improving on lansoprazole (Prevacid) is a good sign. Adenocarcinoma of the esophagus is generally suspected in patients (especially in those over age 45) with long-term gastroesophageal reflux who are losing weight, have difficulty swallowing or have evidence of gastrointestinal bleeding. It is important to note that more recently, a relationship between chronic hoarseness, gastroesophageal reflux, vocal cord polyps and laryngeal cancer has been reported.

Q: I have an upper GI scheduled this week, which I've requested because of my GERD symptoms. Before putting myself through this ordeal, I want to know what it can reveal. Can it show Barrett's? Can it show possibly why I have a constant cough with my GERD? I just need to know if I'm wasting my time. My doctor won't order an endoscopy, so is the upper GI my only recourse?

A: An upper GI series is a good test to look for strictures (narrowing), masses or diverticula but is not as good at detecting mild forms of esophagitis (inflammation of the esophagus).

It is very hard to tell if a patient has Barrett's esophagus based solely on an upper GI series. Barrett's esophagus is a complication of longstanding gastroesophageal reflux. It is a histologic diagnosis that is usually made after analyzing esophageal biopsy specimens taken during an upper GI endoscopy. Esophageal biopsy specimens that show the finding of intestinal metaplasia warrant further surveillance endoscopies.

Intestinal metaplasia is a change in the lining of the lower esophagus with changes more consistent with lining of the small intestine. The radiologist who performs the upper GI series can often detect if gastroesophageal reflux is present on dynamic fluoroscopy.

If you continue to have symptoms despite treatment and a normal x-ray, it may be necessary to perform an endoscopy to look for inflammation of the lining of the esophagus and to biopsy the esophagus as needed. You may benefit from dietary measures called anti-reflux measures. Your physician may also want to try some medications to help treat gastroesophageal reflux disease.

Q: I started having a great deal of gurgling, belching and chest pain about a month ago. I am very susceptible to stress, and have gone to the emergency room twice. My heart was fine, but I'm cautiously anxious. Is a stress test enough, or should I demand an echocardiogram, even, perhaps, catherization? My EKG, enzymes etc., were all fine, however my blood pressure seems a little lower than before. Also, my ability to run has been diminished since the GERD kicked in. Could I be bleeding from daily aspirin regimen?

A: GERD is an abbreviation for Gastroesophageal Reflux Disease. This disease is characterized by reflux of acidic stomach contents into the esophagus causing irritation and, in some patients, pain. The presentation of this disease is very diverse, and the symptoms you describe could certainly be a result of this disorder.

Before you can say that your condition is GERD, other possibilities need to be considered. For example, the following problems can present with similar symptoms: gastritis (or inflammation of the stomach lining); infectious esophagitis; pill esophagitis; peptic ulcer disease; dyspepsia (or recurring pain or discomfort centered in the upper abdomen); biliary tract disease; coronary artery disease; and esophageal motor disorders.

Your evaluation for coronary artery disease in the ER was appropriate (ECG, exercise stress test). You should consult with your primary care physician to determine if further studies are necessary (i.e. echo, cardiac catheterization).

Your hemoglobin is normal so I doubt you have significant gastrointestinal bleeding. A rectal examination to test for microscopic blood in your stool should be done if this is a concern, especially if you use more than one adult strength aspirin a day on a regular basis (or aspirin-like products such as Advil, Motrin, etc.). Aspirin products can cause irritation of the stomach lining and even ulcers that can result in bleeding.

You should be evaluated by your primary care physician so that a complete history and physical exam can be performed. Your physician can help determine the cause of your anxiety and suggest methods to help reduce stress. Stress certainly can aggravate many medical conditions including GERD.

There are other measures that you can initiate to reduce the symptoms of GERD. Elevating the head of your bed 10-15 degrees will prevent stomach contents from refluxing into the esophagus. Avoid eating at least two hours before retiring for the night.

Try to avoid foods that may worsen symptoms such as alcohol, caffeine, chocolate and peppermint products. Have you tried any over the counter medications? If not, you may want to consider this (i.e. antacids, Pepcid AC). Your doctor can also prescribe medications that may resolve your symptoms.

If your symptoms are severe or the above suggestions are not helpful, your physician may recommend that you be evaluated by a gastroenterologist. If necessary, an endoscopic exam using a flexible scope can be performed to evaluate your upper gastrointestinal tract (esophagus, stomach and the first portion of small bowel).

If this is negative, an ultrasound of the abdomen to evaluate the biliary tract may be considered. The gastroenterologist may recommend further studies if necessary.

Q: I am a 32-year old woman who was diagnosed with reflux esophagitis in 1993. I was scoped twice to determine if I had an ulcer and both times nothing was found. I was started on Zantac then switched to omeprazole after a month.

I was on this for about four years with minimal relief of symptoms. I was then switched to Prevacid three months ago and told that I will have to take it for the rest of my life. My question is: does anyone know the long term side effects of this drug and will I eventually have to have surgery to get relief?

A: Concerning your query about long-term lansoprazole (Prevacid) therapy, one can only extrapolate from the experience with omeprazole (Prilosec). Both medicines belong to the category of medications called proton pump inhibitors (PPIs).

omeprazole (Prilosec), when first introduced in this country, was only approved for short periods because of the possibility of developing rare stomach tumors called carcinoid tumors due to prolonged acid suppression. These tumors developed in rats given very high doses of omeprazole (Prilosec).

However, omeprazole (Prilosec) has since been used in Europe in patients with ulcers and gastroesophageal reflux for several years at a time without adverse effects. Therefore, it is currently prescribed in the United States for prolonged periods.

In clinical practice, we try to use lowest dose of omeprazole (Prilosec) or lansoprazole (Prevacid) necessary to control symptoms and try to wean patients off of the drug whenever possible. On the other hand, we will prescribe these medications for longer periods as necessary if clinically warranted.

If you do not obtain relief with lansoprazole (Prevacid) you might want to consider surgical management. You should undergo further testing prior to surgery to confirm the diagnosis of GERD and to rule out other esophageal motility disorders. You should also be aware that any surgical procedure has associated risks. You should consider the risks, benefits and alternatives of any procedure prior to proceeding with surgery.

Q: I am a 47-year old woman and as a result of a severe reaction to chemotherapy for breast cancer three years ago, I now suffer from chronic esophagitis. I have been taking Losec (20 mg) for two and a half years now and am interested in knowing what the long-term prognosis is with this type of condition. I take one tablet per day and have tried to wean myself off the medication only to find that I suffer severe reflux. Is it likely that I will have to take medication long term? Are there any side effects with Losec?

A: Reflux esophagitis (inflammation of the esophagus due to acid entering the esophagus) is a chronic condition. The severity of symptoms can vary but most people will have intermittent discomfort or ongoing problems. It is unusual to have only one episode of symptoms. The backbone of therapy is lifestyle modifications. Recommendations include:

  • Eat three meals only; do not snack.
  • Do not lie down for three to four hours after eating.
  • Sleep with the head of your bed elevated approx 6 inches.
  • Do not smoke or drink alcohol.
  • Avoid fatty foods, chocolate peppermints, coffee, tea, carbonated beverages.
  • During the day chew gum or suck candies to increase saliva production.

If these lifestyle manipulations do not work, then medical therapy is added. Some physicians use a proton pump inhibitor, like prevacid, whereas others use an H2 receptor antagonist. If you are symptom free on the Prevacid, you could ask your doctor to try an H2 receptor antagonist. If symptoms recur, then you would have to stay on the prevacid indefinitely.

At the present time, we believe that long term use of prevacid is safe. We often suggest to our patients that they stop the prevacid every 8 weeks and for several days just use tagamet. This recommendation allows the stomach to make a small amount of acid and removes the continuous suppression.

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