Tums used to serve as a food group for local attorney and filmmaker Stephen Rue.
“I kept a big bottle of fruit-flavored Tums and ate handfuls of them like candy. Six or so at a time at least twice a day and just before I went to bed. I kept a bottle in my car. Maalox was also a staple at my house,” says Rue.
Most adults have experienced at least one episode of nocturnal heartburn. Indicted culprits include certain foods, alcohol and the timing of the last meal before bedtime. It is common to treat attacks of heartburn symptomatically, just like Rue, with antacids and other over-the-counter medications.
Gastroesophageal reflux disease (GERD) is the modern-day name for recurrent or chronic symptomatic acid reflux. The cardinal symptom is heartburn, a burning sensation in the chest and throat, several times a week. Regurgitation of these gastric juices can also cause a brackish taste sensation, cough, chest pain, asthma attacks at night and persistent hoarseness.
The gatekeeper of the stomach is a circular ring of muscle called a sphincter, located at the end of the esophagus. A bolus of food or liquid stimulates this sphincter to open briefly, allowing swallowed contents passage to the stomach – a properly operating sphincter then shuts tightly to prevent any backwash of corrosive gastric juices.
All muscles and tissues sag with age, and the esophagus is no exception. Various food ingredients, drugs and nervous system interplays can impair this muscle. Heartburn is the descriptive name given to the burning acid reflux symptoms when stomach contents breach the usual one-way lower esophageal sphincter.
“It became worse after Katrina. I would particularly be uncomfortable at night. I was a sucker for fried foods. Sorry Al Copeland, but fried chicken was the worse. Also, I live by myself, and I think solitude increases this sort of problem. People who live alone are less healthy eaters. I was never a healthy eater even though I did run marathons,” says Rue, who is six feet, three inches tall and currently weighs about 225 pounds.
“My situation was bad. Fortunately, I found Dr. Price. He fixed my esophageal problem and now I feel fine,” says Rue, whose chronic reflux had caused some lower esophageal ulcerations with scarring that had narrowed the diameter of his lower esophagus.
Dr. Steve Price, a local gastroenterologist, took a look down Rue’s esophagus and into his stomach with a small caliber fiberoptic scope with a strong light source. Price dilated Rue’s narrowed esophagus to allow more normal food and liquid passage and prescribed Nexium to decrease Rue’s stomach acid production.
“I don’t eat all that well. I stay up late and tend to put off eating until the end of the day. Dr. Price was a godsend … Stretching my esophagus really helped, but I’m very careful to take my Nexium daily. Dr. Price and my mother harp on that. I think stress partly caused my problem. I am an attorney and that’s a stressful occupation. But more recently, I’ve been interviewing people day and night working on the definitive Katrina video.”
Over time, daily acid reflux damages the cells lining the lower esophagus and can evolve into a precancerous condition called Barrett’s esophagus. Rue was fortunate his esophagitis had not progressed to that point.
If left untreated for years, inadequately treated heartburn increases the risk of esophageal cancer nearly eightfold. In fact, stomach acid reflux damage to esophageal cells is the major cause of usually fatal esophageal cancer.
According to Dr. Price, occasional heartburn doesn’t necessarily mean GERD, but the chances are high that a person with chronic heartburn carries this diagnosis. He usually recommends a look to visualize the lower esophagus to access damage, if any.
A therapeutic trial of a proton-pump inhibitor such as Prilosec to block stomach acid production is an empiric way to make a diagnosis, but it takes direct visualization of the esophagus to detect and treat underlying abnormalities such as Rue’s stricture.
“Gastroscopy is much more accurate than barium X-rays and allows identification and grading of esophagitis severity. This information is helpful in making treatment recommendations,” says Price, as other stomach and real heart problems can mimic the symptoms of GERD.
“If a good antacid doesn’t immediately erase chest discomfort symptoms, I tell patients to get to an emergency room. Persistent unrelieved chest pain can be a heart attack,” says Tulane cardiologist Dr. Mark Cassidy.
Some foods are more likely to precipitate heartburn than others – acidic, spicy and fatty foods, as well as alcohol and carbonated beverages. Common culprits include our beloved red tomato sauce, citrus-based concoctions, coffee, tea and all carbonated drinks [see box.]
“From my standpoint, the most important factor is the time interval between dinner and bed. I need at least three to four hours for complete gastric emptying. I think type of food is less important than quantity,” e-mails Dr. Kelvin Contreary, a surgeon practicing in New Orleans.
Smoking and alcohol weigh in to relax the sphincter muscle tone and increase stomach acid production. Also, pregnant women often have heartburn in their third trimester due to increased pressure on the stomach from the expanding uterus.
Every treatment treatise for heartburn begins by recommending lifestyle and dietary changes, but losing weight and changing eating styles are not easy options for most of us. The data are scarce that reducing high-fat meals really makes much difference, and who wants to live a life devoid of onions and tomatoes. Persons who skip breakfast, catch lunch on the run and eat until they bloat at night would do well to eat four or five small meals a day.
There are many treatment approaches for symptomatic heartburn. The step-up school starts with the older acid blockers such as Pepcid, Tagamet or Zantac, and works up to more potent acid inhibitors. The step-down advocates prescribe full dose proton-pump inhibitors such as such as Prilosec, Nexium or Protonix in the beginning.
Most gastroenterologists are in the “step-down” camp at least for the patients they see, who are usually those with moderate to severe GERD. Long-term maintenance drugs to reduce stomach acid production are often required.
“It is not enough merely to just treat the symptoms of chronic heartburn sporadically. Acid reflux must be stopped and any damage to the esophagus must be healed. To protect the esophagus adequately, treatment must be aggressive, continuous and indefinite,” says Dr. Price.
The bottom line – heartburn is a symptom that deserves respect. It can be more than a trivial annoyance.
New Orleanians weigh in on the causes of heartburn
Stephen Rue, attorney and film-maker
Pre-Katrina: cheeseburgers with grilled onions from Camellia Grill.
Post-Katrina: Popeye’s fried chicken.
Betty Norris, French Quarter advocate
Iceberg Lettuce. Thank goodness fewer restaurants use it, but I have to be careful with dressed poor boys. Cucumbers are also a no-no for me.
Kelvin Contreary, M.D., surgeon
Creamy, fatty foods and huge steaks that hang around in the stomach longer than starches.
Kevin R. Roberts, art posters collector and photographer
Nachos made with thick-sliced sharp cheddar cheese atop a tortilla chip, garnished with a large slice of jalapeño.
Stacy Horn Koch, executive director, Covenant House New Orleans
Anything with cooked bell pepper in it.
Roger Ledford, apartment cleaner, French Quarter
Red sauces and gravies.
Daniel Turkewitz, waiter, Windsor Court
Chicken fat. It is an old Jewish tradition to keep a jar of liquid chicken fat around so that vampires get heartburn if they don’t get stopped by the garlic.
Bart Farris, M.D., pathologist
My wife’s credit card bills.