Approximately 44% of adults experience heartburn at least monthly, 18% experience heartburn at least twice weekly, and 7% suffer heartburn daily.
Heartburn is an uncomfortable feeling that thousands of people experience. It is usually trivial but can be a symptom of a more serious disorder: gastroesophageal reflux disease (GERD). The pharmacist encountering a patient complaining of heartburn must ask penetrating questions to determine the extent of the problem and the appropriateness of treatment with nonprescription products. The pharmacist can assist patients seeking relief of heartburn by providing counseling on lifestyle modifications and pharmacotherapeutic options, monitoring their medication use and control of the problem, and referring them when necessary.
Heartburn as a Symptom of Reflux
Heartburn is defined as a retrosternal burning sensation that extends from the epigastrium, or lower chest, upward to the pharyngeal/neck area. Heartburn is considered the hallmark symptom of gastroesophageal reflux, a condition in which stomach contents move upward into the esophagus. Because of the typical location of esophageal damage (behind the breastbone), the patient believes that the problem is located in the heart; thus the term “heartburn.”
To help confirm that the patient has pain due to heartburn reflux and not a coronary condition, the pharmacist should ask if the patient noted a feeling of food leaving the stomach to move upward into the esophagus before the pain began. The food does not move far enough into the upper esophagus to be vomited but returns to the stomach. The patient should also be asked if he or she noticed a sensation of liquid rushing into the mouth just before the onset of heartburn. The sensation of water rushing into the mouth is a reflex hypersalivation known as “waterbrash phenomenon.” This reflex is triggered by the retrograde flow of food from the esophagus and also signals that food is in an inappropriate place, occurring with both reflux and imminent vomiting. The pharmacist might ask if the patient notices that specific foods or medications cause the symptoms, whether the patient has been coughing up blood or noted the presence of blood in vomitus or sputum, and the frequency and duration of these symptoms. Each of these may indicate a serious medical condition, or they may be due to reflux.
The Prevalence and Physiology of Heartburn
Heartburn is experienced once daily by at least 7% of US residents (approximately 15 to 25 million adults) and weekly by 18% of US adults. Some 36% to 40% (about 95 million people) suffer the problem at least once monthly. In 20% of Americans, heartburn is moderate, severe, or very severe. These figures underestimate the true incidence/prevalence since most people with heartburn never report the condition to a physician.
Heartburn is caused by gastroesophageal reflux. Reflux allows gastric contents to contact the esophagus, which is poorly protected from acidic and enzymatic assault. Stomach acid is damaging, but pepsin adds to the esophageal insult. Bile salts also add to the damage when they are present. They can be found in the stomach if the patient experienced duodenogastric reflux, in which small intestine contents flow back into the stomach.
The underlying physiological defect behind heartburn is associated with the lower esophageal sphincter (LES). The LES is located at the junction of the esophagus and stomach, surrounded by the diaphragm. As the person breathes, diaphragmatic compressions help close the LES. In the healthy individual, the lower esophageal sphincter is closed most of the time. When a person swallows, the LES opens in response to esophageal contractions. Swallowed food enters the stomach, and the LES closes tightly again.
The defect inducing heartburn was once thought to be a chronically weak lower esophageal sphincter, which allowed food and drink to reflux from the stomach back into the esophagus. According to that theory, gastric contents could reflux at any time, since the LES was never completely contracted. However, recent experiments have demonstrated that the predominant theory of chronic LES weakness may be flawed.
Investigators have obtained simultaneous measurements of lower esophageal sphincter pressure and esophageal pH. The surprising finding was that most episodes of lowered pH occur when a normal LES undergoes intermittent episodes of complete loss of tone. The major trigger for each episode is apparently gastric distention, which stimulates vagal sensory and motor nerves to relax the LES.
Whichever theory of LES malfunction is true for the majority of patients, the fact is that damaging materials contact esophageal tissues to cause heartburn. This refluxate is composed of acid and enzymes. Unfortunately, the esophagus is poorly equipped to withstand damage.
Another problem experienced by many patients with heartburn is abnormal esophageal acid clearance. After a reflux episode, the esophagus begins to generate waves of peristalsis, which move the refluxate back into the upper gastric region. Most patients begin a beneficial reflexive swallowing. Saliva is a higher pH secretion than refluxate since it contains bicarbonate. The combination of rapid clearing from the esophagus and salivary bicarbonate buffering helps prevent most reflux episodes from causing heartburn. However, should a patient’s condition manifest in slower gastric emptying time, the risk of heartburn increases.
Some patients cannot clear the esophagus rapidly through normal peristalsis because they have connective tissue disease in the esophagus or an overall motility disorder. They are more at risk for heartburn because the total load of refluxate is higher than in persons without connective tissue or motility disorders, and because salivary bicarbonate may be insufficient to buffer the total acid load. Those with scleroderma are at particularly high risk for heartburn and severe esophagitis secondary to lower esophageal sphincter dysfunction and impaired esophageal peristalsis. Other patients experience hyposalivation because of xerostomia (dry mouth) caused by Sjögren’s syndrome, anticholinergic medications, cigarettes, or radiation therapy to the thyroid gland, which puts them at higher risk for heartburn and damage to the esophagus than those with normal salivary flow. Fortunately, other factors, such as gastric emptying and inherent intraesophageal tissue resistance, protect patients against reflux-induced damage. As many as 50% to 70% of patients with heartburn have normal esophageal mucosa.
Epidemiology of Heartburn
Heartburn is possible in virtually all ages. However, in those over age 40, the incidence is increased. In a large-scale random survey of 2,000 patients aged 18 to over 80, 38% of respondents reported that their heartburn increased with aging, compared to only 18% who reported it decreasing.
Women are slightly more prone to report heartburn than men are. The mean age of onset in women is 34.7 years, as compared to 29.9 in males.
At least 30% to 50% of women suffer heartburn during pregnancy. In most cases, the patient experiences heartburn only during pregnancy and it ceases shortly after delivery. The incidence varies by trimester. The first trimester exhibits an incidence of 22%, but the figure rises to 39% in the second trimester and peaks at 72% in the third trimester. The etiology may be decreased lower esophageal sphincter (LES) pressure due to elevated hormone levels, increased abdominal pressure from a growing uterus, or altered gastric emptying.
Problems Associated With Persistent Heartburn
Reflux-induced heartburn may exist as an isolated symptom; however, many patients with frequent heartburn develop gastroesophageal reflux disease. If reflux is sustained and pathologic changes occur, the eroded esophagus may undergo stricture. Strictures of the esophagus cause a narrowing of the esophageal lumen, leading to difficulty in swallowing.
Extraesophageal Manifestations of Reflux
The patient who has reflux-associated heartburn may also have other manifestations. Reflux signs and symptoms occur in two forms. Some are related to esophageal damage, and others are extraesophageal. Asking about their presence can help confirm the pharmacist’s recognition of reflux-associated heartburn and assist in ruling out the conditions it mimics, such as angina or myocardial infarction. It is also helpful to counsel the patient that nonprescription therapy may help relieve esophageal reflux symptoms such as heartburn, but the extraesophageal symptoms require a visit to a physician or dentist.
Head and Neck Manifestations
Head and neck symptoms associated with reflux have an underlying pathophysiology different from that of the gastrointestinal manifestations and may occur in the absence of esophagitis. Those symptoms related to esophageal damage are primarily caused by the LES dysfunction, while the head and neck problems are caused by daytime laryngopharyngeal reflux secondary to dysfunction of the upper esophageal sphincter (UES). The UES is a less well-defined area of the upper esophagus that prevents refluxate from leaving the upper esophagus. Head and neck manifestations can include chronic sore throat, dysphagia (difficulty in swallowing), or odynophagia (pain upon swallowing). The patient may also complain of hoarseness, dysphonia, or a change in the timbre of the voice caused by edema or lesions of the vocal cords. Patients also report laryngospasm or a sensation of something being stuck in the throat, induced by irritation of laryngeal tissues. Often, the patient interprets this sensation as something such as viscous mucus stuck in the throat. The patient uses the typical throat-clearing exercises, but they do not help since the sensation is due to damaged tissue rather than viscous materials. Patients may have halitosis, buccal burning, aerophagia (swallowing air), or a tightness of the pharynx.
Globus hystericus is a choking sensation caused by reflux-induced damage, among other etiologies. The patient reports a lump in the throat, stuck to the point that it cannot be dislodged. These patients attempt frequent dry-swallowing.
Chronic cough, apnea, bronchitis, stridor, hiccups, and sudden infant death syndrome (SIDS) may occur along with heartburn. Asthma is increasingly recognized as a reflux-associated problem. Experts estimate that 24% to 98% of patients with asthma have reflux as severe as GERD.
Chest pain is a frightening problem for the patient, who assumes that he or she is suffering a heart attack. From 10% to 50% of chest pain that is not cardiac in origin is associated with reflux.
|Case Scenarios: What Should the Pharmacist Recommend?|
|Case 1: JD, a moderately overweight male in his 50s, exudes an odor of cigarettes. He doesn’t use any medications and denies the presence of any other medical condition, sign, or symptom (eg, chest pain, lightheadedness, bloody stools). He uses calcium carbonatecontaining antacids relatively frequently, but they don’t seem to help. He states heartburn is present most of the time, averaging four to five days every week for the past month.|
|Case 2: A young mother of three, LJ has suffered heartburn three or four times in the past week. She noticed it seems to occur when she has more stressful days than usual. She doesn’t complain of any other symptoms and reports the only products she takes regularly are vitamins.|
|Case 3: GH asks for a recommendation for heartburn because he is going to a wedding reception and always develops heartburn after such affairs.|
|Case 4: MB is 74 and complains that for the past few years, at the end of the day, his voice gets weak and hoarse. He wonders if it is related to his heartburn, which wakes him up occasionally with an acid taste in his throat and mouth. He drinks a lot of coffee and years ago was a chain smoker.|
|Case 5: SW asks what to do for heartburn she gets mostly when lying down. She says it has bothered her several times a week for the past month. Otherwise she is generally healthy.|
|See next table for appropriate pharmacist counseling.|
Provoking Factors for Heartburn
Pharmacists can advise patients of numerous lifestyle modifications that can prevent heartburn.
Foods and beverages may worsen heartburn. Fatty and fried foods are some of the worst offenders. The oils and fats they contain allow these foods to move upward through the lower esophageal sphincter (LES), carrying heartburn-inducing materials. Peppermint candy acts in a similar manner, as does chocolate. Patients may notice a correlation of heartburn with such foods as peppers, garlic, onions, tomato-based products, citrus fruits, and citrus juice. Drinking 12 oz of carbonated beverage and jogging for a mile could release sufficient carbonation to exert severe pressure on the LES; for this reason, carbonated drinks should be avoided in patients prone to heartburn. Caffeine, whether in the form of coffee, tea, or carbonated colas, exerts a relaxing effect on the LES. Coffee stimulates the production of gastric acids, directly irritates esophageal tissues, and promotes reflux. Heartburn is the most common gastrointestinal symptom reported by coffee drinkers. Of patients with daily heartburn, 68% report that it is worsened by coffee. Dietary factors are unique to each individual. For instance, some patients may be able to drink coffee without experiencing heartburn, while others cannot. Patients are advised to avoid those foods and drinks that cause problems for them. Women are more likely than men to report heartburn from fatty foods, chocolate, peppermint, citrus fruits or juices, and tomato products.
Meal-Associated Risk Factors
Since gastric distention has been found to relax lower esophageal sphincter pressure, patients with heartburn are urged to avoid large, infrequent meals in favor of several smaller meals throughout the day. Pharmacists can also instruct patients to eat their last meal no later than three to four hours before bedtime and/or lying down, since a large meal places greater pressure on the LES in a recumbent patient. Eating at restaurants or friends’ houses and consuming fast foods are also more likely to cause reflux than eating meals prepared at home.
Drugs of Abuse
Alcohol worsens heartburn due to its ability to relax the pressure of the LES and to stimulate the production of gastric acid; alcohol-induced heartburn is 64% more common in men. Tobacco products act similarly. These drugs should be avoided to lessen the risk of reflux-associated heartburn.
Posture and Exercise
Poor posture can raise the risk of heartburn. Patients should not bend over excessively (eg, weeding a garden, picking up litter), especially after eating. Bending to lace up shoes caused reflux in 60.7% of patients in a survey. The pressure on the abdomen may facilitate heartburn. Exercise causes heartburn in 25% of patients; this is as common in women as in men. Vacuuming and hanging laundry precipitated reflux in over 52.6% of patients in one survey.
During the day, the upright stance helps keep food in the stomach. However, at night the patient lies down, and material in the stomach is more prone to reflux to cause heartburn. The pharmacist can suggest that the patient raise the head of the bed six to eight inches to allow gravity to augment the effect of the LES. If patients raise the head of the bed by only six inches, they experience one less episode of heartburn or acid reflux per night as compared to lying flat.
Obesity and Abdominal Pressure
Obesity is a prominent risk factor for heartburn. In a random sample of 2,000 adults, obesity demonstrated a positive correlation with heartburn. Those with body mass indexes in the top quartile were more likely to experience daily heartburn than those in the lowest quartile. This is partly because obese patients have chronically low tonicity of the lower esophageal sphincter (LES) and because obesity causes an exaggerated pressure on the abdomen when the patient’s clothing becomes increasingly tight. Losing weight can help reduce the risk. Similarly, straining to pass impacted feces can place sufficient pressure on the abdomen to induce heartburn. Further, any tight clothing may induce heartburn, regardless of the individual’s weight.
Stress may increase the risk of heartburn. Women are 70% more likely than men to report stressful family situations and 55% more likely to report a “hectic day at home” as provoking factors for heartburn. Conversely, men are 24% more likely to report that a week with long work hours causes heartburn and 50% more likely to report that business travel causes heartburn.
Prescription medications may induce reflux. Among these are atropine, calcium channel blockers, narcotic analgesics, nitrates, b-adrenergic agonists, a-adrenergic antagonists, nicotine, and estrogens. Patients with heartburn should also be cautioned to avoid all caffeine-containing nonprescription products, such as stimulants, analgesics, and menstrual products. Aspirin and other NSAIDs may worsen esophageal damage (eg, strictures) and gastric damage due to erosive action.
Use of nonprescription sleeping tablets can worsen reflux. Patients may experience nocturnal reflux as a sudden awakening with a sour taste in the mouth. Patients can minimize the damage by awakening and swallowing several times to buffer the refluxate. If these patients mistakenly choose nonprescription sleeping medications containing diphenhydramine or doxylamine, they may not awaken after a reflux episode, thereby worsening the esophageal damage. The patient who asks the pharmacist about a nonprescription sleep aid should therefore be questioned about the reasons for lack of sleep and the presence of the sour taste. A better choice for these patients is appropriate antiheartburn therapy.
Range of Severity of Heartburn
The most useful categorization of heartburn is in terms of its frequency, the major determinant of the degree of damage reflux can cause.
A single episode of reflux may cause a transient and mild episode of heartburn. In most cases, damage is slight and easily repaired through the body’s natural processes.
This is defined as heartburn that occurs two or more days a week. Minor esophageal damage may repair itself if the pH remains favorable, but if there is further exposure to low pH refluxate, severe esophagitis may develop.
Gastroesophageal Reflux Disease (GERD)
Should reflux episodes occur with a certain frequency (there is no consensus on the exact number), the patient is said to have gastroesophageal reflux disease. GERD is a term that has been in use only for about a quarter century but has gained a great deal of public attention. GERD has a profound impact on the patient’s quality of life, exceeding that caused by such serious conditions as angina, menopause, mild congestive heart failure, and duodenal ulcers. GERD is associated with potentially lethal sequelae, such as aspiration and Barrett’s esophagus. Barrett’s esophagus is about twice as common in men as in women and much more common in white men than in men of other races. Barrett’s esophagus can lead to adenocarcinoma, a cancer that is increasing rapidly in white men, possibly related to the rise in obesity and gastroesophageal reflux disease.
|Patient Scenarios: Pharmacist Counseling|
|Assessment and Recommendations|
|• Has this patient had heartburn too long to be a candidate for self-care?
• What lifestyle recommendations can the pharmacist make for this patient?
• What is the potential for the patient’s problem to be helped with nonprescription products?
|Case 1: This patient has frequent heartburn of less than three months’ duration, which is the maximal duration of self-care for frequent heartburn. At present, nonprescription omeprazole is the only OTC product specifically labeled for frequent heartburn. He should be instructed to take the product once daily in the morning with a glassful of water, before breakfast, and to take it daily for 14 days. He may repeat the course every four months if the heartburn recurs. He could use antacids prn to treat any breakthrough pain, but antacids will not prevent frequent heartburn. The pharmacist should counsel the patient to stop smoking, lose weight, and avoid tight clothing. Other lifestyle recommendations might include advising him to keep a symptom diary of when the pain comes, its severity, and what foods were ingested; that information can be reported to the physician should a more intensive work-up become necessary.|
|Case 2: The heartburn coincides with stress in this mother’s daily life. The pharmacist can offer information on stress reduction techniques and other lifestyle modifications. A 14-day trial of nonprescription omeprazole may be the best choice of OTC product since her heartburn frequency exceeds once weekly.|
|Case 3: The patient reports having heartburn pain only following big meals. He should be reminded that large, heavy meals and alcoholic beverages trigger heartburn. Since it is an infrequent problem, the pharmacist might recommend as a preventive Axid AR, Pepcid AC, Tagamet HB 200 or Zantac 75 (any OTC H2 blocker).|
|Case 4: This patient has extraesophageal symptoms (atypical symptoms of reflux) and should not attempt self-treatment. A physician visit and an endoscopic evaluation are warranted because of the frequency and duration of symptoms. A prescription PPI is indicated.|
|Case 5: This patient notices heartburn both day and night. It has been a persistent problem, so she saw a doctor and had an endoscopy, but it showed no signs of esophagitis. While she may try avoiding late meals, elevating the head of the bed, and lying on her left side to sleep, treatment with a nonprescription PPI would be beneficial. Antacids and H2 blockers should not be suggested because the problem has existed longer than two weeks.|