Eat, drunk and be miserable
By: Judy Foreman
12/23/1996

Then the rolls, with butter, of course. Maybe a veggie or two for color. And wine, naturally, the more the merrier.

Then the pecan might-as-well-make-it-a-la-mode pie. Then the mints and the coffee, lightened, because it's Christmas, with real cream -- make that whipped.

Then -- surprise, surprise -- the heartburn, that burning and churning in the chest that is the hallmark of GERD, a not-so-charming acronymn for an even less charming affliction: gastroesophageal reflux disease.

More than 60 million Americans experience GERD and heartburn at least once a month, government figures show, and 25 million belch their way through this post-prandial misery every day.

But the holiday season is when the gastronomic gods can really take their revenge on a nation of hearty eaters who can't ``just say no.''

And so, we suffer -- most of us mildly, some seriously. In fact, heartburn can be intensely frightening because its symptoms are easily confused with those of a heart attack.

Fortunately, even severe forms of heartburn and reflux can be treated with a growing array of drugs and, if necessary, surgery.

If you're young, you may never have heard of GERD because your lower esophageal sphincter, a circular muscle that opens to let food pass into the stomach then closes again, is doing a fine job of keeping food where it belongs, in your stomach.

Ideally, this sphincter ``should be as tight as your pursed lips when you're whistling Dixie,'' says Dr. Andrew Plaut, chief of the Digestive Diseases Research Center at the New England Medical Center.

But in many older people, as well as those who are overweight and possibly some with anatomical problems such as hiatal hernia (which causes part of the stomach to stick up into the chest through the diaphragm), the sphincter may work poorly.

An ``incompetent'' sphincter relaxes too much, allowing partially digested food and stomach acids to ``slosh north,'' Plaut says.

Sometimes, the backflow reaches as far as the mouth, where it can cause sore throats and tooth decay. Sometimes it washes into the windpipe and the lungs, where it can irritate delicate tissues and cause aspiration pneumonia.

More often, the acids simply flow partway up the esophagus -- especially if you lie down too soon after eating -- and cause a burning pain that moves up the chest, says Dr. Walter Hogan, a gastroenterologist at the Medical College of Wisconsin.

In fact, this burning, upwardly mobile pain is one of the key ways to differentiate heartburn -- which actually has nothing to do with the heart -- from a heart attack, he adds. In general, it's probably heartburn if your chest pain comes on repeatedly after eating, is accompanied by difficulty swallowing or regurgitation and gets better with antacids.

On the other hand, it may be a heart attack if your chest pain gets worse with exercise and better with rest. If you're in doubt, of course, see a doctor fast, though even doctors may have a tough time telling heartburn from heart attack. Sometimes, it may take several tests -- including an electrocardiogram or EKG -- to see if it is heartburn.

In some cases, the case for reflux can be clinched if doctors can see, by looking through a tube called an endoscope put down your throat, that the lining of your esophagus is inflamed. A chronically inflamed esophagus can lead to strictures -- scar tissue that can narrow the esophagus -- and Barrett's esophagus, a pre-cancerous change in the cells that line the esophagus.

In other cases, doctors may ask you to swallow a drink containing a chemical called barium, then watch on X-rays to see if acids flow up from your stomach to the esophagus.

If they still can't decide whether you have reflux or heart problems, they may place a thin tube in your esophagus -- a minor, non-surgical procedure -- to monitor the pH, or acidity. If the acid level is consistently high, you probably have GERD.

They can also check the strength of your sphincter with so-called manometric tests, in which pressure sensors in a tube placed in your esophagus detect how well your esophageal muscles are contracting, says Dr. Mark Callery, a gastrointestinal surgeon at the University of Massachusetts Medical Center in Worcester. If your muscles are weak, you probably have GERD. If so, there are lots of treatments.

``The most important thing you can do,'' says Plaut, ``is elevate the head of your bed'' with bricks, books, wood or the Yellow Pages under the bed or a triangular foam wedge placed on your mattress.

Adding a few pillows won't suffice, he says, because the whole bed must be on a slant to keep your stomach lower than your esophagus. This technique really helps, he says, and ``unless you have satin sheets, everybody stays in bed.''

The other utterly basic remedy, says Callery, is to go easy on foods that contribute to reflux because they decrease the muscle tone in the esophageal sphincter. Nobody really knows why some foods affect sphincter tone more than others, but if certain foods make your reflux worse, it pays to avoid them.

Unfortunately, the list of foods to avoid probably includes many of the goodies likely to be on your holiday table, like all the fried and fatty stuff (which can also make reflux worse by making your stomach empty more slowly), chocolate, mints, including the peppermint in candy canes, and alcohol.

Other culprits include coffee, tea, cola, beer and even whole milk dairy products, because these can increase acidity. If your esophagus is damaged, citrus fruits, pepper, tomatoes and raw onions can worsen things.

Of course, if you take away all the foods you love, ``you may get so unhappy that you'd prefer to have a little heartburn,'' notes Plaut, adding that pleasure counts, too.

You may also be able to help by quitting smoking and losing weight, yet another reason to stick to those perennial New Year's resolutions.

You can buy your way to gastric comfort and joy, too. If your reflux is mild or occasional, you can probably control it with over-the-counter acid neutralizers like Tums, Rolaids, Mylanta, Maalox, Pepto-Bismol and the like. Some people also use foaming antacids such as Gaviscon.

A more sophisticated -- and often more effective -- solution is to take so-called H-2, or histamine-blocking, drugs like Zantac, Tagamet, Pepcid and Axid, which are available over the counter in low doses and by prescription in higher doses. H-2 drugs block the histamine receptors on stomach cells, stopping the signal that tells these cells to make acid.

If H-2 blockers don't work, you can try a class of drugs called proton pump inhibitors, which are available only by prescription. Two such drugs, called Prilosec and Prevacid, were approved for GERD this year by the Food and Drug Administration, although they were already on the market for peptic ulcers.

You may also get relief from prescription drugs such as Propulsid or Reglan, which help empty the stomach by increasing the movement of stomach contents to the intestines.

As a last resort, there's surgery, specifically a procedure called fundoplication. Operating through small tubes surgically inserted into the abdomen, doctors wrap part of the stomach tissue around the bottom of the esophagus to form a kind of collar that can prop up an ineffective esophageal sphincter.

While surgery should be used only if all else fails, says Callery of UMass, it works very well and usually means that patients no longer need to take any reflux medicines.

But the best way to deal with heartburn is to not get it.

So as you face the groaning board this year, think not only of the tempting tastes and tender feelings of your host or hostess, but of your humble esophagus, which seeks nothing more in life than to be a one-way street for your indulgences.

Don't eat everything in sight, and if you do, don't lie down.

Remember: The gastronomic gods don't want you to get heartburn. That's why they left you a sinkful of dirty dishes that can be dealt with only one way: standing up.

Judy Foreman’s column runs every other week. Past columns are available on www.myhealthsense.com.

Listen to her live call-in webcast radio show every Wednesday night from 8:30 to 9:30 EST on http://www.healthtalk.com.