Ask the Flight Surgeon —By Dr. (LTC) Joseph Puskar
Q: I’m a 44 year-old pilot, and have been taking Nexium 20 mg daily for heartburn and reflux. The medicine seemed to help a lot at first, but I still get heartburn mostly at night. What else can I do to help with the heartburn?
FS: Your symptoms of gastro-esophageal reflux disorder, or GERD, are very common in men your age. The prevalence of reflux symptoms such as heartburn and regurgitation of gastric contents into the esophagus and throat seems to be increasing throughout the western world. It is more common with an aging population and the associated physiologic changes, increasing body mass index, and increasing use of many medications, many of which can decrease lower esophageal sphincter pressure thus making it easier for the stomach contents to enter the esophagus. In addition to the often distressing heartburn it causes, GERD can also lead to more serious conditions such as esophageal stricture formation, changes in esophageal cell structure to a pre-cancerous state known as Barrett’s esophagus, and later squamous cell and adenocarcinomas.
Dosage adjustments of the proton pump inhibitor, or PPI, Nexium (Esomeprazole) would be our first step for you since the medicine initially helped. Sometimes simply increasing the dose to a higher level can help reduce the symptoms, and this might help particularly with a larger individual like you. Twice daily dosing is often tried, but studies have shown that this has little effect on the pH of the refluxate in the esophagus for most people, and should be considered for initial treatment only in obese patients with severe erosive esophagitis. A condition exists known as non-erosive reflux disease, or NERD, wherein the majority of people will have a normal endoscopy with no evidence of reflux despite heartburn, regurgitation, and hoarseness. Sixty percent of people in this funny-sounding category of NERDs will not respond to anti-acid therapy since symptoms can be related to both acid and non-acid reflux as demonstrated by impedance pH catheter monitoring of the esophagus. This group will not respond well to PPI therapy, and are considered to have “functional heartburn” with an underlying abnormality in motility or visceral sensation.
The likelihood of reflux symptoms is almost linearly related to body mass index, and male-pattern (abdominal) obesity is much more closely associated with reflux than female-pattern (hip) obesity. This is not simply due to the increased abdominal pressure caused by the abdominal fat, but is also probably related to the harmful metabolic activity of that abdominal adipose tissue. Weight loss improves acid over-production, and reduces reflux symptoms. Elevation of the head of the bed four to six inches to change the angle of the torso (not just propping up your head and neck with pillows) as little as five degrees can help get the reflux back down into the stomach. The left lateral decubitus (or fetal) position also seems to help, but the right not as well for many patients.
Eliminating tobacco use has been shown to decrease reflux, Barrett’s esophagus, and esophageal cancer. Carbonated beverages can aggravate reflux by distending the stomach. Fatty foods delay gastric emptying and may decrease lower esophageal pressure. Probably the most important thing you can do with the diet is to reduce meal size. The more the stomach is distended, the higher the rate of lower esophageal sphincter relaxation.
Medications commonly used to treat acid reflux in increasing effectiveness are: antacids, H2 blockers like Ranitidine or Zantac, and proton pump inhibitors like Esomeprazole. Proton pump inhibitors are by far the most effective in terms of both heartburn symptom reduction and the healing of erosive esophagitis caused by acid reflux; although non-standard, on-demand or non-continuous use of PPIs has been shown to be perfectly adequate for many patients with mild to moderate reflux symptoms for reasons not entirely clear. This is in fact the preferred method to take H2 blockers like Zantac since the more frequently you dose them the more likely it is to develop tachyphylaxis or tolerance. Acid rebound can occur when you suddenly remove the inhibition of a PPI on acid production by the proton pumps in the parietal cells, and the body’s natural response of increasing gastrin production from the G cells to stimulate the parietal cells takes a few days to weeks to taper back down to normal.
Endoscopy should be done in men older than fifty with a five year history of reflux, nocturnal symptoms, obesity, hiatal hernia, tobacco use, or intra-abdominal fat, and also with difficult or painful swallowing, weight loss, or anemia.
Safe flying and see you at the flight line! Doc Puskar
Question for the Flight Surgeon?
The views and opinions offered are those of the author and researchers and should not be construed as an official Department of the Army position unless otherwise stated.
Dr. (LTC) Joseph Puskar is a flight surgeon and the director of the Army Flight Surgeon Primary Course at the US Army School of Aviation Medicine at Fort Rucker, AL.