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When Is Heartburn More Than Just Heartburn? A Conversation with a Gastroenterologist
Dr. John Dowd, gastroenterologist with Concord Gastroenterology Associates, discusses heartburn, what it is, and when you should seek help from a doctor.
Featured Speaker:
John Dowd, DO
John Dowd, DO CLINICAL INTERESTS include Esophageal disorder, inflammatory bowel disease, colorectal cancer screening and prevention, biliary and pancreatic disorders and clinical nutrition. Transcription:
Scott Webb (Host): Sometimes heartburn is just heartburn. And if you just need a couple of antacids, once in a while, there's probably no need to worry. That said, if you're getting heartburn on a daily basis, it's likely time to be evaluated for gastroesophageal reflux disease. And joining me today to discuss heartburn, GERD and more is Dr. John Dowd. He's a Gastroenterologist with Concord Gastroenterology Associates. This is the Health Works Here podcast from Emerson Hospital. I'm Scott Webb. So Doctor, thanks so much for your time today. We're talking about heartburn and when it might be, you know, more than heartburn, so let's start here. What is heartburn? And generally speaking what causes it?
John Dowd, DO (Guest): Heartburn is defined as the effortless regurgitation of acidic contents from the stomach into the esophagus. The stomach makes a very powerful acid, which does a minimal for digestion, but is present. It does more really probably to sterilize our food than it does to digest it. But when that acid comes into the esophagus, it does not have the defense mechanisms that other parts of the digestive tract do. And it causes burning as the symptom.
Beyond that burning, it can cause ulcerations or erosions or damage to the esophagus, especially if it occurs on a longstanding or chronic basis. So, that's what's happening inside the body when we have acid reflux and heartburn is really just a symptom of acid reflux. There are other symptoms that can occur as a result of reflux, including cough, hoarseness, throat pain, throat clearing, chest pain, nausea, even vomiting as well.
Host: Is it just situational? Is it just the foods we've eaten or is heartburn or reflux an indication that there could be something more going on?
Dr. Dowd: I mean, everybody has reflux. Okay. So, reflux is just the acid coming into the esophagus. Everybody has it. What defines whether it's a disease or not is how long that acid is in contact with the esophagus. For instance, we do some certain specialized testing to evaluate reflux. And when we see very high quantities, for very long periods of time, that's pathologic or that designates a disease state. When it's minimal, and it's cleared rapidly people generally don't have a problem with that. But the burning that we're experiencing is actually a chemical burn to the lining of the esophagus.
And it can be quite painful. It can also be mistaken for heart attack. We see this not infrequently. Our emergency room colleagues are seeing patients with what the patients feel is a heart attack. And they come in and they're evaluated for heart disease first because that's much more important than reflux. And the cardiac evaluation is negative and then they give them medicine for reflux and their symptoms improve. So, we see that not infrequently as a presentation for patients with reflux. So, heartburn is just heartburn, if it's mild and occurs no more than twice a week. If it's occurring more than twice a week, or if it's severe or if it's associated with difficulty swallowing or painful swallowing, or evidence of gastrointestinal bleeding or unexplained weight loss, or coughing at night, then it's probably something more severe and it should be evaluated.
Host: Yeah. And I think we all can identify with that there, right? So, you know, if you have heartburn occasionally, maybe once or twice a week, maybe you'd take a couple of antacids and you kind of move on and you maybe you know, with you what foods to avoid, whether it's pasta or chocolate or coffee, or you know, all the good stuff that we all like. But if you're having it more than a couple of times a week, and you think it's, it might be something more than just heartburn and you mentioned disease. So, I assume you're talking about GERD. So, let's talk about GERD. What is it and what do you do for people who are suffering from more than just heartburn and actually have the actual disease that's causing the heartburn?
Dr. Dowd: So, GERD is an acronym for gastroesophageal reflux disease and what separates the disease from just gastroesophageal reflux is that there's some manifestation of the reflux in the esophagus. So, esophagitis or esophageal ulcers or Barrett's esophagus or esophageal stricturing, which is narrowing from chronic reflux. So, what differentiates gastroesophageal reflux disease from gastroesophageal reflux is manifestations of the gastroesophageal reflux that are identified at the time of an endoscopy. So, that implies that there's been an evaluation, including an endoscopy and that there's proof that there's damage.
The other thing to that I think is important is that, you know, there are a lot of other atypical what we call atypical manifestations of reflux. So, I mean, heartburn is the sine qua non, it's what everybody associates with gastroesophageal reflux, heartburn and regurgitation, but those atypical symptoms they cause significant quality of life issues for several patients, including like a chronic cough and adult onset asthma and hoarseness of the voice, chronic laryngitis, like I said, throat clearing earlier, and chest pain. So, unexplained chest pain in a patient who's evaluated for heart conditions first, the default is heart. Always. We always worry about what's gonna, you know, kill the patient first. And reflux doesn't kill people. Heart disease does. So, we evaluate very carefully for heart disease first.
And I've had patients in my career, who've come to me for an evaluation for reflux, and I've sent them to the cardiologist and they've gone straight to the cath lab with critical coronary disease, and had that fixed and guess what, their chest pain went away and they didn't ever really have reflux. Patient said, yeah, every time I'm going up this hill walking my dog and I get this bad pain in my chest. And my doctor sent me here for an evaluation of reflux. I'm like, you're in the wrong place. So, I pick up the phone, I call the cardiologist. I say, I got this patient who's having angina. Can you see them today? And they did. And he was in the, on the cath lab later that day, getting his stents placed. So.
Host: Yeah, well and good that you're on the lookout for that and I see what you're saying now. So, the default is heart until proven otherwise. And if it happens to be proven, of course, that it's heartburn or reflux or GERD, you know we know those things are common and they're also highly treatable. So, let's just talk briefly. What are the treatment options in the short-term and long-term, if in fact people have GERD?
Dr. Dowd: So, most patients with GERD who have relatively mild symptoms, we'll just use over the counter antacids. Over the counter antacids or what we call H-2 blockers, such as Pepcid, previously available, Zantac no longer available, Axid or Tagament are in that class of medications. And that works for a lot of people as well. And those are available over the counter. Patients who require the next level up in therapy, which are called proton pump inhibitors. And those include medications like Prilosec or omeprazole, Protonix or pantoprazole, they have a more severe case of reflux and those patients shouldn't really be on those medications over the counter for long periods of time. Because they should be evaluated by a gastroenterologist, to include an upper endoscopy, especially if they had any of those symptoms that I had mentioned earlier, like difficulty swallowing or painful swallowing, nocturnal symptoms, or signs or symptoms of GI bleeding. Like I mentioned before, GERD implies that there's been an endoscopy or some other proof that there's damage to the esophagus. Endoscopy is probably the best, although an endoscopy is not particularly sensitive for mild reflux.
Only about a third of patients who have reflux, have evidence of damage or gastroesophageal reflux disease when we looked. But when we select the patients who have, you know, more severe symptoms or more longstanding duration of symptoms, that rate goes up significantly. So, if we're looking for patients who have had reflux for a long period of time, and or they're having any of those alarm symptoms that we worry about, difficulty swallowing, painful swallowing, et cetera; then the rate of abnormalities seen in endoscopy is much higher. So, those patients are the ones who really need a gastroenterologist in their care.
Host: So, what are the takeaways today? How do we process all of this? When heartburn is heartburn, and when it might be something more. And what we should do about it if it is in fact something more than just heartburn.
Dr. Dowd: Heartburn is heartburn. If the symptoms are mild and are easily relieved with over the counter medications and only occur no more than once a week. When the symptoms occur more frequently, two or more times a week and requires stronger medications for control or chronic use or ongoing use of medications that are more effective for reflux in the PPI class, pantoprazole, Nexium, Prevacid, et cetera; then they should be evaluated by a gastroenterologist. Anybody, regardless of the severity of symptoms who has difficulty swallowing, painful swallowing, loss of weight or loss of appetite, or signs or symptoms of gastrointestinal bleeding should be evaluated by a gastroenterologist. And will have an endoscopy.
Host: That's great and a great way to wrap up and always great to be on with the Gastroenterologists to go through some of these things, because we all know what heartburn is, but sometimes, you know, especially if you're having heartburn every single day, that's time to tell your primary, see a specialist, have an upper endoscopy and figure out what's going on. It may be GERD. It may be something else. As you said earlier, you default to heart and then we figure it out from there. So Doctor, thanks so much for your time today and you stay well.
Dr. Dowd: Thank you. You too.
Host: Go to Emersongi.org or reach Concord Gastroenterology Associates at (978) 287-3835 for more information or to make an appointment. And thanks for listening to Emerson's Health Works Here podcast. I'm Scott Webb and make sure to catch the next episode by subscribing to the Health Works Here podcast on Apple podcasts, Google podcasts, Spotify, or wherever podcasts can be heard.
Scott Webb (Host): Sometimes heartburn is just heartburn. And if you just need a couple of antacids, once in a while, there's probably no need to worry. That said, if you're getting heartburn on a daily basis, it's likely time to be evaluated for gastroesophageal reflux disease. And joining me today to discuss heartburn, GERD and more is Dr. John Dowd. He's a Gastroenterologist with Concord Gastroenterology Associates. This is the Health Works Here podcast from Emerson Hospital. I'm Scott Webb. So Doctor, thanks so much for your time today. We're talking about heartburn and when it might be, you know, more than heartburn, so let's start here. What is heartburn? And generally speaking what causes it?
John Dowd, DO (Guest): Heartburn is defined as the effortless regurgitation of acidic contents from the stomach into the esophagus. The stomach makes a very powerful acid, which does a minimal for digestion, but is present. It does more really probably to sterilize our food than it does to digest it. But when that acid comes into the esophagus, it does not have the defense mechanisms that other parts of the digestive tract do. And it causes burning as the symptom.
Beyond that burning, it can cause ulcerations or erosions or damage to the esophagus, especially if it occurs on a longstanding or chronic basis. So, that's what's happening inside the body when we have acid reflux and heartburn is really just a symptom of acid reflux. There are other symptoms that can occur as a result of reflux, including cough, hoarseness, throat pain, throat clearing, chest pain, nausea, even vomiting as well.
Host: Is it just situational? Is it just the foods we've eaten or is heartburn or reflux an indication that there could be something more going on?
Dr. Dowd: I mean, everybody has reflux. Okay. So, reflux is just the acid coming into the esophagus. Everybody has it. What defines whether it's a disease or not is how long that acid is in contact with the esophagus. For instance, we do some certain specialized testing to evaluate reflux. And when we see very high quantities, for very long periods of time, that's pathologic or that designates a disease state. When it's minimal, and it's cleared rapidly people generally don't have a problem with that. But the burning that we're experiencing is actually a chemical burn to the lining of the esophagus.
And it can be quite painful. It can also be mistaken for heart attack. We see this not infrequently. Our emergency room colleagues are seeing patients with what the patients feel is a heart attack. And they come in and they're evaluated for heart disease first because that's much more important than reflux. And the cardiac evaluation is negative and then they give them medicine for reflux and their symptoms improve. So, we see that not infrequently as a presentation for patients with reflux. So, heartburn is just heartburn, if it's mild and occurs no more than twice a week. If it's occurring more than twice a week, or if it's severe or if it's associated with difficulty swallowing or painful swallowing, or evidence of gastrointestinal bleeding or unexplained weight loss, or coughing at night, then it's probably something more severe and it should be evaluated.
Host: Yeah. And I think we all can identify with that there, right? So, you know, if you have heartburn occasionally, maybe once or twice a week, maybe you'd take a couple of antacids and you kind of move on and you maybe you know, with you what foods to avoid, whether it's pasta or chocolate or coffee, or you know, all the good stuff that we all like. But if you're having it more than a couple of times a week, and you think it's, it might be something more than just heartburn and you mentioned disease. So, I assume you're talking about GERD. So, let's talk about GERD. What is it and what do you do for people who are suffering from more than just heartburn and actually have the actual disease that's causing the heartburn?
Dr. Dowd: So, GERD is an acronym for gastroesophageal reflux disease and what separates the disease from just gastroesophageal reflux is that there's some manifestation of the reflux in the esophagus. So, esophagitis or esophageal ulcers or Barrett's esophagus or esophageal stricturing, which is narrowing from chronic reflux. So, what differentiates gastroesophageal reflux disease from gastroesophageal reflux is manifestations of the gastroesophageal reflux that are identified at the time of an endoscopy. So, that implies that there's been an evaluation, including an endoscopy and that there's proof that there's damage.
The other thing to that I think is important is that, you know, there are a lot of other atypical what we call atypical manifestations of reflux. So, I mean, heartburn is the sine qua non, it's what everybody associates with gastroesophageal reflux, heartburn and regurgitation, but those atypical symptoms they cause significant quality of life issues for several patients, including like a chronic cough and adult onset asthma and hoarseness of the voice, chronic laryngitis, like I said, throat clearing earlier, and chest pain. So, unexplained chest pain in a patient who's evaluated for heart conditions first, the default is heart. Always. We always worry about what's gonna, you know, kill the patient first. And reflux doesn't kill people. Heart disease does. So, we evaluate very carefully for heart disease first.
And I've had patients in my career, who've come to me for an evaluation for reflux, and I've sent them to the cardiologist and they've gone straight to the cath lab with critical coronary disease, and had that fixed and guess what, their chest pain went away and they didn't ever really have reflux. Patient said, yeah, every time I'm going up this hill walking my dog and I get this bad pain in my chest. And my doctor sent me here for an evaluation of reflux. I'm like, you're in the wrong place. So, I pick up the phone, I call the cardiologist. I say, I got this patient who's having angina. Can you see them today? And they did. And he was in the, on the cath lab later that day, getting his stents placed. So.
Host: Yeah, well and good that you're on the lookout for that and I see what you're saying now. So, the default is heart until proven otherwise. And if it happens to be proven, of course, that it's heartburn or reflux or GERD, you know we know those things are common and they're also highly treatable. So, let's just talk briefly. What are the treatment options in the short-term and long-term, if in fact people have GERD?
Dr. Dowd: So, most patients with GERD who have relatively mild symptoms, we'll just use over the counter antacids. Over the counter antacids or what we call H-2 blockers, such as Pepcid, previously available, Zantac no longer available, Axid or Tagament are in that class of medications. And that works for a lot of people as well. And those are available over the counter. Patients who require the next level up in therapy, which are called proton pump inhibitors. And those include medications like Prilosec or omeprazole, Protonix or pantoprazole, they have a more severe case of reflux and those patients shouldn't really be on those medications over the counter for long periods of time. Because they should be evaluated by a gastroenterologist, to include an upper endoscopy, especially if they had any of those symptoms that I had mentioned earlier, like difficulty swallowing or painful swallowing, nocturnal symptoms, or signs or symptoms of GI bleeding. Like I mentioned before, GERD implies that there's been an endoscopy or some other proof that there's damage to the esophagus. Endoscopy is probably the best, although an endoscopy is not particularly sensitive for mild reflux.
Only about a third of patients who have reflux, have evidence of damage or gastroesophageal reflux disease when we looked. But when we select the patients who have, you know, more severe symptoms or more longstanding duration of symptoms, that rate goes up significantly. So, if we're looking for patients who have had reflux for a long period of time, and or they're having any of those alarm symptoms that we worry about, difficulty swallowing, painful swallowing, et cetera; then the rate of abnormalities seen in endoscopy is much higher. So, those patients are the ones who really need a gastroenterologist in their care.
Host: So, what are the takeaways today? How do we process all of this? When heartburn is heartburn, and when it might be something more. And what we should do about it if it is in fact something more than just heartburn.
Dr. Dowd: Heartburn is heartburn. If the symptoms are mild and are easily relieved with over the counter medications and only occur no more than once a week. When the symptoms occur more frequently, two or more times a week and requires stronger medications for control or chronic use or ongoing use of medications that are more effective for reflux in the PPI class, pantoprazole, Nexium, Prevacid, et cetera; then they should be evaluated by a gastroenterologist. Anybody, regardless of the severity of symptoms who has difficulty swallowing, painful swallowing, loss of weight or loss of appetite, or signs or symptoms of gastrointestinal bleeding should be evaluated by a gastroenterologist. And will have an endoscopy.
Host: That's great and a great way to wrap up and always great to be on with the Gastroenterologists to go through some of these things, because we all know what heartburn is, but sometimes, you know, especially if you're having heartburn every single day, that's time to tell your primary, see a specialist, have an upper endoscopy and figure out what's going on. It may be GERD. It may be something else. As you said earlier, you default to heart and then we figure it out from there. So Doctor, thanks so much for your time today and you stay well.
Dr. Dowd: Thank you. You too.
Host: Go to Emersongi.org or reach Concord Gastroenterology Associates at (978) 287-3835 for more information or to make an appointment. And thanks for listening to Emerson's Health Works Here podcast. I'm Scott Webb and make sure to catch the next episode by subscribing to the Health Works Here podcast on Apple podcasts, Google podcasts, Spotify, or wherever podcasts can be heard.