Heartburn tends to be more prevalent among men mainly due to lifestyle risk factors
IT IS ESTIMATED that up to 60 per cent of the adult population in the Republic have experience of heartburn - most will consider it a passing inconvenience and very few will think about consulting their GP on the issue.
However, frequent and consistent heartburn (more than once a week) may in fact be a symptom of something more serious, a chronic disease called gastro-oesophageal reflux disease or Gord (often called Gerd because of the Americanised spelling, esophagus) which affects an estimated 5-7 per cent of the population.
Also known as acid reflux disease, Gord occurs when stomach acid used for digestion repeatedly backs up, or refluxes, into the oesophagus.
Our bodies are normally pretty well equipped to deal with the problem of acid reflux, using gravity, swallowing and saliva to ensure that stomach acid is kept under control. We also have a muscular valve at the lower end of the oesophagus called the lower oesophageal sphincter (LOS) which keeps the acid in the stomach and out of the oesophagus.
According to consultant gastroenterologist Dr Richard Farrell, with Gord patients this valve relaxes too frequently, allowing stomach acid to flow upward into the oesophagus.
Dietary and lifestyle factors (such as weight gain, smoking, alcohol, caffeine, chocolates, mints, spicy foods), he says, increase acid production in the stomach and at the same time cause the lower oesophageal sphincter to relax, making it easier for acid to travel into the gullet. In about 15-25 per cent of Gord patients, the disease is thought to be caused by the presence of a hiatal hernia, where the upper part of the stomach moves up through the diaphragm.
While anyone (including infants and children) can have Gord, it tends to be more prevalent among men, but only because men are more likely to expose themselves to the associated dietary and lifestyle risk factors. Some complications that can result from Gord, such as Barrett's oesophagus and oesophageal cancer, are more common in men.
"It's like saying that a middle aged spread is more common in men," says Farrell. "It is by no means a male-only problem but men are more likely to be carrying weight, drinking too much alcohol, smoking and so on and are therefore more likely to have Gord."
While the predominant symptoms of Gord are heartburn and acid regurgitation, there are other symptoms - pain in the upper abdomen and chest (in some cases so severe that it is mistaken for a heart attack), nausea, bloating, belching, persistent cough or hoarseness, gum problems, bad breath and sore throat.
In general, symptoms tend to come and go and are worse after a meal. Night-time symptoms can severely disrupt sleep.
The reason that Gord can be considered a chronic disease is that the lining of the oesophagus can become irritated and damaged with repeated exposure to stomach acid.
"The stomach is very resistant to acid, because it is basically bathed in acid all the time," says Dr Barry Kelleher, a consultant gastroenterologist at the Mater Hospital.
"But the oesophagus is very sensitive to acid, so when acid refluxes into the oesophagus, it causes that burning sensation and long term can cause scarring, ulceration and changes to the lining of the oesophagus."
In severe cases of Gord, the lining of the oesophagus tries to heal itself by adapting - becoming more similar to the lining of the stomach and intestine. This is referred to as "Barrett's oesophagus" and is a condition that carries a marginally increased risk of oesophageal cancer.
"Barrett's is relatively rare," says Kelleher "and though it's a contentious issue, we now believe that the risk for Barrett's sufferers getting oesophageal cancer is quite low."
Treatments for Gord include lifestyle modifications, medical treatment and, in some rare situations, surgery. "There is a role for surgery as a Gord treatment," says Farrell, "particularly in young men where they may not want to be on medication long term.
"But the number of patients I refer for surgery I could count on one hand. There is also evidence to suggest that five-10 years after surgery about 50 per cent of patients are back on medication. With surgery you are strengthening the oesophageal sphincter muscle but over time it will relax again."
Lifestyle modifications (see panel) are aimed at reducing the amount of acid produced by the stomach and preventing it from reaching the oesophagus. These are not always effective in isolation, according to Farrell, and the presence of highly effective medication treatment makes them less attractive for many patients.
"There is definitely that risk. When you have a medication that works so well, patients start to wonder why they would bother with the hassle of lifestyle changes."
Medications for Gord include over-the-counter antacids, foaming agents, H2 blockers, prokinetics (motility agents which improve digestive transit) and proton pump inhibitors (PPIs). The latter are widely credited with having revolutionised treatment of Gord and the PPI class of drugs are one of the most lucrative drug categories globally, generating £7 billion sterling (€8.8 billion) in annual sales.
PPIs work by binding themselves to the gastric acid pump, thereby blocking the secretion of acid into the stomach. In Ireland, PPIs are available only with a prescription and the best-selling brands are Losec, Zoton, Pariet, Nexium and Protium.
"They [PPIs] have been around for a long time, are extremely effective and considered to be very safe," says Farrell.
"They have a very low symptom profile. When they came out first, there was a question over whether you can live with a permanently reduced amount of stomach acid. But it is generally accepted now that some people just have an increased level of stomach acid production and that PPIs help keep it at an acceptable level. In the past these people would have just suffered on," he says.
There is considerable controversy regarding over-subscription of PPIs, the cost of the medication and the duration of PPI therapy. Farrell estimates that 60 per cent of patients can come off the medication eventually. "They should be a short-term treatment but I do not believe that patients should be afraid to use them on demand long term."
In an editorial earlier this year, the British Medical Journalreported that 25-70 per cent of patients taking PPIs have no appropriate indication.
"This means," the article went on, "that, at the very least, £100 million from the National Health Service [NHS] budget and almost £2 billion worldwide is being spent unnecessarily on proton pump inhibitors each year."
There is massive oversubscription of PPIs in Ireland, according to Kelleher. "They are safe, well tolerated and have few side effects so in many cases doctors have a patient in front of them with a vague stomach story and they prescribe PPIs. Whether that patient actually requires them is another issue. Up to a year or two ago, PPIs were the biggest-selling medication globally. They are literally a multi-billion dollar industry."
Part of the problem, he says, is that PPIs are often used by doctors as a diagnostic tool. "If you are a GP, a huge amount of your consultation involves abdominal pain and in many cases you institute a trial of PPIs," he says.
"This can lead to long-term PPI use in the patient. In many patients, as soon as they stop they get terrible symptoms, but equally there are patients taking them long term who may not need them. If a patient needs long-term PPI therapy, that is fair enough, but they should be formally assessed before that long-term treatment starts."
Spending on PPIs in Ireland has increased eight-fold since 1995 and, according to the National Centre for Pharmacoeconomics, the total expenditure on the drugs under the Community Drugs Schemes was approximately €81 million in 2004 (about 10 per cent of total drug expenditure).
A 2006 Trinity College study found that since all PPIs are equally effective, Government spending could be dramatically lowered through prescribing of generic alternatives to leading brands.
Measures to reduce Gord
• If you are overweight - shedding even a few pounds could make a big difference to symptoms.
• Avoid fatty foods, chocolate, caffeinated food and drinks, citrus fruit or juices, mints, tomato-based products, alcohol, and spicy foods.
• Eat small meals rather than large ones, and don't lie down within three hours of a meal.
• Reduce your alcohol intake and do not smoke.
• Getting 30 minutes a day of exercise can help greatly but avoid activities that involve bouncing or jumping.
• Avoid tight-fitting clothing and belts that can put pressure on your stomach.
• Try raising the head of your bed by six inches, perhaps by sliding blocks of wood under the bedposts or using a wedged mattress.
• If you suffer from persistent heartburn two or more days a week, you could have Gord. Talk to your doctor.