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San Diego Health: Heartburn and Indigestion

– Hi, I’m Susan Taylor with Scripps Health in San Diego, California. Please subscribe to our
Scripps Health YouTube channel. We’ve got great videos featuring the very latest technology, our stellar doctors, and inspiring patient stories. Today, we’re gonna talk about heartburn, that burning sensation in your chest or throat, that bitter
taste in your throat. Do you suffer from heartburn? What triggers it? Let us know in the comments section below. According to the American College of Gastroenterology, some 60 million Americans
experience heartburn at least once a month, and about 15 million
people have daily flareups. How do you control
heartburn and indigestion? Here to talk about that and to help you cool the burn is Dr. Richard Onishi. He is a family medicine physician with Scripps Clinic in
Carmel Valley, California. Thanks so much for being with us, doctor. – Thanks for having me. – So let’s start off with the basics, what is heartburn? – So heartburn is when you
have an upper abdominal burning that goes into the esophagus and burns the esophagus, and sometimes the back of the throat. – So what is it that’s burning up? Is it stomach acid? – Yes. Your stomach is actually
an acidic environment, and it’s protected by a layer of mucous. You have mucous secreting
cells in the stomach. Unfortunately the esophagus doesn’t have that same protection. So if the acid refluxes through up into the esophagus it
causes a burning pain. – So what triggers it? – There are a variety of triggers. First let’s talk about dietary triggers. So acidic foods, spicy food, fatty foods, fried foods, caffeinated beverage, sorry caffeinated drinks, carbonated beverages. Cigarettes smoking can make it worse. Alcohol relaxes the lower
esophageal sphincter and can make reflux worse. Anatomic things. For example, if you eat a large meal it distends the stomach, and especially then if you lay down. Reflux happens more commonly at night. Other things would be obesity, even pregnancy. Certain medications, aspirin, non-steroidal anti-inflammatants, ibuprofen, motrin, Advil, Aleeve. Different medications used
to treat osteoporosis, Fosamax, Actonel, other bisphosphonates. Chemotherapeutic drugs. There are a variety of
exacerbating factors. – Go back for one second and talk about acidic food such as what? I mean when I think of
acidic or something spicy I think okay salsa, but what other foods are acidic? – Well citrus, tomatoes,
tomato-based foods or sauces, of course your spicy foods, so you know your jalapenos and salsa are good examples. – What about, when you say citrus, what kind of fruits are you talking about? – So oranges, lemons,
that family of fruit. – And what are the symptoms
that you’re having heartburn? – So the classic symptoms
would be that epigastric, the upper abdominal
burning that radiates up. People often complain of regurgitation, so when you get some stomach
contents into the mouth, often patients may even
vomit small amounts of undigested food. Other symptoms are hypersalivation, meaning they produce more saliva, a globus sensation, which is a feeling that
something’s in their throat. – Like they can’t really swallow it down? – Right, right. So it feels like, patients complain of a foreign body in their. It feels like there’s
something in the throat. There’s also painful swallowing, difficult swallowing. They can have extra esophageal symptoms, so symptoms outside of the gastrointestinal track such as cough, a chronic cough, or it can even trigger asthma. – Who is susceptible to heartburn? – You know, like you alluded to earlier, everyone. – (laughing) Well there you go, everyone. – Everyone’s susceptible. But you certainly have risk factors that predispose and increase your risk. So, obesity that I mentioned earlier, and it just causes some compression, increases the pressure there. Same thing, you know,
pregnancy is another issue. The cigarettes smoking, the medication, the alcohol. Also there is an anatomic reason. So people can have a hiatal
hernia, which is fairly common. So a hiatal hernia is
you have your esophagus, and then you have your diaphragm, and then underneath that is your stomach. You actually have a muscle right here called your lower esophageal sphincter that relaxes when you eat food and then contracts so that stomach contents don’t reflux back up. So your diaphragm helps pinch that lower esophageal sphincter. And what happens with the hiatal hernia is the stomach actually leaks
up into the chest cavity and so you don’t have that tone there, and so reflux happens more easily. – Let’s go back and talk
about pregnant women because more than half report symptoms in the second and third trimester, why is that? – Well two main reasons. One is just the anatomic. So as they advance in pregnancy the uterus enlarges, the abdomen distends, and that puts pressure on the stomach, and then again reflux happens more easily. The other is actually hormonal. Progesterone actually relaxes
the lower esophageal sphincter so as they move on in
pregnancy progesterone rises, and that makes, contributes to reflux. – So does this go away
after you give birth? – Fortunately with delivery the heartburn typically resolves. – And how do you know that that burning in your chest is heartburn and not something more serious such as a heart attack? – That’s a very important
differentiation to make, and sometimes it’s not
as easy as it sounds. You know classically cardiac chest pain is a diffuse squeezing, pressure pain, often accompanied by shortness of breath, nausea, vomiting,
sometimes lightheadedness. And patients will complain
of getting sweaty. It’s often related to exertion as well. So classic history was hey I walk up a couple flight of stairs and then boom I get
this diffuse chest pain along with those other symptoms. You know heartburn tends to be more focal. So not diffuse, fairly localized. The nature of the pain is different, it’s a burning pain, and again, typically has
those exacerbating factors. You know alcohol makes it worse, large meals make it worse, and then certain treatments
make it feel better. You know antacids, Tums, Prilosec, you know those types of medication that we may talk about. But it’s a, it’s in two types of patients you have to be very careful. Women often present differently
from a cardiac standpoint and so do diabetics. So I’ve had one patient come in and say hey, doc, I’m having heartburn, but his symptoms were pretty classic, it was a localized burning pain, but it wasn’t better with
the normal treatments and it was worse with exertion, and he was a diabetic. And so I did an EKG, which was fine, but then proceeded with a stress test and he had cardiac disease
and then got stented. So his coronaries got open they put a- – Put a stent in. – Stent in. – To open up. – Yeah, to keep them open, and he did fine. His, what he thought was reflux resolved. – And what is GERD? – So GERD is, well think of heartburn as the symptom and GERD is the disease or the condition. So GERD stands for
gastroesophageal reflux disease. And so basically people with GERD have, it’s defined as heartburn symptoms that occur if they’re a mild degree twice a week or more, or more severe weekly. Or patients have
complications from their GERD, which could be ulcers, strictures. Chronic reflux can even
cause two different types of cancers, adenocarcinoma of the esophagus and lymphoma. – So how do you treat GERD? – Well the first thing I would recommend is try to eliminate the triggers. So if alcohol is a trigger, if cigarette smoking is a trigger, if spicy foods is a trigger, is to eliminate those triggers. Other things to do is weight loss has proven to be helpful. Elevating the height of
somebody’s bed is helpful. So six to eight inches. And so they can put blocks under the top of their beds or they have wedges that elevate the bed. Try to avoid eating three hours, well eat at least three hours or more prior to bedtime. If you eat right before bedtime and then you lay down, you know your stomach gets distended and then reflux is more likely. And then of course there are
a variety of medications. – And eating slowly? – Yes, eating slowly may help too, yes. – And what about rather
than three big meals a day, what about more frequent smaller meals throughout the day? – Yes, that is an excellent idea, and kind of the same premise, is that if you over distend the stomach you’re more likely to get reflux. And if you eat small frequent meals you’re not distending the stomach as much and the pressure is lower. – And what about chewing gum? – You know, eh, maybe, I’m not a big fan of gum chewing to alleviate reflux. I know it’s listed as being a benefit, but patients can certainly try it. But I haven’t found it to make
a whole lot of difference. – And what about drinking
water at room temperature? Does that help with digestion? – Again, if you look at the studies, I don’t think there’s
good clinical evidence that it helps with reflux symptoms so it’s one of those things where some people may feel it’s beneficial and certainly they can use it, there’s no harm in it because in other patients, unless cold water or
cold fluids is a trigger, then warm, you drinking warm water I don’t think would be helpful, but if it is a trigger then doing that is a good idea. – So in a couple minutes we’re gonna come back and talk about this. We want you to hold this thought. When should you say okay
I really tried all this on my own and I really need to go see a doctor to treat this condition. We’ll come back and talk about that in
just a couple of minutes. You mentioned certain
types of medications, let’s go through them, the list to treat heartburn. Let’s start first with over the counter and then go to prescription medications. – And that’s a good point because now the line is
a little bit blurred. A lot of the medications
that used to be prescription are fairly safe and are now over the counter. But the most commonly used ones that have been out there forever are your antacids. So things like Tums and Mylanta. They just neutralize the stomach acid. The next step up would be H2 blockers, which are Pepcid, Zantac, which is famotidine and ranitidine. And those bind to cells in the stomach, parietal cells that produce acid and reduce acid production that way. And then the strongest medication would be Proton pump inhibitors. And so those are things like Prilosec, Nexium, Capadex, (mumbles), Protonix, there’s a variety of them. And they’re the strongest medications to reduce acid. There’s another class of medication, Carafate is a common one that helps coat the stomach. So those are the mainstays of medical treatment. – So how often should
you take this medication, and how long should you take it? – Good question because that now is a little more controversial. In years past we thought
proton pump inhibitors were really benign and patients can use them long term. We still use them long term
in certain high risk patients, but we don’t like to use them longterm if we can get away with it because of potential side effects. – And the side effects are? – Side effects, there’s
a list of side effects. One thing that Prilosec, or PPIs as a class, can do is increase a patient’s risk for osteoporosis. So it does that by two main mechanisms, reducing the absorption of insoluble calcium, which is, soluble calcium
dissolves in water. And so soluble calcium,
it really does not effect the absorption of so milk, dairy products, patients can still absorb the calcium from those. It’s kind of, calcium carbonate, which is a common supplement, it will block the absorption of. Calcium citrate is a
soluble form of calcium, and patients can absorb that fine on a proton pump inhibitor. The other mechanism, how it causes osteoporosis
is it effects osteoclast. For bone remodeling there’s two types of cells, osteoblast, which
cause bone deposition, and osteoclast, which take bone away. So proton pump inhibitors seem to augment osteoclast activity and cause a net reduction or bone loss, and increase the patient’s risk of osteoporosis. And it can also lower magnesium levels, which is equally, if not more important. Magnesium is involved
with muscle contraction and heart rhythms. And so if somebody’s on a proton
pump inhibitor chronically I would recommend they get
that screened periodically, and especially if they’re
at risk for arrhythmia. It may increase some men’s risk of pneumonia, clostridium difficile, which is a type of colon infection, but these risks are fairly low. So I don’t want people to be turned away from these medications if they need them, but they should be aware of some risks. – How do you deal with heartburn during pregnancy without
taking medication? – So the first would be
avoiding the triggers. Secondly, we wouldn’t
want them to lose weight. (laughing) Hopefully, they’re not
smoking or drinking. (laughing) – So no spicy foods, keep it bland. – That’s right, that’s right. So watch the caffeine, watch
the carbonated beverages, acidic foods, the citrusy foods, you know those types of things. The other thing that really can be helpful is again the, elevating
the height of the bed. It sounds like a simple thing, but in some, in a recent metanalysis of 16 different studies, the two things that really
have proved to be effective was weight loss, which obviously is not appropriate in this patient population, and elevating the height of the bed. – So you want your head higher? – Exactly. – Than the rest of your body. – [Dr. Onishi] That’s right. – What about sleeping on your side? – Laying on their left side may be of some benefit. You know, anatomically speaking, the esophagus goes here and your liver’s on the right side, your stomach is more on the left side, so if you think of, if you lay on your right side could this reflux more easily? So potentially laying on your
left side can be helpful. – And let’s talk about indigestion. Does it go hand in hand with heartburn? – Yes. I mean indigestion’s more of a layman’s term, not so much of a medical term, but it’s used to describe
an upper abdominal pain often associated with food. So think of that as a symptom. So obviously heartburn, reflux would fall under that category. But other things can cause
upper abdominal pain with food, you know gallstones, food intolerances, lactose intolerances, celiac sprue, which is a gluten
sensitivity or wheat allergy. So there’s a variety of
causes of indigestion, it’s not just one entity. – So how do you treat indigestion? – So you treat the cause. So basically if it’s the heartburn, you know reflux, you treat it as we talked about earlier. If it is due to gallstones, the treatment there is primarily surgical. There are some medications for gallstones, but they don’t work very well and you have to take them for
an extended period of time. For indigestion, again,
think of that as a symptom, and so find a cause and
then treat the cause. – All right so then, so that
moves us to the next point. We referenced this earlier, let’s come back to it. How do you know it’s time really when you’ve done all you can, that you really need to go see a doctor to treat this? – So let’s say you’re having, you’ve tried some of these remedies, you’re having ongoing symptoms, and none of these have helped. You know certainly you
should see a physician. But there’s also some
earlier danger signs. So if you’re a patient over 60 and you haven’t had heartburn before and you’re having new onset heartburn you should see your doctor. Another danger signs
are painful swallowing, difficulty swallowing,
any signs of blood loss. So vomiting blood, vomiting something that
looks like coffee grounds because that’s what digested or partially digested blood looks like, black tarry stools because black stools are what digested blood looks like. Other things can turn your stool black like Pepto-Bismol or iron, things like that, so it doesn’t mean a stomach bleed, but it could be a stomach bleed. Difficulty swallowing. Unexplained weight loss. And if you have a
first-degree family member with a gastrointestinal cancer, so meaning parent, sibling or child, that increases your risk. – Any final thoughts, doctor? – I think if you’re ever unsure, especially one of the most
important things you brought up is the chest pain, how do you know you’re having cardiac chest pain versus reflux, so if you’re ever unsure see your doctor. If you have significant
cardiac risk factors, so if you’re a diabetic,
have very high cholesterol, high blood pressure, family history, a cigarette smoker, you know I would
definitely be more inclined for you to see your doctor
sooner rather than later. – Thanks so much, Dr. Onishi, for your time and your expertise. – You’re welcome. – If you want more
information on heartburn and indigestion, just click on the link, or go to scripps.org/videos. Want more critical information about your health? We take care of you from head to toe. Please subscribe to our YouTube channel and follow us on social
media at Scripps Health. I’m Susan Taylor, thanks so much for joining us. It’s our mission at
Scripps to help you heal, enhance, even save your life.

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