Frequent Indigestion, Dry Cough Might Mean Reflux Disease

Upset stomach? If you feel heartburn several times a week or more often, it could be more than simple indigestion. It could be gastroesophageal reflux disease (GERD), or more simply, reflux. Or perhaps you have hoarseness in the morning, a dry cough, bad breath, trouble swallowing or chest discomfort. Those symptoms may seem unrelated to your digestive system, yet they could also signal GERD.

Reflux is common, and many remedies are available. Early treatment with the right medication is important, because reflux can lead to more serious health problems, says Reza Shaker, MD, Chief, Division of Gastroenterology and Hepatology, and a Professor of Medicine at the Medical College of Wisconsin.

"Reflux is a very complicated problem, with a multitude of symptoms, or, in some cases, no symptoms at all. For patients with symptoms, the symptoms of reflux vary widely," he notes, "but they break down to three categories that are qualitatively different from indigestion."

• Heartburn - "Pain behind the chest bone - a feeling of burning, pressure or pain that can be mistaken for a heart attack," Dr. Shaker says.
• Regurgitation - "a feeling that food comes up in the throat."
• A collection of symptoms involving the mouth, such as a sour taste in the mouth, excessive saliva, dental erosions, or a feeling of a lump or foreign body in the throat. In some patients, the voice may change, or there's shortness of breath, a dry cough, or more throat-clearing. In children with GERD, symptoms could include earache, pneumonia, and/or failure to thrive.

"Antacids like Alka-Seltzer, Maalox, Mylanta, Pepto-Bismol or Rolaids may work fine for occasional symptoms," Dr. Shaker says. "If they don't relieve the problem, or if the condition recurs frequently - weekly or daily - it could well be more than occasional reflux. My firm recommendation is: If symptoms are persistent and recurring twice a week or more, patients should consult their primary care physician, because untreated reflux can lead to serious problems."

According to the National Digestive Diseases Information Clearinghouse (NDDIC), "Inflammation of the esophagus from stomach acid causes bleeding or ulcers. In addition, scars from tissue damage can narrow the esophagus and make swallowing difficult. Some people develop Barrett's esophagus, where cells in the esophageal lining take on an abnormal shape and color, which over time can lead to cancer."

White middle-aged men are the group most prone to Barrett's, Dr. Shaker says. Beyond that, however, reflux problems are an equal-opportunity disease, regardless of ethnic background, gender or age. "It's the most common disease of the esophagus," he says. "Studies show that between 7% and 10% of us suffer daily heartburn, and 14% experience it weekly."

What Causes Reflux?
In normal digestion, foods start to break down in the mouth from the action of chewing and enzymes in saliva. With swallowing, the windpipe closes momentarily and the esophagus carries food from the mouth to the stomach, where strong acids are ready to break it down further.

At the bottom of the esophagus is a ring of muscle called the lower esophageal sphincter that acts like a valve between the esophagus and stomach. When this sphincter does not close properly, the stomach contents leak back, or reflux, into the esophagus, causing heartburn and other symptoms that can damage not only the esophagus, but also the pharynx and larynx. The pharynx is the part of the airway at the back of the throat, connecting the mouth, nasal cavity and larynx; the larynx guards the entrance to the windpipe and is the primary organ of voice.

Unlike the stomach, which has a lining to protect it from damage, "the pharynx and larynx are not prepared to deal with strong gastric juices," Dr. Shaker says. "When they are exposed to refluxate, the genie is out of the bottle. Some people can cope with the symptoms better than others."

Some patients with reflux also have a hiatal hernia, at the opening (or hiatus) where the esophagus joins the stomach. When the muscle tissue around the hiatus becomes weak, the upper part of the stomach may bulge through the diaphragm into the chest cavity. In this way, a hiatal hernia can predispose to reflux. A hiatal hernia can happen in people of any age; many otherwise healthy people over 50 have a small one.

Ask Physician for Best Treatment
The number of products to treat reflux is staggering, and they do not all work the same way. "Patients should not try to treat reflux without consulting their internist or other primary care physician, " Dr. Shaker emphasizes, and NDDIC agrees: "Your doctor is the best source of information on how to use medications for GERD," it says.

After hearing the patient's symptoms, the doctor might simply recommend antacids. More than likely, he or she will prescribe a type of drug that's either an H2 blocker or a proton pump inhibitor (PPI).

NDDIC describes the drugs' actions this way: "H2 blockers, such as cimetidine (Tagamet HB), famotidine (Pepcid AC), nizatidine (Axid AR), and ranitidine (Zantac 75), impede acid production. They are available in prescription strength and over the counter. These drugs provide short-term relief, but over-the-counter H2 blockers should not be used for more than a few weeks at a time. They are effective for about half of those who have GERD symptoms. Many people benefit from taking H2 blockers at bedtime in combination with a PPI."

Proton pump inhibitors stop acid from being produced. "PPIs include omeprazole (Prilosec), lansoprazole (Prevacid), pantoprazole (Protonix), rabeprazole (Aciphex), and esomeprazole (Nexium)," some of which are now available over the counter as well as by prescription. "Proton pump inhibitors are more effective than H2 blockers and can relieve symptoms in almost everyone who has GERD," but they can take from several hours to several days for full effect."

Lifestyle Changes Might Help
Generally, these well-chosen remedies can ease the discomfort and damage of reflux, along with some lifestyle changes, Dr. Shaker says. NDDIC recommends patients with reflux limit or avoid foods and drinks more likely to cause heartburn, such as:

• citrus fruits
• chocolate
• drinks with caffeine
• carbonated beverages
• fatty and fried foods
• garlic and onions
• mint flavorings
• spicy foods
• tomato-based foods like spaghetti sauce, chili, and pizza

Patients are also advised to keep their weight down, quit smoking and wear clothing that fits loosely around the abdomen. In cases where reflux interferes with sleeping, patients may be advised to raise the head of their bed or sleep in an upright chair. Other recommendations include eating smaller meals, eating slowly, avoiding eating late at night, and remaining upright (do not lie down or bend over) after a meal.

If medications and lifestyle changes don't help, and symptoms persist two years or more, Dr. Shaker says it might be time to see a gastroenterologist - a physician specializing in digestive disorders - for further testing and more advanced treatment.

Dr. Shaker and his Medical College colleagues are conducting research into swallowing disorders and into reflux and how the brain perceives the symptoms of reflux.

Barbara Abel
HealthLink Contributing Writer

This article includes information from the National Digestive Diseases Information Clearinghouse.

MCW Health News presents up-to-date information on patient care and medical research by the physicians of the Medical College of Wisconsin.