Heartburn in the Land of the Double-Bacon Cheeseburger

ROCHESTER, Minn. June 23 - Heartburn is mainly a phenomenon of western culture, according to a systematic review of gastroesophageal reflux disease (GERD).

The review of 31 published studies with data from 77,671 patients suggested that about 5% of Americans have daily problems with heartburn, about 12% have weekly symptoms, and about 25% have symptoms at least once a month.

By contrast, heartburn is significantly less pervasive in east Asian populations. There only 2% say they have heartburn once a day, 4% once a week, and 11% once a month, reported Paul Moayyedi, M.D., of the Mayo Clinic here and Nicholas J. Talley, M.D., of McMaster University Medical Center in Hamilton, Ontario, in the June 24 issue of The Lancet.

Based on their research and a review of current guidelines, the authors cobbled together an evidence-based management strategy.

Published studies, the authors noted, suggested that obesity can increase the risk of reflux (OR 1.43, 95% CI 1.16-1.77) and esophagitis (OR 1.76, 95% CI 1.16-2.6). But the authors pointed out that there is a possibility that this link may be due to residual confounding. Moreover, even if the association is "causal, the modest odds ratio suggests that it will play a minor part in the pathogenesis of the disease."

Likewise, most studies suggest a similarly weak association between smoking and GERD or alcohol consumption and GERD.

They found only two studies that assessed coffee and reflux and both were negative, while there were conflicting findings in two studies that assessed fat intake and reflux symptoms. One study found no association and the other found an association.

A number of observational studies have suggested that Helicobacter pylori infection may be protective against reflux, but the authors cautioned that since those findings came from epidemiological studies "any apparent protective ecological effect of H. pylori could be due to confounding factors."

Genes, they wrote, play a role, noting that studies estimate that 31% to 43% of reflux may originate in the family tree.

Initial diagnosis, they wrote, can be made on the basis of symptoms. Even though the authors suggested that lifestyle modifications such as smoking cessation, limiting alcohol, coffee and chocolate intake and weight loss for patients with a BMI of 25 kg/m² will only yield small benefits, they recommended this as a sensible first step.

Initial pharmacologic therapy should be proton pump inhibitors (PPI) once daily for four to eight weeks, with patients instructed to take the medication 30 minutes before a meal, preferably breakfast.

If symptoms resolve, the drug can be stopped but the authors warned that this is likely to trigger a relapse. Patients who relapse should be restarted on therapy at the level that previously controlled symptoms.

But the drug should not be stopped in patients who have documented severe esophagitis. These patients, the investigators wrote, require full-dose proton pump inhibitor therapy to control symptoms.

Patients with "alarm features, such as progressive dysphagia, or weight loss" should have endoscopy. Likewise, patients who fail to respond to proton pump inhibitor therapy should also be considered for endoscopic evaluation.

"Causes of a lack of response to proton pump inhibitor therapy include inadequate compliance or dosing, nocturnal acid breakthrough (arbitrarily defined as a gastric pH of <4 for >60 minutes despite twice daily proton pump inhibitors), non-acid reflux and wrong diagnosis," they wrote. "Rare causes to consider are acid hypersecretory states (e.g. Zollinger-Ellison syndrome) or drug resistance."

The goal of medical management is to "step down" to the lowest effective dose or to consider surgery, but the authors cautioned that "fundoplication surgery requires an experienced surgeon operating on a fit patient who has responded well to proton pump inhibitors for best results."