You get home from work late with a pepperoni pizza in your arms. You sit down, shake some chili pepper flakes onto the pizza and begin to indulge, washing down the pizza with a beer or two. Perhaps you top it off with a cup of coffee.
It's late, and so you head to bed. Bad move.
You may pay for your late-night indulgence, waking up in the wee hours with heartburn, the hallmark of acid reflux, or what doctors call GERD, gastroesophageal reflux disease.
Your biggest mistake? Lying down so soon after eating, which makes it easy for nasty stomach acid still churning around your pizza to burn its way up your esophagus. But the chili pepper wasn't such a great idea either; neither was the beer or coffee.
Everybody gets a little heartburn now and then, but millions of Americans get reflux from once a month to several times a week. Estimates on exactly how many people fall into this category vary widely. The American Gastroenterological Assn. puts the number at 18.6 million, but other estimates are as high as 60 million.
The problem lies in a circular muscle called the lower esophageal sphincter, which opens to let food slide down to the stomach and is supposed to close afterward. In older people and those with an anatomical problem called hiatal hernia (in which part of the stomach sticks up into the chest through the diaphragm), the sphincter works poorly, allowing acid and sometimes partially digested food to back up.
Symptoms include belching, hoarseness, sort throats, asthma and, more severe, heartburn so bad that people go to the emergency room fearing they're having a heart attack. Sometimes, GERD can cause damage to vocal cords without obvious symptoms such as heartburn.
In bad cases, reflux can lead to ulceration and strictures, or scarring, in esophageal tissue, which is more easily injured by acid than the tougher stuff the stomach is made of.
Reflux can also lead to Barrett's esophagus, in which the lining of the injured esophagus tries to heal itself with cells from the stomach or intestine, a process that raises the risk of esophageal cancer. For reasons that aren't entirely clear, Barrett's esophagus often strikes middle-aged white males, said Dr. Bennett E. Roth, chief of clinical gastroenterology at the David Geffen School of Medicine at UCLA. (Barrett's esophagus can't be diagnosed by symptoms alone; doctors must look down the esophagus with a tube called an endoscope.)
The diagnosis and treatment of GERD costs Americans an estimated $9.3 billion a year, according to figures from the National Institute of Diabetes & Digestive & Kidney Diseases, part of the National Institutes of Health. A good chunk of that goes for medications, including over-the-counter antacids such as Tums, Mylanta and Maalox. These drugs neutralize acid, which provides immediate relief, but they don't stop acid production.
An often more effective solution is a class of drugs called H-2 blockers, which includes Zantac, Tagamet, Pepcid and Axid. These are available over the counter in lower doses than prescription medications. They reduce acid by blocking receptors on stomach cells for histamine, one of the major chemical signals telling cells to secrete acids.
But the biggest guns in the war on GERD are the proton pump inhibitors, or PPIs -- drugs such as Prilosec, Prevacid, Nexium, Protonix and Aciphex. Prilosec is available over the counter (for more than $1 per pill); the others are still prescription-only. Unlike H-2 blockers, which stop only the acid production triggered by histamines, these drugs block acid production triggered by other mechanisms as well, said Dr. William Ravich, a gastroenterologist and associate professor at Johns Hopkins University School of Medicine in Baltimore.
For people who don't mind taking pills daily -- and the side effects are generally minimal -- this can be a simple way to ward off GERD. But for those who don't like pills, other solutions are available.
The most successful treatment is often surgery, specifically a procedure called laparoscopic fundoplication, meaning surgery done through small incisions in the stomach wall to wrap part of the stomach around the bottom of the esophagus to tighten the opening.
"This is the most effective way to treat reflux," says Dr. David Rattner, chief of general and gastrointestinal surgery at Massachusetts General Hospital in Boston. It involves general anesthesia and an overnight hospital stay, but it solves the problem for 80% to 90% of patients.
Less invasive, but probably less effective in the long term, are four procedures done through an endoscope placed in the esophagus. These procedures have all become available in recent years, but some doctors believe they are not ready for everyday use.
If reflux is becoming a habitual problem, see your doctor. And don't forget the simple stuff: Elevate the head of your bed to make it harder for acid to seep up your esophagus. And go easy on spicy food, alcohol and caffeine if they make your symptoms worse.
Judy Foreman can be reached by e-mail through her website, www.myhealthsense.com.