“Never eat more than you can lift” Miss Piggy
Another Thanksgiving celebration looms just around the corner. Abraham Lincoln proclaimed Thanksgiving a national holiday in 1863,though the original celebration was a three day feast in 1621. Captain Miles Standish, the leader of the Pilgrims, invited Squanto, Samoset, Massasoit (leader of the Wampanoags) and their immediate families to celebrate the first successful fall harvest. We know that there was an abundance of food (interestingly, provided in majority by the Indians) and that over 90 Indians were present. Unfortunately, we also know that the peaceful cooperation and coexistence celebrated between the Pilgrims and the Indians at this meal were short-lived. Within years, the Native Americans and colonists were warring bitterly. In any case, the food was plentiful, and our Thanksgiving Holiday has evolved into a celebration of family and feasting. Eating well on such occasions has a tendency to become overeating. And, with overeating comes heartburn–medically termed GERD or gastroesophageal reflux disease. A few comments about this very common problem seem appropriate in this season of excess.
After our Thanksgiving meal, many of us might be able to identify with Orson Wells’ wonderful quote, “My doctor told me to stop having intimate dinners for four. Unless there are three other people.” Not only do we eat large portions on Thanksgiving Day, we tend to celebrate with rich and highly seasoned foods as well. As a baseline, 7–10% of the US adult population experience heartburn daily, and more than a third of Americans have it monthly. Since we know that large meals, fatty foods, chocolate, peppermint, coffee, and alcohol can all aggravate gastroesophageal reflux by decreasing the lower esophageal sphincter pressure, we’re ‘sitting ducks’ after our Thanksgiving feast.
The lower esophageal sphincter (LES) acts as the shut off valve between the stomach and esophagus. When it works efficiently, the stomach contents and acid remain inside the stomach. When it’s loose or open, acid and food splash back can occur. . .creating symptoms of heartburn, belching, water brash, or even a deep, central chest pain that mimics symptoms of a heart attack. Chronic cough, asthma-like conditions, laryngitis, and dental erosions can occur in people with longterm GERD. And, unfortunately, esophagitis, esophageal ulcers, narrowing or stricture of the lower esophagus from scarring, and/or Barrett’s esophagus may be complications of chronic GERD as well.
Since the lining of the esophagus is not meant to be exposed to acid, its normal cells are not equipped to handle the irritation of acid reflux–either short term or longterm. Barrett’s esophagus is an actual transformation of the esophageal cells as a result of their ongoing acid exposure and damage. This cellular transformation can lead to cancer of the esophagus–so it needs to be monitored carefully over time, and the GERD needs to be stopped with changes in lifestyle, and use of appropriate medications.
Over the years, the medical treatment of GERD has evolved. Antacids are useful for relief of immediate symptoms, but longterm use can result in unwanted side effects such as diarrhea and altered calcium metabolism. If antacids are needed for more than two or three weeks, it’s time to consult your doctor.
For chronic reflux and heartburn, H2 blockers are available both by prescription and over the counter. These agents work by inhibiting acid secretion by the stomach. Symptom relief is slower than antacids, but their duration of action is longer. Additionally (especially in prescription doses), they can control symptoms in most patients with mild chronic GERD. Studies have shown that appropriate doses of these drugs can heal esophagitis in about 50% of patients with reflux esophagitis and that twice daily dosing can eliminate symptoms in up to 50% of patients.
Proton pump inhibitors (PPIs) are the newest class of medications for GERD and work by inhibiting an enzyme in the acid-producing cells of the stomach which is necessary for acid secretion. In appropriate doses, these drugs are the most effective agents for healing esophagitis and preventing complications. They also provide rapid relief of symptoms; these are the drugs preferred for the healing and maintenance of moderate and severe erosive esophagitis. They are, however, quite expensive, so longterm use can generate a little ‘mental heartburn’! Other medications that affect motility of the GI tract can be used with some benefit as well, and your doctor can advise you on their possible efficacy for you.
Though you might feel that a surgical procedure is in order as you waddle from the Thanksgiving table, chances are you’ll survive with appropriate food abstinence, antacids, and time. However, avoid the temptation to recline or take a nap. Recumbent positions increase the likelihood that the large quantities of rich food you ingested will make it out of your stomach and into your esophagus. For people with intractable GERD secondary to severe reflux unresponsive to medications and lifestyle changes, there is a surgical procedure called fundoplication that increases the pressure in the lower esophagus. Additionally, some centers are currently experimenting with a lesser surgical procedure that is performed through an endoscope and creates “little speed bumps” in the stomach lining. The intent is to prevent the acid from escaping the stomach. Time will tell whether this procedure offers any additional benefit over current treatment methods.
So, armed with this information, head to your upcoming Thanksgiving banquet. But remember, “Gluttony is not a secret vice” Orson WellsAnd, William Safire reminds us, “After eating, an epicure gives a thin smile of satisfaction; a gastronome, burping into his napkin, praises the food in a magazine; a gourmet, repressing his burp, criticizes the food in the same magazine; a gourmand belches happily and tells everybody where he ate; a glutton embraces the white porcelain altar, or, more plainly, he barfs.”
Enjoy your meals in appropriate quantities. May we all be gourmets, not gourmands or gluttons this Thanksgiving.
Stephen L. Hines, M.D.