8 Reasons why Heartburn and GERD won't go away.
- The most common cause of heartburn is GERD (Gastroesophageal reflux disease).
- Some other conditions may cause heartburn but are far less common than GERD.
- If you are NOT diagnosed with GERD; you should check your doctor to confirm The diagnosis of GERD.
- Up to 40% of GERD patients fail to respond adequately to standard treatment with medications (ref).
- Doctors Consider “refractory GERD” when you still have symptoms despite taking PPIs twice daily.
- The most common causes include:
- Not taking The right medication.
- Faulty use of the medication.
- A condition called functional heartburn.
- Non-acid reflux (For example, alkaline reflux).
- Hiatus hernia.
- Your esophagus is hypersensitive (reflux hypersensitivity).
- wrong diagnosis!
- Development of GERD complications.
(1) You Are Not Taking The Right Type of Medication.
Taking H2 blocker or antacids only.
Antacids such as Sucralfate, Magnesium hydroxide, or Aluminum hydroxide act locally by neutralizing The acid inside your stomach.
Heartburn won’t go away if you are only taking antacids. This is because antacids are not the standard acid reflux treatment. They don’t inhibit acid secretion and they are short-acting.
Also, The same goes for H2 blockers (such as ranitidine or famotidine). H2 blockers are generally weak medications Compared to the standard GERD medications (PPIs).
H2 blockers, when used long term, can develop a phenomenon called “paraphylaxis”. Paraphylaxis means decreased efficacy of the drug after a period of intake. with H2 blockers, paraplylaxis can develop within 10. days.
A “refractory GERD” is considered when you don’t respond to the standard GERD medication which is a proton pump inhibitor (PPI) such as Omeprazole (Prilosec ®).
But what if your heartburn is not going away with The standard PPI treatment? Keep reading the next section to figure out why This can occur.
Heartburn is not going away with PPIs.
Proton pump inhibitors (PPIs) are The standard treatment for GERD and acid reflux. The most commonly used PPIs are:
- Omeprazole (Prilosec ®).
- Esomeprazole (Nexium ®).
- Pantoprazole (ProtonIX ®).
- Rabeprazole (Aciphex, Pariet ®).
- Dexlansoprazole (Dexilant ®).
It’s as Common as 40% of GERD sufferers don’t achieve complete heartburn resolution despite using PPIs. And this can happen for many reasons (such as hiatus hernia, functional heartburn, or wrong diagnosis).
But your heartburn won’t go away because you are using the WRONG PPI!
PP’s are metabolized (Broken down) and deactivated inside your liver. And people metabolize different PPIs at different rates.
Different people have different enzymatic activities. so people respond differently to PPIs.
You may be taking the wrong type of PPI. And you have to switch to a second or even a third type of PPI group mentioned above.
The rule is to switch between different types of proton pump inhibitors before saying “it won’t work for my heartburn”.
(2) You are taking the right medication But the wrong way.
Another common reason why your heartburn isn’t going away is not adhering to best practices while taking the right PPI for you.
Wrong timing or non-adherence to the standard PPI can lead to non-response to the medication.
The most common causes include: –
- wrong time: PPIs should be taken in the morning and 30-60 minutes before Breakfast to work properly. Taking PPIs directly before meals or using single-dose at night instead of the morning can decrease its effects.
- Non-adherence: The standard course of PPI treatment for GERD should last 6-8 weeks at least. Taking PPIs on-demand or for shorter periods may make your heartburn won’t go away.
- Not adhering to lifestyle and diet advice: faulty habits such as binge eating or eating directly before bedtime can hurt your GERD. Also, eating trigger foods (caffeine, fats, acidic foods) can lead to such conditions.
(3) Functional heartburn:
Functional heartburn is one of the most common reasons why you are not responding to optimal GERD Treatment.
Some studies estimate that up to 58% of people with persistent heartburn despite PPI will have “functional heartburn” (ref).
How to suspect functional heartburn (ref):
According to ROME IV criteria, All of The following must be fulfilled (for The last 3 months):
- Burning retrosternal pain or discomfort.
- No relief despite optimal therapy.
- No evidence of reflux esophagitis.
- No reflux-associated symptoms (as cough and laryngitis).
- No evidence of eosinophilic esophagitis or other esophageal motility disorders such as achalasia, diffuse esophageal spasm… etc.
Until now, doctors couldn’t find a definite mechanism for this condition. but it is more common in people with psychological stress or diseases.
Depression and anxiety were found to be commonly associated with the increase in GERD-related symptoms.
(4) Non-acid reflux.
Another reason why your heartburn won’t go away is a condition called “non-acid reflux” (ref).
In this condition, the treatment you receive for heat burn successfully inhibits acid secretion. But this treatment does not prevent reflux of the non-acidic food into your esophagus.
Non-acidic reflux can also cause heartburn & It is suspected when:
- No response to the standard PPI treatment.
- Heartburn occurs mainly after meals.
- You have previously been diagnosed with a hiatus hernia.
Doctors confirm such conditions with endoscopy, PH testing, and manometry (measuring the muscle tone of the lower esophageal sphincter). If you suspect non-acid reflux, work with your doctor to confirm The condition.
How to Fix acid reflux:
- Adhere to The optimal treatment prescribed by your doctor
- Don’t eat large meals.
- Avoid lying down directly after eating.
- Avoid drinking large amounts of water or juice at once.
- If no response, discuss the issue with your doctor other treatment options including anti-reflux surgery.
(5) Hiatus Hernia.
A hiatus hernia occurs when the upper part of your stomach bulges into your chest. This bulging happens through the diaphragm (esophageal opening):
- A small Hiatus hernia usually doesn’t cause symptoms.
- But a large hernia can cause heartburn and it is refractory & won’t go away easily.
- Regurgitation of food and acid up to your Throat and mouth.
- May lead to persistent vomiting, shortness of breath.
- Difficulty swallowing.
- Chest or abdominal pain.
Hiatus hernia is one of the difficult-to-treat GERD conditions. Some people don’t respond appropriately to any type of medicine.
If you have persistent heartburn associated with one or more of the above symptoms, ask your doctor about a hiatus hernia.
It is usually diagnosed by upper endoscopy. You are at more risk of hiatus hernia if you are obese and older than 50 years.
Hiatus hernia symptoms that are refractory to medication & lifestyle modifications usually require repair by surgery or endoscopic intervention.
(6) Reflux hypersensitivity (esophageal hypersensitivity).
Normally, small amounts of acid can be refluxed in most people. If you have a condition of “hypersensitive esophagus”. Any small amounts of acid or gas bubbles trigger heartburn in patients with reflux hypersensitivity.
How Reflux Hypersensitivity is diagnosed:
According to ROME IV criteria, all the following should exist in The last 3 months: –
- Heartburn or chest pain.
- Normal endoscopy & no evidence of other esophageal diseases.
- Monitoring of PH inside your esophagus reveals normal levels despite heartburn.
Reflux hypersensitivity is considered a part of “functional gut diseases” such as “functional chest pain”, “functional dyspepsia. Psychological stress and psychological diseases such as depression & anxiety also play a role in “reflux hypersensitivity”.
(7) wrong diagnosis.
Some diseases have similar symptoms to GERD. If you have one of The below diseases, your heartburn probably won’t get better with treatment. Common diseases that can mimic GERD:
Unlike GERD, Achalasia is a condition occurring when the lower esophageal sphincter fails to open.
It occurs due to damage of esophageal nerves (due to genetic or autoimmune causes).
- Intense pain or discomfort after eating,
- Difficulty swallowing
- Heartburn that won’t go away with PPIs,
- weight loss.
(B) Eosinophilic Esophagitis.
It is an allergic inflammation of the esophagus leading to heartburn & difficult swallowing. No improvement occurs with anti-reflux medications.
(C) Infectious esophagitis.
Similar to symptoms of eosinophilic esophagitis, but caused by infection by bacterial or fungal organisms.
Gastroparesis is a common condition, especially in people with a long history of diabetes mellitus.
With gastroparesis, food stays longer inside your stomach due to decreased spontaneous motility.
Symptoms include loss of appetite, heartburn, bloating, and nausea.
(8) Development of complications:
Untreated or undertreated GERD (acid reflux) can lead to complications such as:
- Esophageal stricture → results in persistent heartburn, difficulty swallowing and maybe vomiting immediately after eating.
- Cancer esophagus → another rare, but serious complication of GERD that can cause persistent heartburn. Besides heartburn, difficulty swallowing, vomiting, and weight loss can occur.
- Barrett’s esophagus: it occurs when the lining of your esophagus transforms into another type of cell. The new type of lining cells resembles the cells found in your small intestine.
Barret’s esophagus carries a risk of transformation into a cancer esophagus. However, in most cases, Barrett’s esophagus doesn’t cause symptoms. persistent heartburn is not a usual sign of Barrett’s esophagus. But the associated severe GERD can lead to heartburn.