Heartburn Is the Symptom. Reflux Is the Problem.

Quick answer: Reflux is stomach contents washing back up into your esophagus. Heartburn is the burning you feel when it happens. Occasional heartburn is a diet-and-habits problem. Heartburn twice a week or more, or any trouble swallowing, is a doctor's problem.

Two words, one fire

You're at the kitchen counter at 1 a.m. with a roll of Tums, and it's the third night this week. You'd call it heartburn, and so would your doctor. But the burn isn't the issue. It's the alarm.

The issue is a ring of muscle at the bottom of your esophagus, the lower esophageal sphincter. It's supposed to open for food, then shut like a good gate. When it relaxes at the wrong time, or gets pushed on from below, stomach acid comes up. That's acid reflux. The burning behind the breastbone is what you notice. Some people also get a sour taste in the back of the throat, a cough that won't quit or a hoarse voice in the morning, and no burn at all.

Reflux that shows up often enough to be a pattern gets a third name: GERD, gastroesophageal reflux disease. The usual yardstick is heartburn at least twice a week. One bad night after a rack of ribs isn't GERD. It's ribs.

Rule out your heart first

Heartburn and a heart attack can feel alike. Pressure, burning or tightness in the chest, sometimes in the upper belly. If the discomfort comes with shortness of breath, a cold sweat, nausea, or pain moving into the arm, jaw or back, don't sit there wondering. Call 911. Don't drive yourself, and don't wait to see if a Tums settles it.

Read what a heart attack actually feels like before you ever need it. A doctor who says "it was just reflux" has done you a favor. A man who talked himself out of the call has not.

What's pushing the acid up

Reflux has causes. Most of them are things you can move.

• Big meals. A stuffed stomach pushes against that gate. Two normal plates beat one enormous one.
• Lying down too soon. Gravity is the cheapest reflux treatment there is, and you cancel it the minute you flop on the couch after supper.
• Belly weight. Extra weight around the middle squeezes the stomach upward. For many people, losing even a modest amount helps more than any pill.
• Tobacco and alcohol. Both can loosen the sphincter. If you needed one more reason to quit, what actually works when you quit tobacco is a good place to start.
• Medications. Anti-inflammatory painkillers like ibuprofen can irritate the stomach and esophagus, and some prescriptions are known to aggravate reflux. Ask your pharmacist about anything you take daily. Don't stop a prescription on your own.
• A hiatal hernia. Part of the stomach slides up through the diaphragm and the gate stops working properly. Only a doctor can find it.

Foods get blamed constantly. Fried and fatty food, chocolate, mint, coffee, citrus, tomato sauce and spicy dishes are the usual suspects. But the evidence that cutting every one of them helps everybody is mixed. Don't swear off your whole kitchen. Keep a two-week log of what you ate and when the burn came. You'll likely find one or two real offenders, and the rest you can keep.

Fixes that cost nothing

Start here before spending a dollar at the pharmacy. They work better than most men expect, and they're the same things your doctor will tell you first.

1. Stop eating three hours before bed. If supper is at 8, bedtime isn't 9.
2. Raise the head of the bed. Six to eight inches, using a foam wedge or sturdy blocks under the bedposts. Stacking pillows just bends your middle and makes it worse.
3. Sleep on your left side. Studies suggest it keeps acid down better than the right.
4. Loosen the belt. A cinched waistband is pressure you're applying yourself.
5. Eat smaller, slower. Put the fork down between bites. It's dull advice, and it works.
6. Lose the weight if you're carrying extra. Slowly, with your doctor's blessing.

Give it a few weeks. If the burn fades, you've solved it with discipline and a few wooden blocks. That's the best outcome there is.

What the drugstore aisle actually offers

There are three tiers, and they do different jobs.

Antacids (Tums, Rolaids, Maalox) neutralize acid already in your stomach. They work in minutes and wear off in an hour or two. Good for a rare flare-up after a big dinner. Useless as a nightly routine, because the problem comes right back.

H2 blockers (famotidine, sold as Pepcid) turn down acid production. They take about an hour to kick in and last longer. Useful when you can predict the trouble, like taking one before the chili cook-off.

Proton pump inhibitors, or PPIs (omeprazole, esomeprazole, lansoprazole) shut down most acid production at the source. They're the strongest option and they need a few days to reach full effect. The over-the-counter versions are labeled for a 14-day course, no more than once every four months, unless a doctor says otherwise. Read that label. A lot of men treat a 14-day course as a lifestyle.

That's the catch. PPIs are good medicine, and for real GERD or a damaged esophagus they can be the right call, sometimes for years. But long-term use has been linked to problems such as low vitamin B12 and magnesium, and to a higher risk of bone fractures. Taken without a reason, they're a bad habit. Taken with a reason and a doctor watching, they're a treatment. Don't stop a long-running one cold either, since acid can rebound. Talk to your doctor about stepping down.

When medication makes sense, and when it's a visit

Treat it yourself for a few weeks if the heartburn is occasional, you can name the cause, and the habits above are helping.

Make the appointment if:

• You need heartburn medicine more than twice a week
• Two weeks of the OTC course didn't clear it
• You're over 50 and this is new
• You wake at night coughing, choking or burning
• Food seems to stick on the way down, or swallowing hurts

Skip the appointment and go straight to the ER, or call 911, if you vomit blood, pass black or tarry stools, or have chest pain with the symptoms described earlier.

That list isn't there to scare you. Reflux that goes on for years can irritate and change the lining of the esophagus. Men get a condition called Barrett's esophagus more often than women, and it only gets found by looking, usually with a scope. Most reflux never gets there. The visit is how you know yours isn't one that does.

Stress can also be a factor in how often the burn hits and how much you notice it. It doesn't cause reflux by itself, but it's worth reading why stress doesn't stay in your head if your stomach is the first thing to complain on a bad week.

Bring your log to the appointment, along with every pill and supplement you take. A doctor with two weeks of notes can do more in ten minutes than one working from "it burns sometimes."

Move the supper up. Prop up the bed. If you're still reaching for the roll of Tums at 1 a.m., put it down and call the office.