Can't Swallow That?

Difficulty swallowing, known medically as "dysphagia", is a very common complaint. In fact, up to nearly a quarter of patients seen in primary care settings will suffer from this problem. Dysphagia is definitely more common in the older population, whether they are in nursing homes or living independently.

What causes dysphagia? The most common cause depends on the age. In small kids, there may be structural problems present from birth that may need surgical correction. In adults, however, the cause is often something that can be fixed more simply, with medications and/or behavior changes.

Smoking, excess alcohol, and obesity all tend to increase stomach acid refluxing back up into the esophagus, which can cause pain or difficulty in swallowing. Reflux, also known as GERD (Gastro Esophageal Reflux Disease) is a very common cause of dysphagia that is seen in otherwise healthy people. Quitting smoking, stopping excess alcohol and weight loss can all improve symptoms, as well as taking medications that reduce acid production.

Medications such as NSAIDS (like ibuprofen), potassium supplements, antibiotics and osteoporosis medications can all cause problems with swallowing, so both diagnosis and treatment of dysphagia in this case may involve stopping prescription medications.

• Let me take this opportunity to caution against "DRY SWALLOWING" pills. I cringe when I see people grab an ibuprofen and swallow it without a drink. Every time you take a pill or capsule, swallow it along with at least a half glass of liquid. Dry swallowing can essentially "scrape" or chemically irritate the lining of your esophagus. And please, let gravity help you get that pill all the way to your stomach- don't lie down for at least five or ten minutes after you take medications.

Less commonly, the more serious causes of dysphagia are to blame, including cancers, strokes, neurologic disorders such as Parkinson's Disease, advanced infections, or scarring from prior trauma or radiation.

BOTTOM LINE: Don't ignore trouble swallowing, especially if it persists or is getting worse. Schedule an appointment with your family doctor!

Caffeine, Alcohol and Peppermints, Oh My!

As if the cough last week weren't enough, are you now plagued with with heartburn? Yes, in our commercial-literate world, we may call it GERD (Gastro-Esophageal-Reflux Disease), but heartburn is still a great descriptor. December is often a very tough month for health! We are fully into cough and cold season, and at the same time, we are frantically running around in crowded public areas...touching the same escalator handrail, doors, etc. as the sneezing, coughing folks ahead of us. In addition, we are meeting old friends for our annual "catch up" coffee, drinks or meals, and burning the candle at both ends.

Caffeine, alcohol, and peppermints (did someone say candy canes?) abound, and ALL THREE of these have one common side effect in the body- they loosen the sphincter between the esophagus (food tube) and stomach that is supposed to function to keep acid down south in the stomach. Instead, these substances allow it to relax, and acid can slosh back up into the esophagus, and voila- HEARTBURN FOR THE HOLIDAYS!

What to do? Okay, first things first, stop the burn by popping a few antacid tablets. Not enough relief? Add in an OTC acid relief product like cimetidine (Tagamet) or ranitidine (Zantac) or even the next level up of acid blockers such as omeprazole (Prilosec). Still no relief? Time to see your doctor! Of course, it SHOULD go without saying that you need to STOP THE OFFENDING CAUSE (yes, the coffee, drinks and mints) if your symptoms are persisting beyond the occasional event!

I'd be remiss if I didn't add NICOTINE to the the list of irritants for GERD, by the way, so here is my chance to beg you to make QUITTING SMOKING your number one New Year's Resolution!

BOTTOM LINE: Caffeine, alcohol, peppermints and nicotine all cause HEARTBURN- watch out for the symptoms and recognize the cause!

Medicine Cabinet Staple #7: TUMS

What else is in the front of my medicine cabinet? This season's favorite flavor of TUMS. Over the counter antacids are still the fastest way to speed relief for indigestion, and a quick fix for an extra blast of calcium (especially in rapidly growing pre-teens and teens.) Yes, there are fancier and more expensive acid blockers out there (see my "Q&A about GERD"), but I only keep TUMS in my cabinet because it works fast and it is inexpensive and easy to take: no water required! Our family prefers the rapid, smooth-dissolve texture and flavor of the name brand product versus the generic equivalents, but the other brands work as well.

Calcium supplements were recently in the news with a link to heart disease, but the take-home message is that it is better to get extra calcium from your diet than to rely on a pill. Additionally, if you are going to take calcium supplements chronically (whether it's via an antacid or other supplement product), Vitamin D should also be supplemented.

Another use of antacids/calcium supplements beyond indigestion is for nighttime leg cramps. Occasionally "growing pains" (leg pain, typically worse at night during growth spurts) often respond to an extra helping of calcium in the evening.

Antacids can potentially block absorption of other medications, so it's best to take them alone. If you find you are needing the antacids more than once or twice per week, it's time for a visit to your doctor to determine the cause and a more lasting solution.
BOTTOM LINE: Keep a bottle of antacid tablets in your cabinet to have on hand for occasional indigestion or leg cramps.

Heartburn or Broken Bones?

Okay, I'm interrupting my summer tips with this "breaking" report. The FDA has issued a warning regarding proton-pump inhibitors (PPI's) which are medicines that stop acid production such as Prilosec, Nexium, Prevacid, etc. Six of seven studies showed that people, especially those over 50, who take these medications- whether they are the over the counter version or prescribed- for over a year or in high doses, have increased risk of fractures in their hips, spines, and/or wrists.

So what does this mean? Do you have to choose heartburn or broken bones?

Of course not. What it means is that these drugs, like every other class, have potential side effects. We need to use them judiciously, and not as a band-aid for a long term problem. GERD is typically caused by behaviors that can be modified: caffeine, alcohol, and nicotine are at the top of the list. Consider switching gradually to decaf, decreasing your alcohol intake, and quitting smoking instead of routinely grabbing your acid pill every day.

BOTTOM LINE: All medications have side effects; please review ALL of your medications with your doctor and see which, if any, can be reduced or eliminated if you are willing to make some behavioral changes.

Q&A about GERD

Since I brought up caffeine yesterday, let me follow with a related common question I hear in the office. "What can you give me for my heartburn?" or, sadly, since the dawn of commercials telling us what we "need", "I think I need the purple pill for my GERD (Gastro-Esophageal Reflux Disease)"! And what do I say? My response is "Let me teach you what YOU can do to improve your heartburn."
There are certainly a plethora of medicines we can use to treat reflux, from over the counter antacids to expensive proton pump inhibitors, and they all work very well. However, why not address the CAUSE of the problem? Heartburn comes from stomach acid sloshing back upwards into the esophagus rather than flowing downstream. This happens when the sphincter- the band of tissue that surrounds the connection between the esophagus and the stomach- relaxes. What causes it to relax?
You already know the answer if you picture what people do after overeating, and they want to relieve their distended stomach. Tobacco, alcohol, caffeine and peppermints all relax that sphincter, letting our stomachs feel less distended, but allowing acid reflux in the process. Remember this when the waiter sets your mints down as he refills your coffee with desert.
BOTTOM LINE: If you're having heartburn on a regular basis, limit the causes of reflux- smoking, alcohol, caffeine and mints- BEFORE you head to the doctor for a quick fix.