Fly Well

Heartburn and the art of aircraft maintenance

March 1, 2011

You might experience heartburn when, during aircraft maintenance, you are told, “The left sprogulator needs replacing; it will cost a gazillion dollars [a real number, my son assures me] and we’re out of stock for six months.” But there’s another kind of heartburn.

Heartburn is often a manifestation of gastroesophageal reflux disease (GERD) when stomach contents wash up into your gullet or mouth. The acronym “GERD” sounds like the noise made when gastric contents flow up the esophagus! The stomach has a special lining to withstand the environment within, but the esophagus does not—that’s why symptoms are experienced as acid inflames and erodes the wall. These include burning sensations behind the breastbone or neck, bitter taste in the mouth, constant sore throat, chronic dry cough, vomiting, problems swallowing, and sometimes—especially in children—asthma, as acid enters the lungs.

Chest pain always merits a visit to the doctor, but if GERD is on the radar, consider going early because this condition is easier to treat early. Many people try over-the-counter medications such as antacids. If these initially stop all symptoms but they return, go to your doctor, as GERD may be progressing or something more sinister is lurking.

The lower end of the gullet has a complex valve to allow food down and prevent stomach contents from seeing the light of day. If this fails, sometimes in conjunction with hiatal hernia, GERD can follow. The “hiatus” is a gap in the diaphragm through which the esophagus passes from the chest to join the abdominally located stomach. If circumstances allow, the stomach can take a trip north to a different climate inside the chest—a hernia (see “ Fly Well: Hernias are Like Troublesome Neighbors,” November 2010 AOPA Pilot).

Other issues causing heartburn are obesity, pregnancy (the enlarged uterus raises pressure inside the abdomen), smoking (it really mucks up everything), diabetes (so lay off the sodas), and some rarer conditions with damaged connective tissue or Zollinger-Ellison syndrome, in which the stomach makes too much acid because of gut or pancreatic tumors.

When you go to your doctor he or she will ask seemingly odd questions and prod and poke to ensure your symptoms are not due to something else, because GERD has few obvious signs. Referral to either a gastroenterologist or a surgeon with an interest in GERD and diagnostic tests will follow, beginning with an endoscopy or a look-see with a flexible telescope first; you will be sedated, so have no worries. A GI series in which X-rays are taken after a barium drink may show areas of narrowing, hiatal hernia, or obvious reflux. Incidents of reflux are measured over 24 hours by placing a thin esophageal probe connected to a mini-computer clipped to your belt. Pressures in the valve and esophagus are measured with a probe to define what therapy is best for you.

Initially, address those things that are under your control—stop smoking, lose weight, wear loose-fitting clothes, avoid attack-triggering foods and drinks (a food diary really helps), elevate the head of your bed, don’t get horizontal directly after eating, or bend at the waist to pick up objects. Stress or weight reduction with acupuncture or yoga may help, and some swear by naturopathic therapies such as chamomile, slippery elm, or licorice.

If simple antacids fail, over-the-counter (OTC) medicines that reduce gastric acid such as cimetidine (one of several “H2 receptors”) may help. Acid may also be blocked with OTC “proton pump inhibitors” such as omeprazole or lansoprazole. If these don’t do the trick, your doctor has stronger versions available and may add another class of drug that enhances esophageal propulsion.

If drugs don’t work, symptoms dominate your life, or you want freedom from medication, there are surgical options. Often done under laparoscopic guidance—the scope-through-the-belly-button routine—in which surgeons create a new valve by wrapping the top of the stomach around the lower esophagus, hiatal herniation is fixed if present. In good hands, the results are impressive; use resources such as the American College of Surgeons website to find a qualified surgeon near you. Less invasive alternatives still being evaluated include cinching together where stomach and esophagus meet or using radiofrequency energy to induce lower esophageal controlled scarring.

Before embarking on any treatment journey, avail yourself of the benefits of the AOPA Medical Services Plan to help obtain less expensive drugs and navigate FAA regulations.

Left untreated, GERD can get really troublesome, beyond its irritating symptoms. Constant exposure to acid causes esophageal scarring and narrowing, interfering with swallowing—or painful bleeding ulcers can form. Eventually, as the gullet lining attempts to deal with all this aggravation, Barrett’s Esophagus can develop—not a good thing as this can become cancerous.

If your heartburn only occurs after a $100 hamburger or opening your maintenance bill, no problem—but if it’s more regular, see your doctor. Now, if someone can just help me with my sprogulator problem….

Dr. Jonathan Sackier is a U.K.-trained surgeon and active private pilot. E-mail the author at jonathan.sackier@aopa.org.