Make the heartburn pain stop, please.

March 18, 2007 1:54 AM

I have terribly painful heartburn. Less frequently since my doctor prescribed Prevacid a year or so ago, and less frequently still since I've been watching what I eat and losing weight for the last five months. But I still get a bout of it every month or two, usually hitting in the late evening, and keeping me awake until 6 or 7am before it subsides. How can I get some sleep instead of staying awake all night in pain?

A little more about the pain: It's pretty much right there at the solar plexus and I can usually feel it all the way through into my back and shoulder blades. It feels as if it might feel better if I arched my back and stretched, but doing so doesn't actually help. It also feels as if a good burp would make it feel better, and when I can force one out, it actually does feel better... for a few seconds. Originally, years ago (6-8) when I first was having heartburn pain, the pain was very much a stabbing sensation. Back at the start, it was every other month or so, usually shortly after a problematic meal, and almost never late at night. 2-3 years ago, the frequency increased, the delay from the offending meal increased, usually to late at night, and the sensation changed slightly. Most recently, I've come to think of the pain as a bit more of a ripping or tearing pain sensation.

Things that seem to instigate or aggravate the heartburn: fatty meats, red/thai chilis, hot curry, hot cinnamon, and/or eating a large meal. (This saddens me as some of my very favorite foods are extra spicy and BBQ.) Sometimes it seems totally random and without specific cause.

My heartburn can sometimes set in MANY HOURS (upto 10+) since I last actually ate anything. It's very rare for me to feel anything that might be a heartburn precursor sensation shortly after a meal.

I've had an upper endoscopy that showed no obvious signs of damage or ulcer.

I've asked my doctor if he could prescribe anything for the times when a heartburn attack happens despite the drugs and my best efforts to avoid it, and he declined to. (Yes, I should probably go back and ask again, or at least ask for an explanation.)

Sometimes it seems as if Maalox Max or Alka Seltzer will keep the late night pain from happening if there's some sign of it early in the evening, but once the big pain has actually kicked in, they do absolutely NOTHING for it.

So I stay up, trying to force a burp every now and again, from midnight to 7am, then if it's a weekday, call into work and let them know I'm gonna be out or late. Again. Because my heartburn kept me awake all night.

I'm doing my best with the drugs and the diet and the weight loss, but sometimes the pain comes regardless. What can I do to stop the pain?

posted by xiojason to health & fitness (30 comments total)

And yes, this is why I'm awake right now. I would really rather be asleep.
posted by xiojason at 1:57 AM on March 18, 2007

IANAD, but I used to suffer from night time heartburn. But I haven't, for many years now.

If you smoke, stop.

I would also suggest that, prophylactically, you make a point of drinking 1 or more 12 oz glasses of water each night, before you go to bed, regardless of what you have eaten, although it would be good thing to avoid eating after 8 p.m. Digestive enzymes work by hydrolyzing fat and protien molecules in the stomach. If you haven't drunk enough water to supply your stomach with the molecular water it needs for digestion, especially of the foods you describe, it may not be able to break your stomach contents down completely, and will continue to excrete additional acid, trying to itself supply water for hydrolysis. This is a possible reason for nighttime heartburn. So, by drinking a large glass of water, or two, an hour before you go to bed, you supply more than the amount of water needed for digestion, and in time for your stomach to discharge its contents to your small intestine, and close your pyloric sphincter, before you lie down. This can help prevent mechanical reflux, and is one of several physiologic signals that help to shutdown the production of stomach acid, too.

I hope you've also been checked for H. pylori infection, a relatively common stomach infection that has been overlooked for nearly a hundred years, that seems to be responsible for much stomach distress, that is easily cured with several weeks of oral antibiotics. Unfortunately, you, as a patient, may need to ask about this, as not all doctors will routinely, yet, suggest such screening. Although the situation is slowly changing, it is still a case of the squeaking wheel getting the grease, in some instances.
posted by paulsc at 2:52 AM on March 18, 2007

Thanks for the response, paulsc. Looks like I'm already on the good path:

Nope, I don't smoke, and I never really have.

I nearly always drink 16-20oz of water just before bed. This is just a coincidence -- I'd never heard advice of this nature before, I just started doing it 'cause it seemed like a good idea several years back.

I believe my doctor did check for H. pylori before/as part of my endoscopy, and it came up negative.

Any ideas for coping with or reducing the pain that several ounces of prevention didn't quite prevent?
posted by xiojason at 3:04 AM on March 18, 2007

One thing that was repeatedly suggested to me was sleeping slightly reclined (or, if you prefer, slightly sitting up) instead of completely flat on the bed--such as with a bed wedge. It didn't do much for me as my heartburnesque pain that I'd describe as being like yours would hit while I was awake and only last 1-3 hours--but it did seem to go away faster if I remained upright. My doctor was also happy to prescribe a hefty dose of cocodamol, which was pretty effective. Don't take ibuprofen, aspirin, or any other non-steroidal anti-inflammatory drug for the pain. They tend to retard your stomach's reproduction of it's protective mucous lining and this will lead to more stomach problems (and they probably won't be effective in the short term either). Don't take them for anything else unless you have to, and not for too long.
posted by Martin E. at 3:49 AM on March 18, 2007

If you've got a competent gastroenterologist on the case, I'd be a fool to suggest, one by one, all the things he/she may have already checked, and ruled out. But hiatial hernia is certianly something that fits your symptoms. If I was still having symptoms of this severity, I'd go back to the doctor that was treating me, and request further workups or explanations, until I felt I truly understood the cause of the problem, and the best way to manage it. Probably, they'll want to further restrict the size and content of your meals, and suggest you eat 5 or 6 small food portions a day, each a couple hours apart, to minimize any chance for your stomach to extrude through your diaphragm due to eating. And I'm sure that they are going to want you on a much blander diet, immediately. If it comes to that, you're going to have to decide how much you can stand to hurt, in exchange for indulging in spicy foods.

I'm concerned for you, that from your question, it sounds as if your doctor doesn't appreciate the severity of your distress, when these attacks occur. I think it's time to have another chat, and raise this issue again.
posted by paulsc at 4:18 AM on March 18, 2007

A hiatial hernia certainly does match the symptoms, but an upper endoscopy should have confirmed or ruled out that possibility if they were looking. Which they should have been.

If you're taking your Prevacid in the morning, you might want to try taking it just before your evening meal instead. Or chopping it in half and taking a half-dose twice per day.
posted by Martin E. at 5:32 AM on March 18, 2007

I second the notion of sleeping with your top section propped up. This helps me quite a bit.
posted by Clay201 at 5:53 AM on March 18, 2007

In the past when I had an ulcer I found Gaviscon worked well at dealing with the pain. I know an ulcer is not the same as heartburn but maybe it will help.
posted by nola at 6:36 AM on March 18, 2007

Have you tried rantidine? (Also available under the brand names Gavilas and Zantac.) Other heartburn remedies don't work well for me, but this relieves it within about twenty minutes almost always. (I also get heartburn sometimes a long time after eating, or having eaten something very bland which I wouldn't expect to cause it.)
posted by paduasoy at 6:54 AM on March 18, 2007

You describe my wife exactly. She has fought this for years and last month had an endoscopy of her esophagus. The stomach acid has burned the lower part terribly. And it is swollen. She is on a new Prevacid that she dissolves on her tongue. No attacks since she began that. We hope it lasts.
What really works for her is to elevate the bed as mentioned and to eat smaller meals and lose weight. Hard for her to do that but it really avoids the pain attacks.
Those photos taken during the endoscope were unbelievable. It is plain to see where her problem lies and how stomach acid sure can play a number on the esophagus. You have my sympathy. Good luck. But you will have to change your habits permanently to avoid the terrible pain.
posted by JayRwv at 7:27 AM on March 18, 2007

Have you tried sleeping on your left side to help alleviate the pain?

"Sleep on your left side. Make gravity work for you, even when you're lying down. Your esophagus enters your stomach at a slight angle on the right side of your body, so sleeping on your left side allows stomach contents to pool away from your esophagus." source
posted by phatkitten at 8:09 AM on March 18, 2007

Oddly, I don't see any mention of the simple, cheap remedy for heartburn: calcium carbonate tablets. Sold under the brand names Tums and Rolaids, and available very cheaply as generics in most drug stores. Try chewing several tablets just before bed. Works wonders for most people. (Since these work by directly neutralizing stomach acid, they can't really fail.)
posted by jellicle at 8:20 AM on March 18, 2007

Try eating an apple every night before bed. Why? I don't know but this works for a friend of mine who works in healthcare. A teaspoon of apple cider vinegar before bed is also said to help. Most importantly, lose weight, eat small dinners, avoid rich fatty foods at night, not too much snacking after dinner and don't drink too much. For those nights when it is really bad, get yourself a recliner, you know a Lazy-Boy style chair, and sleep sitting up.
posted by caddis at 8:23 AM on March 18, 2007

Based on your description, I suggest doing a bit of googling to see if you think your symptoms might match those of gallstones. At least, that sounds like a strong possibility to me.
posted by j-dawg at 8:36 AM on March 18, 2007

Second the gallstones Meta-Diagnosis. From j-dawg's link:

Symptoms of gallstones are often called a gallstone "attack" because they occur suddenly. A typical attack can cause

• steady pain in the upper abdomen that increases rapidly and lasts from 30 minutes to several hours
• pain in the back between the shoulder blades
• pain under the right shoulder
• nausea or vomiting

Gallstone attacks often follow fatty meals, and they may occur during the night. Other gallstone symptoms include

• abdominal bloating
• recurring intolerance of fatty foods
• colic
• belching
• gas
• indigestion

posted by Civil_Disobedient at 10:27 AM on March 18, 2007

Slippery Elm Powder is rather good. Tastes ok too (especially when compared to the standard involuntary shiver of revulsion range of delights). It's kinda like bland dirt. It does come in tablets but that would be like swallowing a throat lozenge. Be sure to whisk any lumps (trust me they're pretty awful if you feel a bit icky) Just great stuff and it's quite good for you too.
posted by mu~ha~ha~ha~har at 10:44 AM on March 18, 2007

I was once hospitalised with similar symptoms, right down to the heavy meal beforehand, and after a couple of weeks poking and prodding, when everything came up negative, I was told "it was probably a viral infection in the tissues surrounding the heart that caused inflammation". Gallstones were another possibility that was mentioned. I was told that abdominal pain that "feels" like it's in one place can actually be seated somewhere else, so don't discount the possibility that this problem is unrelated to your stomach.

Omeprazole may help, but that's something to discuss with your doctor.

If you happen to be a user, I've seen a small amount of cannabis make abdominal pain that even morphine wouldn't touch disappear in minutes. Really amazing results. Just don't get trapped into relying on it long-term in preference to a healthy lifestyle and a cure.
posted by Leon at 10:52 AM on March 18, 2007

I recently had gallstones and what you are describing sounds exactly what I went through...especially the pain radiating through the shoulder blades and the pain starting at night and lasting till the wee hours of dawn. I also have reflux and am on Omneprazol (spelling?), but the medication did nothing to alleviate the horrible pain. I at first just thought it was heartburn and was visiting my doctor and not getting anywhere. It took an emergency room visit to get me listened too.

My first attack where I knew it was more than heartburn was after my husband and I attended a Lumpia cook-off (Lumpia is a Philippine egg roll)...Lots and Lots of fried little egg rolls to try and judge...boy, it was bad BAD BAD.

Possibly go to your doctor and have them perform an ultrasound? If there are gallstones the technician should be able to spot them right away. Unfortunately, in my case, after the emergency room visit I had to wait another month to get out because my insurance said that a Laparoscopic cholecystectomy (gallbladder removal) was an elective surgery (asses). So I was stuck eating broiled chicken and salmon for a month. It seemed that if I avoided all carbs, all veggies, all milk products, all sweets and spices, AND all anything that tasted even remotely good, I could get the attack down to where it would only happen about once a week. Heating pads really helped.
posted by Jenny is Crafty at 10:52 AM on March 18, 2007

I was once hospitalised with similar symptoms, right down to the heavy meal beforehand, and after a couple of weeks poking and prodding, when everything came up negative, I was told "it was probably a viral infection in the tissues surrounding the heart that caused inflammation". Gallstones were another possibility that was mentioned. I was told that abdominal pain that "feels" like it's in one place can actually be seated somewhere else, so don't discount the possibility that this problem is unrelated to your stomach.

I had the exact same experience, except that they also thought the infection made it to the inner tissue of the heart, based on some bloodwork they did.
posted by !Jim at 11:04 AM on March 18, 2007

The condition is called myo- or pericarditis by the way.
posted by !Jim at 11:04 AM on March 18, 2007

This sounds a lot like a gall-bladder problem. I had similar symptoms last year, which were not initially diagnosed correctly because I didn't seem to be in 'sufficient' pain. Ask for an ultrasound scan to see if this is the case. If so, you'll need surgery but it's laporoscopic and I was back at work after three days.
Prior to the gall bladder issues, I had heartburn issues that ALSO sound like your problems! Except the onset was usually quicker - 2 hours after eating rather than 10.
The main thing that used to help me was ranitidine (most commonly sold as Zantac) which would usually stop the heartburn after 20 mins or so as mentioned above. I also used to take ranitidine as a preventive measure at times when I thought I was likely - if I had a fatty or spicy meal or if I was exceptionally tired.
The heartburn stopped happening about six months before the gall bladder woes, so I don't know if they were connected. The pain was in a different place, and had a different quality, so it seemed like a different thing. The gall bladder pain did not respond in the slightest to ranitidine.
So to summarize: Try ranitidine (Zantac) if you haven't already and get an ultrasound scan of your gall bladder (especially if ranitidine doesn't work).
On preview, everybody already said all this, so it must be good advice.
posted by nowonmai at 11:12 AM on March 18, 2007

Thanks for all the feedback. I'll address several questions/topics in one go here:

• From the reading I did last night, hiatial hernia very much deserves some discussion with my doctor.
• Once the pain has hit, an elevated bed does nothing to alleviate the pain.
• I've been thinking of asking my doctor to up me to a two-a-day dose of Prevacid.
• If I can catch the oncoming sensation early enough, Gaviscon has helped, but if the pain has come on fully, Gaviscon does not help in any noticeable way.
• I was prescribed ranitidine prior to Prevacid. It seemed to have no effect on the frequency or intensity of my heartburn, and if I'm in the middle of an attack, taking ranitidine does nothing to relieve the pain.
• If there's just a hint of what's to come, I increase the elevation of the head of my bed, and attempt to sleep on my left side. It's of no help once the pain is in full-swing, however.
• Calcium carbonate sometimes helps at the earliest signs of heartburn onset, but provide no relief whatsoever in the situations when I'm being kept awake until the wee hours by the pain.
• I've heard the apple cider vinegar anecdote before but not tried it. Two tablespoons of raw honey has seemingly been helpful in staving off a full attack if its onset is detected early enough or is of a weaker attack.
• I've had a couple of torso/gut ultrasounds done in the past several years with no sign of stones (gall or kidney).
• Does slippery elm provide any sort of pain relief?
• I'm don't have a problem with other folks smoking weed, but it's not for me (it causes me to think in a distressingly recursive manner).
• I LOVE lumpia. :)
• Hm. A viral infection seems odd, but I'll put it on the list to ask the doc.

The pain subsided around 6am, but I haven't slept yet.

Thanks again, everyone, for your advice. Any further advice particularly relevant to pain reduction when the attack cannot be prevented would be very much welcome.
posted by xiojason at 2:43 PM on March 18, 2007

Anecdotally, prilosec (which is over the counter) works much better for me than prevacid (even though they are both in the same category, protonpump inhibitors).

You take them every day?

Do you have constipation or lift weights or do any other straining? Straining / valsalva maneuvering will increase your intraabdominal pressure, which will be more likely to open up the lower esophageal sphincter and push acid up.

How about other triggers of heart burn? Caffeine, coffee, chocolate, cooked tomatoes--could it be that you're ingesting these and not realizing they're involved?

I've also been taught that calcium carbonate, while effective at initially buffering the acid and making it less acidic, will actually increase acid production in the stomach, due to a calcium receptor.

I was thinking hiatal hernia too, but a good GI doc should have been able to rule that out. If TRULY everything has been ruled out, you could ask your doctor to refer you to a general surgeon to discuss a Nissen Fundoplication, which used to be the treatment of choice before acid blockers like Zantac, Tagament, Prilosec, and Nexium came to the market.
posted by gramcracker at 3:15 PM on March 18, 2007

Oh yeah, have you ever had a pH probe?
posted by gramcracker at 3:16 PM on March 18, 2007

I hate making medical suggestions for all the obvious reasons, but I feel your pain. They gave me Nexium. Fine, but expensive, and I don't like drugs if I can avoid them. When I stopped after two months, the heartburn came back far worse than ever before. Currently I'm going DGL and lots of water. It's beginning to do the job. Lots of web hits on the subject, and this is what the Feds have to say about it. Best source is probably here.

Mrs Jones had the problem as well and this worked (after some months, alas) where the inhibitors did not. Requires a bland diet for the duration as well, alas.

Good luck. Updates on your progress welcome.
posted by IndigoJones at 7:21 PM on March 18, 2007

Following up some more:

I took OTC Prilosec for a while before getting a prescription. At first, the doctor put me on ranitidine, which proved to be useless, then he put me on Protonix, which was an improvement, but my insurance company didn't like paying for, so we switched to Prevacid, which seems to be working decently well 58 days out of 60 or so.

I take one pill every day, usually in the evening right after getting home from work.

I'm rarely constipated (although I do seem to 'go' a bit less often than most). I don't currently do much in the way of weight lifting.

Diet Coke used to be an occasional trigger when my heartburn was at its most frequent. Coke Zero seems less offensive to my stomach these days (with the drugs). I don't drink coffee. I love tomatoes and have not really noticed them being a trigger. Nor acidic fruits. Oranges seem ok, too.

I saw mention of the Nissen Fundoplication procedure in some of my recent reading. I'll investigate that some more.

I've never had a pH probe.

My heartburn seemed to be even worse than before when I was off the medication for a couple of weeks between Protonix and Prevacid.

I've never heard of DGL (but I love black licorice -- and I've heard before that licorice can be soothing to the stomach, but I believe I've had heartburn attacks before that I could blame on eating Australian black licorice...).

Thanks for the suggestions!
posted by xiojason at 7:29 PM on March 19, 2007

Well, I was in a similar boat (similar symptoms, different diagnoses offered and ruled out, rotating medications of varying effectiveness) and it was my third or fourth medication combination that seemed to really be effective, and it took about a year and a half or more to be nearly normal again. The only additional thing I can suggest is insisting that you be prescribed cocodamol or something similar for the pain. If your current doctor won't give it to you, ask your friends or coworkers to refer you to one who will (or you can get it OTC in some countries if you visit or have a friend in one).
posted by Martin E. at 2:35 AM on March 20, 2007

This sounds a little weird, but what worked for me, right away, was eating a few nuts, peanut butter, or something with a little protein. Keep a little jar of nuts by the bed. Not much, just a bite, and the pain went away and allowed me to sleep. For long-term heartburn management, I've cut down on breads and starches (the heartburn alleviation the only positive I found out of the Atkins diet, really) and found that I can drink coffee, wine, and eat spicy foods again without pain or feeding the pharmaceutical industry! Note that IANAD and YMMV, but this has worked for me.
posted by jenh at 8:55 AM on March 20, 2007

I recently gave myself a hiatial hernia by using an ab-crunch machine at the gym. The heartburn was terrible and the only description of how I felt was that I was going to die for sure!

I got online and found a cure that worked for me immediately. I slowly drank about a half gallon of water, slow enough to allow it to go into the bottom of my stomach and not just enlarge the top that was sitting above my diaphram. If you drink it too fast you might feel more stomach pulling up, making a larger balloon above the diaphram, and more pain. After all the water was in my stomach I jumped off a bottom step of the staircase about 50 times. I felt my stomach go back through the sphincter and a burp came up at the same time. If you have a hiatial hernia you might be noticing weird little burps in your throat.

My stomach came back up a couple of times within a few days of the original injury, both times while bending over doing yard work, but now it has finally stayed down for a few weeks.

I saw a surgeon and he said all this was impossible to happen and I could not have possibly torn my diaphram in the gym and the water thing could not possibly work. Well, it did happen three times and each time I cured it by drinking water and jumping off a step! Each time I jumped until I felt my stomach go back down, and also taking breaks to smooth my stomach down from the solar plexus and to the left with my fingers.
posted by dela at 6:50 AM on May 30, 2007

I found this searching for solutions to my heartburn awhile ago and I did find a solution for myself.

Prilosec worked really well at first, but soon I started getting lower GI side-effects as well as burping problems. So I shifted to diluted apple cider vinegar+honey, which BTW has a ph similar to beer/wine/kombucha. That worked for me, but it didn't completely stop to reflux, just lessened it. I had to make dietary changes to really stop it.

My diet now is bland, with an occasional treat if I have things under control. For me a lower-carb diet with lots of lean protein and soluble fiber worked best for my GERD and my IBS. If I slip up badly it does come back and I have to use the ACV again for a few days, but mostly I have it under control.
posted by melissam at 11:17 PM on July 3, 2007