Trouble sleeping doesn't seem like reason for concern. After all, half of Americans struggle with insomnia at least a couple of nights each week. It may simply be caused by heartburn and acid regurgitation.
Gastroesophageal reflux disease (GERD), characterized by stomach acid that backs up into the esophagus and results in heartburn, could be the reason that many people toss and turn and wake up in the middle of the night.
Unfortunately, GERD is not generally a preliminary suspect with a patient reports insomnia and nighttime awakenings. Additional awareness among doctors and patients could help change that.
"We found that as many as a third of patients who have trouble sleeping may have undiagnosed reflux," said Dr. Anthony J. DiMarino Jr., the William Rorer Professor of Medicine with Thomas Jefferson University and chief of the division of gastroenterology and hepatology at the Thomas Jefferson University Hospital. "With medicine we can improve the quality of sleep and (patients) benefit from that."
GERD and lifestyle
GERD may seem like a simple disorder that mostly causes patients heartburn discomfort. But over time a backwash of acid can inflame the lining of the esophagus, potentially leading to more serious effects, according to The Mayo Clinic.
Cancer of the esophagus, esophagitis, characterized by inflammation or swelling of the esophagus, or Barrett's esophagus, a change in the lining of the esophagus that can lead to cancer, are possible. Nocturnal reflux is the leading cause of Barrett's esophagus. Other complications include dental problems or esophagus narrowing from scarring due to the inflammation.
Most patients are diagnosed with GERD based on a description of symptoms. A treatment plan is developed, but if that isn't successful, testing generally follows.
About 40 percent of the U.S. population has experienced GERD. Risk factors are varied but include pregnancy, alcohol consumption, smoking and obesity.
"Everyone is getting overweight in this country," Dr. DiMarino said. "About a third of children are obese in this country. A big theory in the increase of reflux is being overweight. Those who are overweight have much higher instances of reflux."
A pH probe test that evaluates the extent of acid reflux by determining when and how long acid remains in contact with the esophagus may be given for discomfort that doesn't seem to go away. The test often involves insertion of a thin wire through the nose and into the esophagus, though a wireless device also may be used. A wearable monitor indicates the amount of acid produced over a 24 to 48-hour period.
Other methods for diagnosing GERD include an x-ray of the upper digestive system to measure and study the shape and length of the top portion of the stomach and the esophagus.
An endoscopy, that features a flexible tube with a camera attached that is inserted from the mouth into the stomach and esophagus, and a mobility study, which requires putting a catheter through the nose and into the stomach and esophagus to measure pressure and movement, also are possible diagnostic tools for GERD.
Sometimes it can be managed through lifestyle changes such as smaller meals, weight loss and giving up smoking. Many also take over the counter or prescription medication for the disorder. One of the most popular types of medication helps control the production of acid.
Antacids or stronger medications such as proton pump inhibitors that decrease stomach acid production also may help some patients. Surgery is an option for those who do not have success with other treatment options. The Mayo Clinic reports that about 90 percent of patients report no longer having heartburn a month after an anti-reflux operation.
Negative Implications for Sleep
Dr. DiMarino has spent years studying GERD and its impact on sleep. He has published more than 80 original papers and is currently investigating an increase in cancer of the esophagus.
"People are not sleeping as well as they were 20 to 30 years ago. They're sleeping about an hour less as a population, and these patients receive a higher number of prescriptions for sleep medicine," said Dr. DiMarino.
If insomnia is left untreated, it can result in increased illness and morbidity, according to the National Sleep Foundation. Those with insomnia also tend to have poorer health, are more likely to be depressed and are more likely to miss days at work.
About 75 percent of GERD patients report trouble sleeping. Many report that symptoms such as heartburn worsen at night, or that the episodes lengthen.
A large-scale study published in Clinical Gastroenterology and Hepatology in 2009 linked GERD to sleep, but also associated sleep with development of GERD.
It was found that insomnia could influence the development or increase the severity of GERD, but that GERD also may influence or increase the severity of sleep problems. The connection between the two was significant even after adjustments for numerous factors including stroke and gastrointestinal symptoms.
Treating nighttime GERD
Nights are tough for heartburn patients. Symptoms may be more uncomfortable at night, making if difficult to fall asleep and stay asleep.
"Most people (with GERD or heartburn) opt for some kind of sleep aid like Ambien or over the counter medication," said Dr. DiMarino.
However, prescribing sleeping pills to GERD patients can cause worsening heartburn and acid reflux at nighttime. Patients with GERD are often awakened at night when acid refluxes up the esophagus from the stomach. It could be once an hour for some patients.
"Every time that happens they have an awakening. It certainly interrupts their sleep," said Dr. DiMarino. "You don't awaken so the acid goes back to the esophagus. You're not aware of it so you just sleep through it and acid stays in the esophagus for a longer period of time."
Severe cases could cause serious esophagus problems such as Barrett's esophagus or even cancer of the esophagus. Patients aren't usually aware of those risks.
The sleepless nights often prompts patients to head to their primary care doctor, complaining of trouble sleeping or requesting prescription sleep medication to help them snooze through the night without waking. Patients often attribute the sleeplessness to anxiety or stress due to work or family obligations.
Few think to mention they have experienced heartburn, primarily because they simply have not considered that could be what is keeping them up at night. Often they walk away with a prescription without a doctor even considering whether they might have GERD.
"If you give sleeping pills to (a GERD patient), you're potentially making things much worse," Dr. DiMarino said. "The message to patients is that if you have trouble sleeping, it may not be anxiety or work stress. It could be undiagnosed GERD. You should ask your physician to investigate for you."
Instead of going to sleep drugs when GERD symptoms keep you up at night, Dr. DiMarino suggests instead talking to a physician about taking medications that treat heartburn and acid reflux. He suggests trying a month's worth of medication to treat acid reflux to see if that results in better sleep.
"It's cheap and safe," said Dr. DiMarino. "If you're sleeping better, you could have undiagnosed reflux."
