Heartburn: is it due to MS?

My main problem is the recent development of severe gastroesophageal reflux and heartburn, which wakes me up at night and affects my sleep and quality of life. Is it MS related?

Case study

Dear Prof G, I have had MS for just over ten years, but my main problem is the recent development of severe gastroesophageal reflux and heartburn, which wakes me up at night and affects my sleep and quality of life. My MS is well-controlled on dimethyl fumarate, and I am fully functional. I am a little overweight (BMI 27.4). Is gastroesophageal reflux related to having MS? 

Photo by Yaoqi on Unsplash

Prof G’s response

This story is so familiar to me. I see one or two patients a week with MS who have gastroesophageal reflux or GERD (gastroesophageal reflux disease). And with the current NHS crisis, people with multiple sclerosis (pwMS) are seeing their general practitioners less often for these sorts of common problems. As a result, I am often providing advice and treatment for common problems, such as heartburn, that may not necessarily be MS-related. GERD is so common that I am convinced pwMS are at increased risk of developing GERD. Please note that some of the symptoms of GERD are atypical and could be ascribed to MS. The following is a list of symptoms due to GERD:

1. Heartburn: this is the most common symptom of GERD. It's characterized by a burning discomfort or pain usually occurring in the chest just behind the sternum or breastbone. This sensation often comes after eating and may worsen when lying down or bending over.

2. Regurgitation: this involves the sensation of acid backing up into your throat or mouth. It can produce a sour or bitter taste; sometimes, you may even regurgitate food or a liquid.

3. Dysphagia: difficulty swallowing, feeling like food is sticking in your throat or oesophagus.

4. Chest pain: in some cases, GERD can cause chest pain, particularly when lying down or at night.

5. Chronic cough or hoarseness: reflux can irritate the airways and lungs, leading to respiratory symptoms like a persistent cough or hoarseness.

6. Sore throat: a sore or irritated throat can occur if acid frequently enters the throat.

7. Laryngitis: inflammation of the voice box from refluxed acid.

8. Asthma symptoms or worsening asthma: for those with asthma, GERD can exacerbate symptoms.

9. Dental erosion: acid from the stomach can damage the enamel of the teeth.

10. Nausea: some people with GERD experience nausea, though this is less common.

11. Bloating, burping, or a feeling of fullness: these symptoms can occur due to the stomach contents refluxing into the oesophagus.

Please be aware that not everyone with GERD experiences heartburn, and some may present with atypical symptoms, for example, nausea, dysphagia, hoarseness and chronic cough. The symptoms of GERD can vary greatly in intensity; some pwMS might experience mild symptoms, while others might have severe symptoms that significantly impact their quality of life. GERD is a serious condition, and if left untreated, it can lead to more serious health problems, including oesophageal damage (stricture and obstruction) and complications like Barrett's oesophagus, which is a premalignant condition that can lead to oesophageal cancer.

A quick literature search for GERD and MS reveals very few hits, which means it is an understudied MS comorbidity. The relationship between MS and GERD is likely to be influenced by several factors, which include:

Mobility and physical activity: reduced mobility and physical activity, common in pwMS, contribute to GERD. 

Medications: some symptomatic medications have side effects that may exacerbate GERD. For example, muscle relaxants can relax the lower oesophagal sphincter, leading to reflux.

Autonomic dysfunction: MS can result in autonomic nervous system dysfunction, which includes the control of digestion. This dysfunction could contribute to GERD.

Lifestyle factors: poor diet, stress and a raised body weight, common in pwMS, may exacerbate GERD.

Direct effects of MS: MS lesions in specific brain (hypothalamus and brain stem) and spinal cord locations might directly impact gastrointestinal function. The correlation between specific MS lesions and GERD is poorly studied and, from my reading of the literature, needs more work. 

Why does GERD occur?

Gastroesophageal reflux occurs when stomach contents, including acid, flow back (reflux) into the oesophagus, the muscular tube that connects the mouth to the stomach. This backwash (acid reflux) can irritate the lining of the oesophagus, leading to gastroesophageal reflux disease (GERD) when it happens frequently or is associated with symptoms or complications. 

Image from Wikipedia

Several factors and conditions can contribute to gastroesophageal reflux:

1. Lower oesophageal sphincter dysfunction: the lower oesophageal sphincter acts as a valve between the oesophagus and the stomach. If the sphincter is weak or relaxes inappropriately, it can allow stomach contents to flow back into the oesophagus.

2. Hiatal hernia: this occurs when the upper part of the stomach bulges through an opening in the diaphragm (the hiatus), which can impair the function of the lower oesophageal sphincter, making reflux more likely.

3. Raised intrabdominal pressure:

   1. Pregnancy: hormonal changes and the physical pressure of the growing foetus can increase the risk of reflux during pregnancy.

   2. Overeating or eating certain foods: large meals can increase stomach pressure and lead to reflux. Certain foods and drinks, such as fatty or fried foods, tomato sauce, alcohol, chocolate, mint, garlic, onion, caffeine, …. can trigger reflux. 

   3. Obesity: excess weight can put pressure on the abdomen, pushing up the stomach and causing acid to back up into the oesophagus.

4. Delayed stomach emptying: conditions that slow gastric emptying, such as gastroparesis, can contribute to reflux. MS does not cause gastroparesis as such, but some symptomatic medications can slow gastric emptying. 

5. Smoking: smoking can relax the lower oesophageal sphincter and also decrease the production of saliva, which helps neutralise acid.

6. Medications: certain medications, including some asthma drugs, antihistamines, pain relievers, sedatives, and antidepressants, can relax the lower oesophageal sphincter and exacerbate GERD.

7. Lying down after eating: lying down too soon after eating can make it easier for stomach contents to back up into the oesophagus, especially if the lower oesophageal sphincter is weakened.

8. Alcohol: alcohol can relax the lower oesophageal sphincter and also increase acid production in the stomach.

9. Stress: while stress itself doesn’t cause reflux, it can lead to behaviours that trigger reflux and can increase sensitivity to the symptoms.

Understanding these factors can help in managing and preventing gastroesophageal reflux. 

Management

Managing GERD involves a combination of lifestyle modifications, dietary changes, and possibly medication. The goal is to reduce the frequency and severity of symptoms and to prevent complications. Here are some general strategies:

Lifestyle modifications

1. Weight management: If you are overweight, losing weight can reduce the pressure on your stomach and prevent reflux.

2. Elevate the head of your bed: Raising the head of your bed by about 10-14 cm can help prevent acid from travelling back into the oesophagus during sleep.

3. Avoid tight clothing: Tight clothing can increase abdominal pressure and contribute to reflux.

4. Quit smoking: Smoking weakens the lower oesophagal sphincter (LES) and exacerbates GERD symptoms.

5. Limit alcohol consumption: Alcohol can relax the LES and trigger reflux.

6. Avoid lying down after eating: Wait at least 2-3 hours after eating before lying down or going to bed.

7. Dietary changes:

   1. Avoid trigger foods: common triggers include spicy foods, chocolate, caffeine, citrus fruits, tomatoes, onions, and fatty or fried foods.

   2. Eat smaller meals: large meals can increase stomach pressure and the likelihood of reflux.

   3. Drink water: drink plenty of water, but try to avoid drinking large amounts of liquids with meals.

   4. Mindful eating: eat slowly and chew thoroughly to aid digestion.

Medications

1. Antacids: Over-the-counter antacids can provide quick relief by neutralising stomach acid.

2. H2 Blockers: These reduce acid production and include medications like ranitidine and famotidine.

3. Proton pump inhibitors (PPIs): These are more powerful acid blockers and include omeprazole, esomeprazole and lansoprazole.

4. Prokinetics: In some cases, medications that help to empty the stomach more quickly may be prescribed.

Alternative therapies

1. Herbal remedies: some people find relief with herbal remedies like ginger, chamomile, or liquorice. 

2. : stress can worsen GERD symptoms, so practices like yoga, meditation, or deep breathing exercises may be beneficial.

When to raise the issue of GERD with your HCP:

• If over-the-counter medications are not effective.

• If symptoms are severe or persistent.

• If you experience difficulty swallowing, unintentional weight loss, or recurrent vomiting.

Monitoring and follow-up

Regular follow-up with your HCP is important, especially if you are on long-term medication for GERD; some medications may require monitoring. Long-term suppression of gastric acid production is associated with bacterial colonisation of the stomach and an increased risk of aspiration pneumonia. 

The management of GERD is highly individualised. What works for one pwMS may not work for another, so working closely with your HCP is important to develop a personalised management plan.

GERD is a common condition that can be associated with a variety of comorbidities. It exacerbates MS-related sleep disorders and is associated with obstructive sleep apnea. GERD can also exacerbate mental health problems, in particular anxiety and depression. The chronic nature of GERD and its impact on quality of life can contribute to psychological stress. Due to altered eating habits and self-imposed dietary restrictions, it can lead to nutritional deficiencies. 

I know that GERD is off-topic and unrelated to MS, but it is an important topic to cover. I would be interested to hear if any of you suffer from GERD and whether you think it is related to your MS. 

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General Disclaimer

Please note that the opinions expressed here are those of Professor Giovannoni and do not necessarily reflect the positions of Queen Mary University of London or Barts Health NHS Trust. The advice is intended as general and should not be interpreted as personal clinical advice. If you have problems, please tell your healthcare professional, who will be able to help you.