Heartburn, Reflux

What is heartburn?
Heartburn, reflux and indigestion are very common symptoms and are usually due to the regurgitation of acid from the stomach to the oesophagus (gullet), known as gastro-oesophageal reflux disease. The most typical symptom, heartburn is often described as burning behind the chest bone commonly after food. Other symptoms of reflux include belching, flatulence and chest pain. Occassionally, dry cough, sore throat, wheezing and hoarse voice may be due to acid reflux. Reflux is very common affecting up to 1 in 4 of the population and appears to be increasing. Obesity is probably responsible for some of this increase. Generally reflux is not dangerous although is a very irritating symptom. Occasionally, reflux can lead to a condition called Barrett's oesophagus and very rarely cancer of the oesophagus. Sometimes heartburn can be caused by non-gastrointestinal causes such as heart disease (Angina), inflammation of the breast bone joints, pain from the great vessels in the chest or referred pain from spinal problems. The different conditions can only be diagnosed by seeing a doctor. See the links below to understand more about the condition.
The stomach is normally very acidic and acts as a barrier to infections reaching the intestine. A circular muscle (Lower oesophageal sphincter - LOS), normally prevents this acid from refluxing up into the oesophagus. When this anti-reflux mechanism fails, acid freely refluxes into the oesophagus causing inflammation (Oesophagitis) and all the symptoms described. Most reflux occurs during the day, although can occasionally be more prominent at night. 'Night refluxers' often also experience choking, sore throats, wheezing and coughing. The most common causes are listed below:
After eating the stomach becomes full increasing the pressure and the chance of reflux. Therefore a heaving meal will increase the risk of reflux, particularly fatty/oily food.
The valve between the stomach and oesophagus normally relaxes slightly to allow gas to vent from the stomach into the oesophagus. If this valve opens up too much, gas and acid can vent leading to acid reflux. It is thought that foods containing caffeine increase this risk.
Hiatus hernia. This is where the top of the stomach herniates through the diaphragm into the chest cavity. This reduces the 'anti-reflux barrier' thus allowing more acid to reflux.
Some medicines can relax the LOS, such as nitrates, calcium channel blockers, diazepam and theophylline.
Some medicines can irritate the oesophagus including aspirin, non-steroidal anti inflammatory drugs and osteoporosis drugs such as alendronate.
How is reflux investigated?
Normally the diagnosis is very clear from the symptoms and no tests are needed. If you are older than 40 and the symptoms are new and do not respond quickly to treatment a consultation with your doctor may be needed. If the diagnosis is unclear, then tests may be required including
Oesophageal physiology - measurement of the oesophageal muscles and acid.
Reasons for urgent investigation of reflux symptoms would include difficulty in swallowing, loss of appetite and weight loss.
How is reflux treated?
We always suggest lifestyle changes in addition to other treatments. There are a few lifestyle modifications which can be of help:
The first is to avoid eating late. And leave at least 4 hours before going to bed if you have had a heavy meal
Meals high in fat also delay stomach emptying and increase reflux so avoid large, heavy meals
Irritating foods such as those high in spices (Chilli), vinegar and citrus fruits/juices should be avoided
Avoid caffeine
Reduce alcohol consumption
Medicines for indigestion
Antacids such as Gaviscon can reduce symptoms rapidly. Take them when your symptoms are most common, for example after food or before bed.
Medicines which reduce acid production include ranitidine (An H2 antagonist) and omeprazole (A proton pump inhibitor - PPI). These are best taken 30-60 minutes before food for the best effect. They can be bought in low dose in pharmacies but need a prescription for higher dose.
Anti-reflux surgery
Anti-reflux surgery appears to be most effective for patients who respond well to PPI therapy. It is therefore ideal for patients who do not want to take tablets or are unable to tolerate tablets. It is also useful for symptoms not responding to PPI therapy such as regurgitation, acid brash and belching. There are however side effects after surgery and rarely some serious complications. Please see the link to 'anti-reflux fundoplication' for more details.
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