Heartburn and reflux disease

What is heartburn?


Heartburn occurs when acid in the stomach refluxes – or flows backwards – into the gullet or esophagus.

Your stomach is built to withstand the acid, which is there to help you digest your food, but your esophagus is not. So when acid backs up into your esophagus, it causes an uncomfortable burning sensation that rises from the stomach or lower chest up towards the neck. This is known as heartburn. In some cases, stomach acid may be regurgitated into your mouth, causing an unpleasant sour taste.



Almost everyone suffers from heartburn occasionally. But if symptoms related to acid reflux become troublesome and you find that they interfere with your daily life, you may have reflux disease, which is also known as gastroesophageal reflux disease or GERD (see What is reflux disease or GERD?).



What causes reflux?


When you eat or drink something, the food passes from your mouth into your esophagus, then into your stomach (Figure 1), and on into the rest of the digestive system.


Figure 1. The esophagus

There is a valve mechanism at the top of your stomach called the lower esophageal sphincter or LES (Figure 2), which acts as a one-way valve, opening to let the food into the stomach and then closing to prevent the contents of the stomach from moving back into the esophagus.


Figure 2. The lower esophageal sphincter acts as a one-way valve to let food into the stomach but not to exit the same way

Sometimes this valve is not completely effective and allows acidic stomach juices to flow back into the esophagus (Figure 3) – a condition known as reflux or gastroesophageal reflux. Exposure to harsh stomach acid irritates the sensitive lining of the esophagus, causing the unpleasant sensation referred to as heartburn. In some cases, stomach acid may be regurgitated into the mouth, causing an unpleasant sour taste. Other symptoms may include pain and difficulty in swallowing, belching or burping, persistent coughing or hoarseness, upper abdominal pain (epigastric pain) or chest pain.


Figure 3. If the LES does not work correctly, acid is allowed to pass back into the esophagus

If you suffer from reflux, you may find that certain things make it worse, including:

• Food
  
  
  
  • Certain foods or drinks, such as fatty or highly spiced food, onions, alcohol, fruit juices, coffee and chocolate.
    
  • Large meals.
    
  • Eating too close to bedtime – a stomach full of food and acid is more prone to reflux, especially when you are lying down.
    
  
  
• Smoking
  
• Pregnancy, which increases pressure within the abdomen, pushing the stomach contents into the esophagus.
  
• Medical conditions
  
  
  
  • If the valve mechanism in the LES does not work properly.
    
  • If the stomach produces too much acid, it will be more likely that acid may leak into the esophagus.
    
  • Delayed stomach emptying – some people have stomachs that empty their contents into the intestines very slowly.
    
  • Patients with hiatal hernias (where a small part of the stomach protrudes beyond the diaphragm into the chest) have an increased risk of suffering from reflux.
    
  • People who are obese are more likely to suffer from reflux.
    
  
  
• Some medicines can affect the LES so that it does not work properly. These include theophylline, oral contraceptives, benzodiazapines and calcium channel blockers.
  
• Wearing tight clothes around the stomach
  
• Exercise or bending
  

What is reflux disease or GERD?


Most people experience heartburn occasionally, but some suffer from it more regularly. If you suffer from heartburn or other reflux symptoms (see What are the symptoms of reflux disease?) that you find troublesome, you may have reflux disease or gastroesophageal reflux disease (GERD) and you should consider consulting your doctor.

You may find it troublesome if:

• you suffer from mild acid reflux symptoms occurring two or more days per week, or moderate/severe symptoms occurring more than one day per week
  
• reflux and heartburn negatively affect your daily life (by making it difficult to sleep or painful to take exercise, for example).
  

When you consult your doctor about your heartburn and other reflux symptoms, he or she will need to know about their frequency, severity and how they affect your life. You can record this by completing the GERD Impact Scale questionnaire and then take it along to discuss with your doctor.





[url=javascript:openQ();]

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[url=javascript:openQ();]Click here to complete the interactive GERD Impact Scale questionnaire.[/url]

You can also use the PDF version




What are the symptoms of reflux disease?


Heartburn is the most common symptom of reflux disease (also called gastroesophageal reflux disease or GERD). Heartburn is usually felt as an uncomfortable burning sensation that rises from the stomach or lower chest up towards the neck.



On some occasions, stomach acid may come up into your mouth, causing an unpleasant sour taste.

Other symptoms include:

• pain and difficulty in swallowing
  
• belching or burping
  
• persistent coughing, particularly at night
  
• persistent hoarseness, sore throat and throat clearing
  
• upper abdominal pain (upper stomach pain), also called epigastric pain
  
• chest pain that is not related to heart problems
  

GERD may also play a role in the development of chronic sinus problems, asthma and wheezing.

If you suffer regularly from reflux symptoms more than twice a week and find that these interfere with your life, you should think about consulting your doctor. The good news is that medication is available to provide freedom from these symptoms.



How can GERD affect your life?


The pain and discomfort caused by heartburn and other symptoms of GERD can have a considerable effect on your daily life and interfere with:

• manual work, housework, gardening and sport, because acid reflux symptoms are often worse during physical activity
  
• social occasions (such as eating with family and friends), because acid reflux symptoms are often worse during and after meals
  
• sleep, because acid reflux symptoms are often worse when lying down
  
• work, because acid reflux symptoms disturb sleep and cause tiredness the following day.
  

GERD symptoms may cause sleep disturbance

If you feel that your acid reflux symptoms are severely restricting your life, you should consult your doctor. Medication is available that can help to return your life to normal by providing freedom from these symptoms.



What is esophagitis?


Over time, refluxed acid may damage the lining of the esophagus, leading to a condition called esophagitis. Esophagitis is an inflammation of the lining of the lower end of the esophagus.

• In most people, esophagitis is caused by the digestive juices in the stomach repeatedly moving upwards into the lower esophagus.
  
  
  
• In severe cases, the lining of the esophagus may become ulcerated, leading to pain and possible narrowing due to scarring. This may lead to difficulty in swallowing (a condition called dysphagia), first of solid foods and then even of more liquid foods.
  
• Doctors know that approximately half of their patients who have gastroesophageal reflux disease (or GERD) also have esophagitis.
  

It is not possible to tell whether or not you have esophagitis from the frequency or severity of your acid reflux symptoms. You may suffer from severe heartburn every day and not have esophagitis, whereas someone with milder heartburn that occurs two or three times a week may have esophagitis.

If your doctor is concerned that you may have esophagitis, you are likely to be given an endoscopy to see whether or not this is the case (see What is an endoscopy?). The medications used in the treatment of esophagitis are the same as those recommended when esophagitis is not present.



Can GERD lead to more serious problems?


For most people with gastroesophageal reflux disease (or GERD), the main problem is the symptoms that may result in a poor quality of life and decreased productivity with regard to work and social activities.

• Acid reflux can, over time, cause the inflammation and damage to the esophagus that is called esophagitis.
  
• In severe cases, the lining of the esophagus may become ulcerated, leading to pain and possible narrowing due to scarring. This may result in difficulty in swallowing (a condition called dysphagia), first of solid foods and then even more liquid foods.
  
• Esophagitis may also result in bleeding from the esophagus. If you experience red or black faeces (blood in your stools when you go to the toilet), cough up blood, or suffer from anaemia, you should speak to your doctor.
  
• Severe, long-standing GERD can cause a condition known as Barrett’s esophagus, where the normal lining of the esophagus is replaced by a lining more like that of the stomach or intestine. It is thought that this replacement may be an attempt by the body to protect itself from further injury by acid.
  
  
  
• Untreated GERD may also increase the risk of more serious complications, such as esophageal cancer, in a small number of people.
  

It is therefore important that you do not ignore your acid reflux symptoms and that you seek treatment by consulting your doctor about them.

How is GERD diagnosed?


Your doctor will diagnose gastroesophageal reflux disease (GERD) by asking about your acid reflux symptoms and when they occur – for example, whether heartburn is provoked by eating, drinking or physical activity. You may find it useful to keep a diary of your symptoms to help you remember. You may also like to complete the GERD Impact Scale Questionnaire, which asks questions about your reflux symptoms and their impact on your daily life. You can then take this to show your doctor.





[url=javascript:openQ();]

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[url=javascript:openQ();]Click here to complete the interactive GERD Impact Scale questionnaire.[/url]

You can also use the PDF version


In a few cases, your doctor may arrange for further investigations, such as an endoscopy, (see What is an endoscopy?), to discover whether the lining of the esophagus is affected and you have reflux esophagitis. However, the medications used in the treatment of esophagitis are the same as those recommended when esophagitis is not present.



What is an endoscopy?


During an endoscopy, a narrow, flexible tube with a fibre-optic light and camera at the end, is placed into the mouth, then the throat and esophagus (the upper part of the digestive system). This allows the doctor to see the inside of the esophagus to look for any reddening or sores on the esophageal wall. It is also possible to take a small sample (a biopsy) to check for any abnormalities.



The procedure may be uncomfortable but is not generally painful. You should not need to stay in hospital or the clinic overnight, but you may need someone else to drive you home.



How is GERD treated?


Fortunately, heartburn and gastroesophageal reflux disease (GERD) can be treated by making the stomach contents less acid. This reduces the discomfort caused by refluxed acid and enables the lining of the esophagus to heal. Drug treatment is often only needed for a short time period, although it usually needs to be represcribed.

Your doctor is likely to prescribe one of the two main types of prescription medications that are available for the treatment of GERD:

1. Proton pump inhibitors (PPIs).
Proton pump inhibitors are a group of medicines that includes esomeprazole, lansoprazole, omeprazole, pantoprazole and rabeprazole.

• Proton pump inhibitors provide rapid relief from heartburn and the other symptoms of GERD and are highly effective in healing esophagitis.
  
• These medicines block the action of the stomach’s proton pumps, which are located in parietal cells in the stomach walls (Figure 1). The proton pumps pump hydrogen ions into the stomach, making the stomach acidic.
  
  
  
  
  Figure 1. The proton pump
  
• By blocking the proton pump, proton pump inhibitors reduce the acidity in the stomach. They therefore reduce the acidity of the stomach contents leaking back into the esophagus, which reduces the incidence of heartburn and other acid reflux symptoms.
  
• Proton pump inhibitors are available from your doctor on prescription and, in some countries, can also be bought over the counter from a pharmacist.
  
  
  
  
  Figure 2. Proton pump inhibitors block the final step of acid production in the stomach
  

2. H2 antagonists
Histamine2 (H2)-receptor antagonists are a group of drugs that includes cimetidine, nizatidine and ranitidine.

• These medicines work by stopping (blocking) the action of histamine (a chemical released by the stomach). The presence of histamine in the stomach results in the release of hydrogen ions, which makes the stomach more acidic.
  
• H2-receptor antagonists only partially block acid production in the stomach and are therefore less effective than PPIs in reflux disease.
  
• Many H2 antagonists can be bought over the counter at low doses, but a doctor’s prescription is needed for higher doses.
  

Other medicines (called pro-kinetic agents) increase the movement of the stomach. They work by increasing the pressure of the lower esophageal sphincter (the point where the esophagus joins the stomach) and promote emptying of the stomach.

Antacids and alginates
There are a number of over-the-counter preparations, such as antacids or antacid-alginates, which can be taken to relieve occasional heartburn. These remedies, however, do not reduce acidity in the stomach sufficiently to help the lining of the esophagus to heal and are not usually recommended to treat the frequent heartburn suffered by people with GERD.

Antacids provide relief from heartburn by neutralising the acid in the stomach. Their main ingredients are:

• Aluminium hydroxide
  
• Magnesium salts
  
• Calcium carbonate
  
• Sodium bicarbonate
  
• Potassium bicarbonate
  
• Bismuth salts
  

Antacids sold over the counter may contain one or a combination of these products. For example, aluminium and magnesium salts are often combined to reduce the incidence of diarrhoea or constipation.

Antacids are best taken when the symptoms of heartburn first occur, preferably about 1 hour after a meal. However, antacids may interfere with the absorption of other medicines from the digestive system into the blood, so a gap of at least 2 hours should be left between using an antacid and taking other medicines.

Some antacids contain sodium alginate. Sodium alginate forms a ‘raft’ that floats to the top of the stomach, forming a barrier between the acid and the esophagus, thus preventing acid reflux into the esophagus.



What can you do to help to reduce your GERD symptoms?


If you have heartburn or other symptoms of gastroesophageal reflux disease (GERD), you should consult your doctor. You should describe your symptoms, explain how troublesome you find them to be, and how they affect your daily life. Your doctor can then confirm the diagnosis and provide you with a treatment plan.

Avoiding factors that make acid reflux worse may help to reduce the symptoms of GERD, but this is not an alternative to treatment:

• You may find it useful to keep a diary of your symptoms and the food you eat, so that you can see which foods affect you. Avoiding caffeine, alcohol, hot spicy food and fatty or fried food may reduce the occurrence of heartburn.
  

Your symptoms may be provoked by particular foods

• Avoid eating too close to bedtime (try to leave at least 2–3 hours before you go to bed)
  
• Avoid lying down after meals
  
• Eat small, regular meals
  
• Avoid tight clothing that places pressure on your stomach
  
• Lose weight, if necessary
  
• Give up smoking
  
• Raising the head of the bed by 20 cm (4–6 inches) may help to reduce night-time reflux.
  
  
  

What if you are not happy with the treatment you have been prescribed?


Some people find that the medicine their doctor has prescribed is not effective in stopping their heartburn. If you are currently taking a prescription medication for your heartburn, and you can answer ‘yes’ to either of the following questions, you should go and talk to your doctor.

• Do you still experience acid reflux symptoms, despite taking your medicine as instructed?
  
• In addition to your prescription medication, do you need to take non-prescription remedies for the relief of heartburn or other acid reflux symptoms?
  

If you are taking an H2-receptor antagonist, you could be given a proton pump inhibitor (PPI). If you are currently taking a PPI, you could switch to a different PPI – several PPIs are available, which differ in how effective they are. By sharing your concerns with your doctor, you can work together to identify the treatment that is the most effective for you.


Is surgery the answer for GERD?


Surgery, using a procedure known as ’fundoplication’, is an appropriate choice for a small number of patients with gastroesophageal reflux disease (GERD).

Fundoplication was originally done as open surgery, which involved making an incision into the abdomen under general anaesthesia. However, fundoplication has become much more popular since the development of laparoscopic techniques (also known as minimally invasive or keyhole surgery), which offer faster recovery and fewer complications. While the vast majority of patients will be deemed suitable for laparoscopic surgery, a few will not, such as those who have had previous abdominal surgery, or individuals with certain other medical conditions.

How fundoplication works
In fundoplication, the surgeon creates a new ’valve’ between the esophagus and the stomach by wrapping the upper portion of the stomach around the lowest portion of the esophagus. As the stomach becomes distended after eating, the wrap compresses the esophagus, preventing stomach acid from escaping. If the patient has other problems – for instance, a hiatal hernia, a swallowing disorder, or a shortened esophagus – these may also be corrected during surgery.

Fundoplication is a relatively safe operation
The most common complication of fundoplication is perforation of the stomach or esophagus, which occurs in around 1 in 100 patients. Rarely, perforation or bleeding will be missed during the procedure and the patient will have to undergo a second operation. In addition, around 5% of patients will start off being treated laparoscopically but will then be converted to open surgery.

Surgery versus drugs
Fundoplication has become an increasingly popular treatment for GERD. Exponents of surgery believe that it removes the need for drug therapy and reduces the risk of esophageal cancer. Indeed, a study conducted in the late 1980s initially appeared to confirm the superiority of surgery over drug therapy for controlling the signs and symptoms of GERD. However, 10 years on, the researchers revisited the study participants and were surprised to discover that almost two-thirds of the surgery patients still needed medication to control their symptoms. In addition, patients who had undergone surgery a decade previously were just as likely to have developed esophageal cancer as those who only received medication.

A controversial issue
On the basis of their findings, and from weighing up the relative risks, benefits, and financial costs of surgery and drug therapy, the researchers concluded: “Long-term medical therapy with proton pump inhibitors is the preferred strategy for patients with GERD and severe esophagitis.” Most experts agree that there are some patients in whom surgery may be preferable to drugs – for instance, individuals who are unable to tolerate proton pump inhibitors due to side effects, patients who develop additional symptoms such as cough, chest pain, or hoarseness, or those who completely respond to drug therapy but relapse with symptoms when medication is withdrawn. But, with the advent of more effective and better-tolerated drugs, the advantages of surgery appear to be less clear-cut for the majority of patients with GERD.

Discuss your treatment options
If you are diagnosed with GERD, you should discuss your treatment options carefully with your doctor, and be aware that drugs and surgery each have advantages and disadvantages. As Dr. Stuart Spechler, who undertook the study described above, advised: "Patients who are going to have an operation should consider very carefully their reasons for having the surgery. If they believe that surgery will allow them to never again take medicine for the treatment of reflux disease, or that they are preventing a cancer of the esophagus, this study does not support either of these contentions."


Can dysphagia be helped by surgery?


Over time, untreated gastroesophageal reflux disease (GERD) may cause dysphagia or difficulty in swallowing. In most cases, treatment with an effective medicine for GERD can resolve this problem. However, in some cases, dysphagia may be due to esophageal stricture or narrowing of the esophagus.

Esophageal stricture may occur when there is repeated inflammatory injury to the esophagus, and healing, re-injury and rehealing due to persistent untreated esophagits. The resulting build up of scar tissue narrows the opening of the esophagus, causing problems with swallowing. There are a number of procedures that may be carried out to widen a narrow esophagus.

• Guided wire – Dilators are passed over a thin wire, which is positioned in the narrowed tube.
  
• Balloons – Long, narrow balloons can be passed into the esophagus and then gently inflated to open up the narrowed tube.
  
• Bougie – A series of increasingly larger, soft rubber or plastic dilators are placed over the narrow part of the esophagus, gently widening the tube.
  

Patients with swallowing difficulties will normally obtain complete relief after one of these procedures. During, or after the procedure you may experience a small amount of bleeding from the esophagus. Complications from the procedure, such as excessive bleeding due to damage to the esophagus, are rare.