Heartburn / Reflux
What is heartburn / reflux?
What causes heartburn / reflux?
Heartburn / reflux is actually a symptom of a condition called ‘gastro-oesophageal reflux disease’ (GORD). GORD occurs when the mechanisms designed to keep acid and bile from refluxing back into the oesophagus do not function properly. This usually involves a problem with the lower oesophageal sphincter (LOS) which is the muscle at the bottom of the oesophagus that controls what leaves and enters the lower oesophagus. If there is a mechanical, neuromuscular or hormonal change that impairs the LOS function, reflux can occur. Also, there are conditions in which an excess of acid production or pressure from the abdomen can overwhelm the LOS and acid/bile can flow backwards into the oesophagus.
Some of the well described causes of LOS dysfunction are:
– Hiatal hernia (part of the stomach slides into the chest)
– Pregnancy (progesterone decreases LOS tone and the growing foetus pushes the stomach up)
– Smoking (nicotine relaxes the LOS)
– Medications (e.g. some blood pressure medications stop the LOS form closing properly)
Causes of increased acid production/increased intra-abdominal pressure:
– H. pylori (bacteria that lives in the stomach)
– Obesity (increased pressure on the stomach)
– Altered digestive anatomy from surgery
– Acid producing foods (see list in treatment section)
– Pancreatic tumour – Zollinger-Ellison Syndrome
What are the symptoms and complications of heartburn / reflux?
– a burning feeling in the chest
– a bitter / acidic taste
The symptoms are often worse after meals and when lying down (often at night).
Interestingly, only about half of people with reflux have these classic symptoms. Others experience no symptoms at all (silent reflux) or have atypical symptoms such as:
-Chronic cough
-Nausea +/- vomiting
-Trouble swallowing
-Recurrent sinusitis and middle ear infections
Untreated reflux can lead to complications that include:
(i) a peptic stricture (narrowing) of the distal oesophagus due to inflammation and scar tissue. This typically presents with difficulty swallowing
(ii) severe inflammation leading to oesophageal ulcers and bleeding
(iiI) Barrett’s Oesophagus – this is a pre-cancer condition where the delicate lining of the oesophagus undergoes cellular changes.
(iv) Oesophageal cancer – this is usually preceded by a change in the lining of the oesophagus (Barrett’s). It also presents with progressive difficulties in swallowing.
How do you diagnose reflux / heartburn?
(i) A presumptive diagnosis of gastro-oesophageal reflux disease (GORD) can be made based on clinical assessment and a careful review of symptoms. If no ‘alarm symptoms’ are present, trial of dietary intervention or an acid-suppressing medication can also help support a diagnosis if an improvement in symptoms is seen.
However, if there are “alarm symptoms” or symptoms that do not resolve with simple treatment, testing may be indicated. The alarming symptoms are:
– Trouble swallowing
– Nausea / vomiting
– Vomiting blood
– Loss of appetite
– Unexplained / unintentional weight loss
– Recurrent fever/chills
– Night sweats (your entire pillow is soaked with sweat in the morning)
– Anaemia on blood tests
(ii) Gastroscopy: If symptoms are not responding to acid suppressing treatment, they are best investigated with a gastroscopy. During this procedure a thin flexible camera is inserted through the mouth and into the oesophagus and stomach. It provides a detailed look at the upper digestive tract in order to look for any structural abnormalities, to confirm the diagnosis of acid reflux and to screen for reflux complications. Sedation is given and the procedure takes approximately 5 mins.
(iii) Manometry: This test looks at how well the oesophageal muscles and the lower oesophageal sphincter (LOS) are functioning. A probe with pressure sensors is inserted through the nose and into the oesophagus which then records the effectiveness of multiple swallows. This test can be useful in exploring the underlying cause of reflux (e.g. LOS dysfunction) and in troubleshooting difficult to treat reflux.
(iv) pH testing: This test measures the amount of acid or bile that is coming into the oesophagus over a 24hr period. Symptoms are recorded by pressing a button during the study and are then correlated with the oesophageal recordings to determine the underlying problem. This test can be help diagnose patients with atypical GORD symptoms and can help determine the effectiveness of treatment (i.e. are the anti-acids really working). This test can also be used to determine if it is safe to get patients off reflux medications.
All of these tests are available at Gastro IQ.
How is heartburn / reflux treated?
There are multiple treatment options for reflux / heartburn. The first step for all patients should include dietary and lifestyle modification.
1. Dietary – Because there are many foods that can exacerbate heartburn symptoms, having a dietitian specialized in digestive diseases is vital to control of heartburn symptoms. This can help alleviate symptoms and avoid the need for long term medications. A dietary approach is complex, however common food offenders include: alcohol, caffeine, peppermint and sugar-free gum, chocolate, as well as spicy, acidic and fatty foods.
2. Lifestyle factors:
(i) Stress also plays a role in heartburn / reflux and is known to cause an increase in acid production. Meditation, yoga and mindfulness are all strategies that are used to reduce the influence of stress and does decrease reflux symptoms for some patients.
(ii) For people who suffer with heartburn/reflux at night, avoidance of eating late (within 3 hours of going to bed) is recommended. Also, raising the head of the bed (add an extra pillow of or 2) can be helpful in reducing night time reflux.
(iii) Weight management. Decreasing overall weight as well as abdominal fat will also help reduce heartburn / reflux by reducing abdominal pressure. There are many options including diet / exercise programs, pharmacological therapies as well as minimally invasive procedures performed during a gastroscopy (e.g. Orbera balloon and ESG) that are available at Gastro IQ.
3. Medications: There are both over-the-counter (OTC) as well as prescription medications that can be used to treat heartburn / reflux. These include:
(i) Neutralizing Antacids – e.g. mylanta, quikeze and gaviscon. These work within minutes by neutralizing stomach acid but provide only short-term relief. All of these medications are available over the counter.
(ii) Anti-histamine medications (H2): Histamine is part of the acid production pathway in the stomach. Shutting down this pathway will reduce acid produced in the stomach. Nizatidine is an example of a commonly used medication in this group..
iii) Proton pump inhibitors (PPI): These are the most potent medications in the treatment of GORD. They work by blocking the secretion of acid by the acid producing pumps in the stomach. Nexium, Somac, and Losec are examples of PPIs. These medications are prescription medications.
(iii) Pro-motility agents: These medications stimulate the stomach to contract and push the acid down from the stomach into the intestines, thus reducing the risk of reflux into the oesophagus. Domperidone and Prucalopride are examples of pro-motility agents. These are prescription medications.
4. Surgery – called a Nissen fundoplication is a procedure performed to tighten the junction between the oesophagus and stomach. While an appealing option to many people, a significant proportion of surgical patients still need to take prescription anti-acids every day to control their heartburn. Post-operative complications can also occur that include swallowing difficulties, ongoing reflux and chronic ulcers at the surgery site. In general surgery for reflux is reserved when there is a large hiatus hernia present and all lifestyle and medication options have been exhausted.
1) Nicholas J. Shaheen , MD, MPH, FACG1 , Gary W. Falk , MD, MS, FACG 2 , Prasad G. Iyer , MD, MSc, FACG 3 and Lauren B. Gerson , MD, MSc, FACG4 ACG Clinical Guideline: Diagnosis and Management of Barrett’s Esophagus American Journal of GASTROENTEROLOGY VOLUME 111 | JANUARY 2016