• Heartburn
• Symptoms
• Tests
• Diet and lifestyle
• Medication
• NO better on tablets
• Surgery
• Long-term problems

An area of ulceration at the junction between the oesophagus and the stomach

Heartburn is the symptom of “burning discomfort” behind the “breastbone”.

• Heartburn results from acid in the oesophagus.
  • The stomach is designed to handle acid but the oesophagus has a different lining and is more sensitive to the effects of acid.
  • This sensitivity to acid varies significantly from person to person.
    
• The basic abnormality is weakness of the valve between the oesophagus and the stomach.
  • This "valve" is designed to allow food into the stomach but to prevent acid and food refluxing back into the oesophagus.
  • Weakness of the valve (sphincter) does not improve over time;
    • in fact - may tend to weaken further over the years.
  • This “valve” function is adversely affected by a hiatus hernia.
    • A hiatus hernia is when the top part of the stomach is sitting up in the chest instead of being below the diaphragm.
    • This causes the valve to be working at a disadvantage (not as effective for reasons that are not entirely clear).
      
• Reflux may be aggravated by
  • fatty foods; spicy foods
  • alcohol
  • smoking
  • chocolate
  • peppermint
  • caffeine
    
• Some drugs can aggravate reflux;
  • Asthma treatments.
  • Anti-inflammatory drugs.
  • Calcium channel antagonists - given for high blood pressure.
    
• Stress does not cause reflux but can make the symptoms more distressing.

Symptoms

• Acid reflux becomes more common after the age of 40 years.
  • This may be because of gradually weakening of the “valve”.
  • Weight gain is common in the middle years (particularly around the waist which may increase the pressure on the stomach).
  • Even modest weight gain can lead to new symptoms in susceptible people.
  • Once heartburn becomes a troublesome symptom for a given individual it may wax and wane in intensity but spontaneous remission is uncommon.


• Heartburn is very common.
  • 35% of the population have heartburn more once per month.
  • 7% have daily episodes.


• The typical symptoms are;
  • Heartburn
    • a burning sensation behind the breastbone.
    • This commonly occurs 1-2 hours after a meal (particularly larger fatty meal).
  • Regurgitation
    • The easy flow of stomach contents (acid and food) into the back of the throat.
    • This is different from vomiting
    • There may be a sour or bitter taste in the mouth<
  • Belching
    • Not all belching is associated with reflux - this can be due to air swallowing.
    • Excess belching can be due to excess fermentation in the upper small bowel - excess fibre should be avoided.


• Less common symptoms (not "typical")
  • Hoarseness, sore throat, repetitive throat clearing, cough, choking sensations.
    • These symptoms can be caused or aggravated by reflux but there are many other causes and review by an ENT specialist is usually required.
    • Acid reflux is often blamed for many throat problems but the response to acid lowering treatment is often disappointing.
    • If there are no symptoms of heartburn or acid regurgitation then it is unlikely that acid reducing treatment will have any effect./li>
    • pH studies (see below) can often help sort out whether acid reflux is involved.
  • Asthma
    • Reflux is common in asthmatics.
    • However, the response to acid lowering treatment (in terms of improved asthma control) is usually modest.
  • Sometimes reflux is the underlying cause of chest pain.
    • The term "chest pain" means a more generalised chest discomfort or pain rather than just behind the breastbone.
    • Initial investigations may have focused on the heart.
    • If these tests are normal the term "non-cardiac chest pain" is used.
    • In this setting acid reflux is the explanation for the pain about half the time.
    • If there is no response to treatment to reduce acid then a drug called amitriptyline can work - the theory is there is hypersensitivity of some structures in the chest
    • Often oesophageal pH monitoring is required (see below).


• Any symptoms of difficulty swallowing, pain on swallowing or weight loss needs further assessment by gastroscopy without delay.

• Gastroscopy is the most important test.
  
  • Gastroscopy is best performed before starting treatments such as Losec or Somac.
    • There is however, some value from the test at any stage during treatment.
  • The presence of ulceration at gastroscopy (called reflux oesophagitis - see picture above) suggests more severe disease.
    • 50% of people with symptoms suggestive of reflux will have a normal endoscopy.
    • Troublesome symptoms can occur even if the gastroscopy is normal.
  • Finding a hiatus hernia.
    • Larger hiatus hernias are associated with more severe disease.
    • Small hiatus hernias are of less importance.
    • The appearance can vary from one examination to another (a sliding hiatus hernia – variable size).
  • If the gastroscopy is normal then a diagnosis of acid reflux can be made if there is;
    • A suggestive history of heartburn,
    • and a good response to treatment
  • An important potential finding at gastroscopy is Barretts oesophagus (see below).


• Oesophageal pH monitoring is an investigation that may help resolve some uncertainty about the diagnosis.
  • This test is a direct measure of the amount of exposure of the oesophagus to acid over a 24-hour period.
    • It involves passing a thin catheter through the nose into the oesophagus. This is secured in place and connected to a recording device.
    • At the completion of the test the pH recordings are downloaded on to a computer and a graph of pH over the day is produced.
  • The procedure allows for the correlation of chest pain / heartburn or other symptom with oesophageal acid exposure.
  • This test requires an initial specialist consultation.
  • It is available at the Mercy Specialist Centre, Epsom, Auckland (09 6301838).

• Life-style changes are important.
  • This approach tends to be ignored now that we have very effective medications but I think this is a mistake.
  • The presence of heartburn is a sign that the body is not “enjoying” the current eating pattern or other aggravating factors.
  • Smoking should be stopped.
    • Unfortunately if there is weight gain after stopping smoking this may aggravate reflux.
  • Weight reduction is crucial.
  • Elevation of head of the bed is not helpful (and not well tolerated) for most people.
  • Treatment of constipation can help reflux.


• Dietary changes.
  • Reduce intake of fatty foods and reduce the volume/size of meals.
  • Reduce alcohol, spicy foods, carbonated drinks, coffee, chocolate, peppermint.
    • citrus juice, and spicy foods (chilli) directly stimulate nerve endings in the oesophagus.
    • Coffee and Coke are  'sensitisers' for the oesophagus (and rest of gut!)./li>
    • Alcohol, peppermint - relax the lower oesophageal sphincter.
    • Fatty foods stimulate more acid secretion.
    • Curry stimulates acid secretion.
  • Avoid eating late at night or night-time / pre-bed snacks.
  • If excess belching - decrease increase of fibre.
    

• Antacids
  • Are relatively weak compared to medications described below.
  • They can briefly neutralise gastric acid.
    • The effect may only last for 30 -60 ins.
  • Gaviscon and Mylanta are simple and convenient treatments and can be tried first for infrequent mild symptoms.

• H2-antagonists such as ranitidine (Zantac) and famotidine (Pepcidine).
  • They are effective for mild symptoms.
  • They are often the best choice for “as required” treatment.
    • There is rapid onset of relief (within 30mins.
    • The effect tends to weaken with regular use.
    • Therefore intermittent treatment "gets the best out the drug".
  • The dose available in “over-the-counter” preparations is relatively small.
    • Therefore less effective than a prescription for the same medication.
  • I favour famotidine at a dose of 40mg (only available on prescription at this dose).
    • This can be taken up to three times daily if required (see below),
    • but better taken on an intermittent basis (as discussed above).


• Proton pump inhibitors.
  • Proton pump inhibitors (PPI) such as Losec and Somac are very effective in control of gastric acid secretion over the 24-hour period.
    • They have become the mainstay of treatment of reflux.
    • A single morning dose is usually sufficient but 1/3 of people will need a second dose before the evening meal.
  • Remember that Losec and Somac are most effective if given 30mins prior to meals.
    • This means that the optimal dosing is 30mins before breakfast and then 30mins before dinner.
    • The commonest error is to take the evening dose last thing at night.
    • Absorption is not as good when taken with (or after) the meal.
    • It is more effective to split the dose (e.g Losec 20mg twice daily) than to take 40mg in the morning.
    • A small proportion of people (<20%) are able to get a good effect from lower doses.
      • e.g Losec 10mg daily or 20mg every 2nd day.
  • These tablets should be taken long-term if significant oesophagitis(ulceration) was observed at endoscopy.
  • There is increasing confidence that Losec and Somac are safe during pregnancy.
    • A large number of pregnancies have been reviewed.
    • There is no increase in risk of birth defects.
    • Losec does cross the placenta more than Somac (therefore theoretical advantage for Somac).

• If you have daily symptoms of heartburn then regular daily medication is required for adequate relief of symptoms.


• If the symptoms are less frequent then many people can have intermittent treatment.
  • This may be using Losec or Somac.
  • Another option is to accept the less powerful treatment with H2-antagonists (Zantac or Pepcid) and concentrate on lifestyle modifications.
    • These tablets are best designed for "as required" use.
    • They have the advantage of rapid onset of action (much faster than Losec or Somac).
  • The long-term goals should be to:
    • lose weight.
    • eat a better diet with lower fat content.
    • stop smoking.
    • moderate alcohol consumption.
  • This must also be good for overall health and lead to reduced risk of heart disease.
  • If some success is achieved with above life-style changes then reduction in dose or stopping medication may be possible.
  • Otherwise it is usual to have the same symptoms again within a few days of stopping medication.
    • Sometimes long-term treatment in younger people is accepted when more intermittent treatment might work.
    • There can be an apparent increase in symptoms during the first week after stopping regular medication.
    • This may be due to an increase in sensitivity of the oesophagus while on effective treatment or perhaps a temporary rebound in acid secretion.
  • There has been a dramatic increase in the use of Losec and Somac.
    • Some of this relates to appropriate use but many people are better to concentrate on life-style changes rather than to rely on medication.


• Is long-term treatment safe?
  • The main safety concerns with proton pump inhibitors have been the theoretical concerns about long-term reduction in acid secretion.
    • or put another way - why do we need acid?
  • Several studies of long-term treatment (now over 25 years) have now been reported which allay any fears.
  • Digestion is not affected by the suppression of normal acid secretion.
    • Surprisingly acid is not essential for the normal digestion of food.
    • There may be a marginally lower level of vitamin B12 - this is not relevant.
  • Drug interactions can occur with Losec - particularly with Warfarin.


• Suddenly stopping the medication can lead to a rebound of high acid secretion and more severe symptoms for up to a week.
  • This is not usually a problem but can be a reason why some people don't manage to get off the treatment when they really could manage without.

• About 1/3 rd of people with symptoms suggestive of reflux to do not respond to the usual dose of Losec or Somac.
  • This may be may be due to inadequate control of acid.
    • An increased dose could be effective.
  • Some people simply do not respond to Losec or Somac at any dose.
    • Sometimes a switch to a different type of treatment is successful (i.e famotidine 40mg three time daily).
  • The other option is to combine treatments.
    • i.e Losec 20mg before breakfast and dinner and famotidine 40mg at bedtime and midday if necessary.


• The symptoms could be due to another problem and not due to heartburn (from acid reflux).
  • The diagnosis may need to be reviewed and specialist advice is usually required.
  • The symptoms may be due to irritable bowel syndrome or a motility disorder or stress could be playing a major role.
  • A sensation of a "burning mouth" or a lump in the throat are not usually caused by acid reflux.
  • Some people have chest pain that is not due to heart problems or due to acid reflux.
    • The reason for this type of pain may be unknown.
  • Some chest pain can be part of a generalised musculoskeletal sensitivity called "fibromyalgia" - characterised by multiple trigger points.


• Sometimes the symptoms are due to a “sensitive oesophagus”.
  • There is acid reflux but it is relatively mild.
    • However, because of the sensitivity of the oesophagus, it doesn’t take much acid exposure to cause troublesome symptoms.
  • This can be a difficult problem to manage.
  • It has some overlap with irritable bowel syndrome.
  • Sometimes the addition of amitriptyline at night is helpful.

• Anti-reflux surgery (laparoscopic fundoplication) is an option for the people who have symptoms well-controlled on Losec or Somac who do not wish to take long-term medication.
  • If the reflux symptoms have not responded to Losec or Somac then careful evaluation by a gastroenterologist is required before considering an operation.
  • Oesophageal pH monitoring is an important part of the investigations before an operation is considered.


• There are some potential problems with the operation.
  • The operation may aggravate bloating and flatulence and cause an inability to belch.
    • For most people this is a minor problem but for some (1/4) it is a significant disadvantage of this operation.
    • Problems with bloating are worse in women and particularly if there has been some problems prior to the operation.
    • Irritable bowel symptoms may also be a risk factor for having troublesome bloating after an operation for reflux.
  • Difficulty swallowing.
    • This is common over first 3-6 months but resolves in majority.
    • Perhaps 1-2% continue to have troublesome problems with swallowing and need to have the operation revised or completely reversed.
  • Diarrhoea is a rare side-effect.


• The outcome of surgery.
  • This is good for 85%, average for 10%.
  • 5% are concerned enough about the adverse effects to be unhappy or ambivalent about outcome.
• The proportion of people who come off treatment in the long-term is variable in different reports.
  • Overall it seems that at least 30% (maybe up to 50%) of people continue treatment with Losec or Somac after the operation.
  • This means that there may be some disappointment if one of goals of surgery was to "come off the medications".
• Safety issues.
  • The operation is comparatively safe however any operation and anaesthetic has a risk.
  • Reports suggest 1 death in 500-1000 operations.
  • About 5% will have some complication during the recovery period.
  • 2-3% will need a re-operation.

Barrets oesophagus is a change in the lining of the oesophagus - now a darker orange colour - this is more unstable and there a small but definite risk of changing to cancer of the oesophagus


A stricture or narrowiing of the oeophagus from scar tissue. This can be the result of long-standing ulcers


Barium swallow of a stricture

Barrett’s oesophagus

• This is a change in the lining of the oesophagus which results from long-standing reflux.
  • This change can occur with relatively mild symptoms.
  • Barrett's oesophagus often reduces the sensitivity of the oesophagus to acid leading to less heartburn.

• • Careful specialist follow-up is required.
  • Repeat gastroscopy at a regular interval will usually be recommended.
  • The risk is greater for men and if there are more extensive changes in the oesophagus.
    • Being significantly overweight and smoking increases the risk.
    • Smoking and heavy alcohol intake are also risk factors for getting cancer of the oesophagus.
  • Multiple biopsies are taken from the oesophagus to check for a change called dysplasia.
    • This finding implies some instability of the lining of the oesophagus and an increased likelihood of progressing to cancer of the oesophagus.
    • If the changes are called "high grade" then surgery may be recommended to prevent the possible progression to oesophageal cancer.
    • Other endoscopic techniques are being investigated.
  • Long term treatment with Losec (or similar medication) will be recommended but this is not enough to prevent possible progression to cancer.
  • If you have any problems with swallowing then urgent gastroscopy is required.

Oesophageal stricture

• This is a narrowing in the oesophagus as the result of inflammation, ulceration and eventually scarring in the oesophagus – all due to acid reflux.


• This leads to difficulty swallowing.
  • Treatment with Losec or Somac will improve the symptoms.
  • Often a dilatation of the oesophagus is required (performed at the same time as a gastroscopy).
  • Sometimes more than one dilatation is required.

Lump in the throat sensation

• Having a lump in the throat sensation is normal with an intense emotional experience.


• Having a persistent sensation of a lump is also common.
  • Up to 15% of people in survey stated that they had experienced this symptom in the last year
  • The medical term is "globus".


• The cause is unknown.
  • However, there is clearly an association with stressful life events.
  • No abnormality of the throat or oesophagus can be shown.
  • The "globus" is often better with swallowing.
    • i.e this symptom is NOT related to blockage of the oesophagus
  • There is no treatment but it always settles (eventually!).
  • A gastroscopy examination will provide reassurance.