Heartburn: More than just a nuisance
According to the American Gastroenterological Association, one in three adults experience occasional heartburn, most after eating a large meal or rich, fatty, or spicy foods. Citrus fruits and juices, alcohol, and caffeine-containing drinks can also trigger symptoms.
As anyone who has ever experienced heartburn will know, it is more than just a nuisance. It can interfere with sleep, cause pain or vomiting, force sufferers to avoid certain foods and drinks, prevent participation in physical and leisure activities, and generally have a detrimental effect on quality of life and overall wellbeing.
Simple lifestyle changes can help
Fortunately, simple lifestyle modifications can be helpful in people who suffer only mild or occasional heartburn. Measures such as avoiding foods and drinks that produce symptoms, losing weight, and avoiding lying down soon after eating are also likely to be beneficial. Some simple steps you can take to alleviate heartburn are summarised below. Over-the-counter drugs such as antacids can be helpful too, and should be taken after meals or when symptoms occur.
Lifestyle changes
Avoid factors that make acid reflux worse – for instance:
- Large meals
- Spicy, fatty, or fried foods
- Mint products (ie, peppermint, spearmint)
- Carbonated drinks
- Citrus fruits or juices
- Tomato sauce, ketchup, mustard, vinegar
- Aspirin and most pain medicines (other than acetaminophen)
- Caffeine (remember that tea and chocolate contain caffeine)
- Smoking
- Tight clothes that put pressure on the stomach
- Being overweight
Other things you can do:
- Elevate the head of your bed by 4–6 inches (simply using more pillows is not adequate)
- Keep a diary of your symptoms to help identify “triggers”
- If you are taking medications for any other conditions, check with your doctor that they won’t interact with your GERD medications or make your heartburn worse
- Take all medications prescribed by your doctor, even if you feel better
Heartburn may indicate more serious disease
When heartburn is more severe or occurs more often – daily or several times a week – this indicates the presence of GERD, a serious medical condition that warrants treatment by a qualified physician. GERD, or acid reflux, is a recurrent condition where digestive juices travel up from the stomach towards the mouth via the oesophagus, the “swallowing tube” more commonly known as the gullet. These stomach juices are highly acidic and irritate the delicate lining of the oesophagus, with a multitude of serious medical consequences.
Importance of treating GERD
As mentioned above, heartburn is the most common symptom of GERD, but the other major complication is inflammation of the oesophagus, known as oesophagitis. This occurs when the lining of the oesophagus is repeatedly exposed to stomach acid, resulting in bleeding and ulceration. In addition, the lower part of the oesophagus, nearest the stomach, may become narrow and make it hard to swallow.
In more severe cases, this narrowing is associated with changes in the cells that line the gullet and is known as Barrett’s oesophagus. Lung problems may also develop when acid reflux causes stomach juices to overflow into the airways. This usually occurs at night when the person is lying down and can cause wheezing, asthma, bronchitis, pneumonia.
Not all GERD sufferers have heartburn
Since heartburn is a common symptom of GERD, and GERD causes damage to the oesophagus, it seems reasonable to assume that the more severe the heartburn, the more severe the oesophageal damage. But is this true? Recently, American scientists published the results of a study that examined this very question and showed, conclusively, that the answer is “no”. The researchers examined data from five large clinical trials involving almost 12,000 men and women with GERD. All patients had their symptoms thoroughly assessed and underwent a procedure called endoscopy to confirm the presence or absence of oesophagitis.
Elderly patients least likely to have heartburn
The researchers found that many patients who reported suffering from severe heartburn did not show any signs of damage to the esophagus. More worryingly, many patients who never or rarely suffered from heartburn had serious damage to the gullet, including ulceration, bleeding, and Barrett’s oesophagus. Elderly patients were particularly likely to have serious disease while reporting little or no heartburn.
John de Castecker, a specialist in GERD at Leicester Royal Infirmary, explains: “Some patients will have terrible symptoms but no oesophagitis – that’s common in younger patients. Others, especially older people, can have extremely severe oesophagitis but no heartburn, although they may have bleeding, anaemia, or difficulties swallowing. The only way to diagnose oesophagitis is with endoscopy.”
Using endoscopy to diagnose esophagitis
Endoscopy is a special procedure that involves passing a narrow, flexible tube containing a light and camera through the mouth and throat and down into the oesophagus. This allows the doctor to look directly at the lining of the gullet to detect the presence of ulcers, reddening, or bleeding. The doctor may also remove a tiny piece of the oesophageal wall so that it can be examined under a microscope.
Results of the endoscopy will then be used by the physician to guide how best to manage the patient, including whether further tests are needed and the most appropriate treatments.
GERD can be effectively treated with drugs
In patients with no oesophagitis and only mild or occasional heartburn, symptoms may be improved through a combination of lifestyle modifications, as described above, and drugs such as antacids. If the endoscopy shows the presence of oesophagitis, indicating damage to the gullet, patients are typically prescribed drugs known as proton pump inhibitors, which target the stomach wall and reduce the amount of acid produced. These drugs help prevent further damage to the oesophagus and can relieve symptoms in almost everyone who has GERD. Other drugs used to control heartburn include histamine2-receptor blockers, alginates, and prokinetic agents. In the most severe cases, surgery may be necessary. Medications used to treat heartburn are summarized below.
Medications
Antacids
Proton pump inhibitors
- Work by blocking acid production in the stomach
- Also reduce leakage of acid into the oesophagus
- Usually taken once a day
- May be prescription-only or over-the-counter depending on where you live
- Examples include omeprazole, esomeprazole, and pantaprazole
Alginates
- Work by floating on top of liquid in the stomach, therefore forming a barrier between the acid and the oesophagus
- May be combined with antacids
- Particularly useful in heartburn caused by pressure on the stomach, eg, in pregnancy
- Useful in mild or occasional heartburn
- Best taken when heartburn occurs, preferably about one hour after eating
- Can be bought over-the-counter\
- Examples include sodium alginate
Histamine2-receptor antagonists
- Work by blocking the action of histamine, a chemical released by the stomach
- Make the stomach less acidic
- Can be bought over-the-counter (although high doses may be prescription-only)
- Usually taken once a day
- Examples include cimetidine, ranitidine, and nizatidine
Prokinetic agents
- Work by strengthening the valve at the lower end of the oesophagus so less acid can travel back up towards the mouth
- Also reduce time that food stays in the stomach
- Must be prescribed by a physician
- Taken every day
- Examples include metoclopramide, domperidone, and bethanechol
Further information:
National Heartburn Alliance
http://www.heartburnalliance.org/
The American Gastroenterological Association
http://www.gastro.org/
National Digestive Diseases Information Clearinghouse
http://digestive.niddk.nih.gov/ddiseases/pubs/gerd/
GERD Information Resource Center
http://www.gerd.com/
Digestive Disorders Foundation
http://www.bdf.org.uk/
MedlinePLUS:
http://medlineplus.gov/
Mayo Foundation for Medical Education and Research)
http://www.mayoclinic.com/
References:
de Caestecker J. ABC of the upper gastrointestinal tract. Oesophagus: Heartburn. BMJ 2001; 323: 736–739.
Johnson DA, Fennerty MB. Heartburn severity underestimates erosive esophagitis severity in elderly patients with gastroesophageal reflux disease. Gastroenterol 2004; 126: 660–664.
Lagergren J, Bergstrom R, Lindgren A, Nyren O. Symptomatic gastroesophageal reflux as a risk factor for esophageal adenocarcinoma. N Engl J Med 1999; 340: 825–831.
Locke GR, Zinsmeister AR, Talley NJ. Can symptoms predict endoscopic findings in GERD? Gastrointest Endosc 2003; 58: 661–70.