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What is heartburn?
Heartburn, also known as gastro-oesophageal reflux disease (GORD) or indigestion, is a very common condition in which the stomach contents and/or acid are able to move back upward into the oesophagus, and occasionally back into the mouth.
An estimated 15-20% of people experience an episode of heartburn at least once a week, with all age groups affected.  Most people can manage their symptoms with antacid tablets and avoiding trigger factors, but some chronic (ongoing) cases will require treatment.
When food is eaten, it travels from the mouth, through the oesophagus to the stomach. The oesophagus is a muscular tube, which is part of the digestive system and uses rhythmic muscular movements (peristalsis), along with gravity, to move food downwards.
Just before the food reaches your stomach, it must pass through a small band of muscles called your lower oesophageal sphincter. When you eat, your oesophageal sphincter relaxes and lets food pass through, down into your stomach and then closes again - much like a valve. During heartburn, the oesophageal sphincter does not work properly, allowing stomach contents and/or acid to rise upwards, irritating the oesophagus. In some cases, the stomach content and acid can travel up all the way to the back of the mouth.
Risk factors for heartburn include:
A hiatus hernia is a condition in which part of your oesophagus or stomach bulges into your chest cavity, through a gap in your diaphragm called your hiatus. This distorts the anatomy and can affect the lower oesophageal sphincter, contributing to heartburn. This condition typically develops gradually over time, in adults. Heartburn may be the only symptom of a hiatus hernia.
Obesity and age
Being pregnant can put a great deal of pressure on your digestive system, especially as you reach the final few months. Your growing womb pushes your stomach upwards and your oesophageal sphincter relaxes, allowing acid reflux to occur.
You may find that certain fatty or spicy foods, chocolate, coffee and other caffeinated drinks, tomato products, peppermint, hot drinks and also alcohol may cause symptoms.
The chemicals released when you smoke relax your oesophageal sphincter, making heartburn more likely.
Taking certain medications can make your heartburn symptoms worse either by relaxing your oesophageal sphincter or irritating your oesophagus. The most commonly implicated drugs are:
- Non-steroidal anti-inflammatory pain-relief drugs (NSAIDs), such as ibuprofen or aspirin;
- Calcium-channel blockers - these are prescribed to help with blood pressure, circulation and heart problems;
- Corticosteroids - these are given when you are have inflammatory conditions or autoimmune reactions;
- Selective serotonin reuptake inhibitors (SSRIs) - these are commonly prescribed antidepressants;
- Bisphosphonates - these are used to improve bone strength in conditions, such as osteoporosis, and;
- Nitrates - these are a group of medicines that relax and dilate your blood vessels.
Signs and symptoms
This is an uncomfortable burning sensation, or pain, felt behind your breastbone (sternum) and lower chest usually after you have eaten. Lying down or leaning forwards makes it worse. The pain can often worsen late at night some hours after eating as lying down allows acid to reflux into the oesophagus.
You may experience an acidic, unpleasant taste in your mouth or throat caused by stomach acid refluxing back into your oesophagus. Sometimes you may regurgitate small amounts of undigested food and liquids back into your mouth.
You may feel sick, especially after eating, smoking, drinking or lying down soon after a meal.
This is also called water brash and is a common symptom of heartburn, due to the fact that saliva neutralises regurgitated stomach acid.
You may find yourself constantly belching, often with an acidic aftertaste. Your abdomen may also feel bloated and uncomfortable.
Coughing and hoarseness
You may develop a cough at night, or when you lie down, and feel as though you are having difficulty breathing. If you already have asthma, heartburn can irritate your airways and make symptoms worse. You may find your voice becomes hoarse or you get constant laryngitis (inflammation of your voice box).
Pain or difficulty swallowing.
You may experience pain (odynophagia) or difficulty swallowing (dysphagia). You might also feel as if something is stuck in your throat or behind your breastbone. These symptoms should be mentioned to your doctor as they can also be signs of other conditions.
Symptoms in babies or small children
Heartburn can occur in young children, as their oesophagus is much shorter than an adults, which means it is easier for their stomach contents to be regurgitated (brought up). If your child often brings up food, cries while arching their back and is irritable after feeding, heartburn may be the cause. These symptoms can be caused by other conditions, so it is important to seek advice from your doctor if you are concerned. Keeping your child's head higher than the level of their stomach during feeding and afterwards may reduce the incidence of reflux.
Seek medical attention if these symptoms appear
- New or regular or severe symptoms;
- Pain (odynophagia) or difficulty swallowing (dysphagia);
- Vomiting blood or vomit of coffee-grounds appearance;
- Dark blood (may have a black, tarry appearance) in your stools;
- Choking sensation, and;
- Unexplained weight loss.
Methods for diagnosis
Your doctor can usually suspect heartburn by asking about your symptoms and taking a full medical history. Further testing may be required, such as:
Gastroscopy uses a thin, flexible tube containing a camera and light to view the internal lining of the oesophagus, stomach and parts of the small intestine. You will usually be given light sedation to make you relax during the procedure. Often, you will be asked to fast for 12 hours prior to the test. Gastroscopy can accurately provide a detailed view of the oesophagus and exclude other causes for the symptoms.
An oesophageal manometry is a test designed to discover if your oesophageal sphincter is functioning properly. It involves a tube being inserted through your nose into your oesophagus and down into your stomach to measure the pressure of your oesophageal contractions. It is usually only done in cases where surgery is being considered.
A barium swallow is a procedure in which you swallow a radioactive substance that will show up on an X-ray. This test is usually done to examine your pharynx and oesophagus. It can assess the function of the oesophageal sphincter.
24-hour pH monitoring
This procedure is usually only offered if you still have symptoms after a course of treatment and a gastroscopy hasn't revealed the cause. It will monitor whether acid reaches your oesophagus during a 24-hour period. A thin tube, which is attached to a device measuring acid levels, is inserted through your nose into your oesophagus and left there for 24 hours. You will be asked to record all your reflux symptoms in a diary during this time. An alternative form of this procedure involves attaching a similar device to your oesophagus via endoscopy. This device transmits its readings and then is excreted with your stool.
Types of treatment
In the majority of heartburn cases, dietary and lifestyle changes, along with medication, are the mainstays of treatment. Your doctor may advise the following changes before prescribing you any medications:
- Keep a food diary to identify links between symptoms and certain types of foods. These foods are then best avoided to reduce future symptoms. Spices, fatty foods, coffee, cola, caffeinated energy drinks, chocolate and peppermint are common triggers for heartburn;
- Try to eat small regular meals instead of large ones, as these extend your stomach. Don't eat immediately before lying down. Therefore, try to eat at least three hours before bedtime;
- Stop smoking - smoking relaxes your oesophageal sphincter and also causes you to produce less saliva;
- Avoid excessive alcohol consumption;
- Raise the head of your bed by placing blocks of wood under the legs of the bed, as this will lessen reflux by keeping your head at a higher level than your stomach, and;
- Avoid any situation that puts pressure on your oesophagus, such as wearing tight clothing or leaning over soon after eating.
There are numerous medications available for heartburn:
- Antacids - these are alkaline tablets or liquids that give immediate relief by neutralising the acid in your stomach. They may offer immediate relief and are generally used as a short-term solution for infrequent and/or mild heartburn;
- Alginates - these seaweed compounds coat and protect your stomach and oesophagus from acid;
- Histamine antagonists (H2 antagonists) - these drugs work quickly by reducing the amount of acid your stomach produces. They tend to be effective for mild to moderate cases of heartburn, and;
- Proton pump inhibitors (PPI) - these work by reducing the amount of stomach acid produced and are considered more effective than H2 antagonists. These tend to be the most effective medication for heartburn.
Surgery is generally offered in severe cases of heartburn that haven't responded to lifestyle changes and other forms of treatment. Laparoscopic (keyhole) surgery is generally used to perform fundoplication, which is the gold-standard treatment. It involves wrapping the top of your stomach around the lower part of the oesophagus to tighten up the oesophageal sphincter. The surgery can be combined with other procedures, particularly treatment of a hiatus hernia, if present. Heartburn surgery is a major surgical procedure, which is performed under general anaesthesia and involves several days in hospital. It carries the potential for severe complications, such as difficulty swallowing, damage to internal organs, and even failure of the procedure. Careful consideration and thorough discussion with your surgeon are recommended before embarking on any surgery.
While the majority of cases tend to improve with lifestyle changes and medications, if not adequately treated, heartburn can lead to damage to the lining of the oesophagus. The lining of the oesophagus is not designed to cope with persistent exposure to stomach acid, so it can lead to the following conditions:
You may develop ulcers in your oesophagus, due to constant irritation from acid. These can cause pain, bleeding and make swallowing uncomfortable. Sometimes these ulcers can bleed, but you may not realise it, as it can be subtle, or lead to dark stools (rather than the typical blood stained stools). A simple stool test can detect the presence of any unseen blood in your stool. Antacids can be taken to reduce your stomach acid and alginates can be taken to relieve the symptoms.
Barrett's oesophagus only occurs after repeated bouts of acid reflux, which change the type of cells that grow in your lower oesophagus. It is more common if you are between 50-70 years of age. This condition carries a higher risk for oesophageal cancer, but your doctor can arrange regular monitoring to help prevent this.
This is heavily linked to Barrett's oesophagus. If caught early enough, this type of cancer can usually be treated.
If you have the following, you have a higher risk of developing oesophageal cancer:
- Having heartburn symptoms at least several times per week;
- Having heartburn for more than 10 years;
- Being male, and;
- Being a smoker.
After repeated exposure to stomach acid, your oesophagus can become form scar tissue. This can cause stricture, or narrowing of the oesophagus, making it difficult for food to pass down to the stomach. Typical symptoms include difficulty swallowing, regurgitation and heartburn.
Throat and lung problems
Repeated episodes of heartburn can leave your throat feeling hoarse and irritate your vocal cords. If stomach acid is inhaled into your lungs, it can cause aspiration pneumonia and symptoms similar to asthma. If acid continues to enter the lungs, it can cause damage resulting in permanent complications, such as bronchiectasis or pulmonary fibrosis.
Many cases of heartburn respond well to lifestyle changes and medications. If you experience recurrent heartburn, it is important to talk to your doctor, rather than simply endure the symptoms.