Heartburn, Acid Reflux and Indigestion

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Acid reflux and heartburn are similar conditions that are caused by Gastroesophageal Reflux Disease (GORD). GORD is a very common condition where acid from the stomach leaks out into the oesophagus (gullet) and can travel all the way up to the throat.

There are various reasons why someone may suffer from acid reflux or heartburn, the most common being a failure of the lower oesophageal sphincter. This sphincter comprises a ring of muscles that act as a valve, allowing food to enter the stomach whilst keeping acid from exiting. If the lower oesophageal sphincter doesn’t close fully, it can let acid leak up out of the stomach.

There are known triggers that can contribute to experiencing acid reflux and heartburn, these include:

• Being overweight: Carrying extra weight can place increased pressure on your stomach. This pressure can lead to a weakening of the lower oesophageal sphincter allowing acid to move back up your gullet from your stomach
• Being pregnant: Fluctuating hormonal levels can weaken the lower oesophageal sphincter
• Eating a diet high in fat. The stomach takes longer to dispose of stomach acid after digesting a high-fat meal
• Tobacco, coffee, alcohol or chocolate: All these can relax the lower oesophagus sphincter
• Hiatus hernia: where part of the stomach protrudes up through the diaphragm
• Certain medicines: Calcium-channel blockers and nitrates can relax the lower oesophagus sphincter. Non-steroidal anti-inflammatory drugs (NSAIDs) can irritate and inflame the oesophagus lining, leading to heartburn
• Stress
• Eating large meals or lying down after eating a meal

Acid reflux will involve stomach acid being regurgitated into your throat and mouth. This regurgitation will commonly lead to a sour-bitter, ‘acidy’ taste at the back of your mouth and throat.

Heartburn differs slightly as it will present as a discomforting burning pain just below your breastbone. This pain can move into the chest and even into the throat. This pain is usually found to be worse after eating, or when bending over or lying down.

If you are only experiencing symptoms a few times a month that can be attributed to food and/or drink then it may not be necessary to see a doctor; self-diagnosis and treatment is likely to be appropriate.

If the symptoms are new in onset or become more severe and frequent and the use of over-the-counter remedies has proven ineffective then it is then recommended to seek medical advice.

Less common symptoms that can be the result of regurgitated stomach acid include:

• Nausea
• A persistent cough that worsens at night
• Wheezing
• Chest pain
• Tooth decay
• Laryngitis

If you have any of the above symptoms, you should discuss them with your GP first.

For the majority of cases, a doctor will be able to diagnose gastroesophageal reflux disease from your symptoms and medical history – this is covered as part of your consultation. For mild and infrequent cases of acid reflux, indigestion or heartburn that are associated with food, alcohol or other known causes, self-diagnosis may be appropriate.

If you have any of the following symptoms, physical examination by your doctor will be required:

• Pain when swallowing. This is also known as odynophagia.
• Difficulty when swallowing. This is also known as dysphagia.
• Symptoms have not improved despite having taken prescription medication such as Omeprazole or Ranitidine.
• Symptoms that are new in onset, especially if you are aged over 45 years.
• Other serious symptoms such as severe pain, persistent diarrhoea/constipation or blood in the stools.

If required, your doctor can carry out further testing of your symptoms using various different methods. These include:

• Endoscopy: This is performed using an endoscope, which is a long flexible tube with a camera and light at one end. This tube is inserted into the throat and can help visually detect any damage to the oesophagus.
• Manometry: This is performed using a small tube that contains pressure sensors. The device is inserted through the nose and fed down to the lower oesophageal sphincter where it is able to detect the pressure generated by the muscle and how well it is performing.
• Barium swallow test: This test involves drinking a non-toxic liquid called barium solution. This solution shows up clearly on X-rays. Once the liquid has moved down into the upper digestive system a series of X-rays are taken. These X-rays can then reveal any blockages or problems with the muscles used when swallowing.
• 24-hour pH monitoring: This test is designed to measure the acidity levels around the oesophagus. It uses a small probe, which is fed down to the oesophagus via the nasal cavity. The probe is connected to a small monitoring device that attaches to your wrist. Every time you become aware of your symptoms you push a button on the device. After 24 hours the probe is removed and the data then analysed.

There are many treatment options available for this condition. Very mild cases can sometimes be treated using over-the-counter medications, such as:

• Pepto Bismol
• Maalox
• Calcium Carbonate preparations, such as Bisodol, Remegel, Rennies
• Alginate preparations, such as Gaviscon and Peptac

Most over-the-counter antacid remedies work by neutralising the effects of stomach acid. Alginate preparations, such as Gaviscon work differently. Alginates provide a protective coating, designed to shield the lining of the stomach and oesophagus from the effects of stomach acid. These work best if taken just after eating a meal.

If over-the-counter treatments are proving ineffective then you may try a proton-pump inhibitor (PPI). Proton-pump inhibitors are widely used as they are well tolerated by most patients and rarely produce side effects. PPIs work by reducing the amount of acid produced by the stomach. Examples of PPIs include:

• Omeprazole (Losec)
• Esomeprazole (Nexium)
• Lansoprazole (Zoton)
• Pantoprazole (Pantoloc)

When prescribing PPIs, such as Omeprazole, you start with the lowest possible dose that will be effective in controlling your symptoms. If Omeprazole 10mg Capsules are ineffective, it is important to inform your prescriber so they can assess and potentially increase your dose.

Another type of treatment is H-2 antagonists, such as Famotidine. Famotidine blocks the production of stomach acid by a different mechanism to PPIs but with the same acid-reducing effects. Ranitidine is a long-established and effective treatment for acid reflux and heartburn that is well tolerated and normally causes few side effects.

If PPIs, such as Omeprazole, and H-2 antagonists, such as ranitidine, have proven ineffective or if the thought of taking medication on a long-term basis is unappealing, then surgery can be an alternative. You should discuss this with your GP.

There are steps you can take which will help reduce the risk of experiencing acid reflux and heartburn. These include:

• Losing weight may reduce your symptoms as it will relieve the pressure on the stomach.
• Changing your eating habits to include smaller, more frequent meals as opposed to three large meals. Ensure your final meal of the day is eaten three to four hours before going to bed.
• Avoid trigger foods, such as alcohol, coffee, chocolate, tomatoes and anything fatty or spicy. If any of these have proven to make your symptoms worse, it is recommended they be avoided.
• Smoking can irritate the digestive system, making symptoms worse. Giving up smoking will help reduce the risk of developing acid reflux or heartburn.
• Raising the head of the bed by approximately twenty centimetres (8 inches). This technique can help reduce symptoms in some people. Ensure the bed is stable and sturdy before sleeping in it. Don’t use extra pillows as this can add pressure on the abdomen.
• If you suspect the acid reflux and heartburn are side-effects of a medicine you are currently taking, it is advised to discuss with your GP whether an alternative is available. It is not recommended to cease taking prescribed medication without first discussing it with you doctor.

There are many treatment options available for acid reflux and heartburn. Very mild cases can sometimes be treated using over-the-counter medications (available without a prescription from your pharmacy), such as:

• Pepto Bismol
• Maalox
• Calcium Carbonate preparations, such as Bisodol, Remegel, Rennie and Tums
• Alginate preparations, such as Gaviscon and Peptac

Most over-the-counter antacid remedies work by neutralising the effects of stomach acid. Alginate preparations, such as Gaviscon work differently. Alginates provide a protective coating, designed to shield the lining of the stomach and oesophagus from the effects of stomach acid. These work best if taken just after eating a meal.