Acid Reflux

Heartburn - What is Heartburn (Acid Reflux)?

Heartburn is a symptom rather than a disease. It is a symptom of Gastro-esophageal reflux disease or “acid reflux”. This is a common condition when the acid produced in the stomach leaks out and seeps back into the esophagus or food pipe.

The esophagus is a tube made up of muscles and lined with sensitive mucosal layer within that runs from the mouth to the stomach. As the stomach’s acid leaks into the esophagus, it leads to heartburn or burning chest pain or discomfort. Despite the fact that the pain has nothing to do with the heart, its location is the reason for the nomenclature.

The leakage of the acid into the esophagus also leads to a sour or bitter taste in the back of the mouth and in severe cases pain and difficulty swallowing. Most people have stomach acid reflux at some point in their lives, either as heartburn or acid regurgitation.

Causes of heartburn

Acid reflux or heartburn may be caused due to multiple factors. Normally the esophagus is guarded at its lower end by a valve like gate called the lower esophageal sphincter (LES). The LES acts like a valve, opening to allow food to be pushed into the stomach. It closes to prevent acid leaking out of the stomach and into the esophagus. In persons with acid reflux the muscle of this sphincter may not be working properly.

In addition those who are smokers, alcoholics, take pain relievers like Ibuprofen and consume a spicy or high fat diet, are obese, overweight or pregnant, are at a greater risk of getting acid reflux and heartburn.

In addition caffeine containing foods like chocolates, coffee and peppermint also weaken the LES. Some people get heartburn when they bend over or lie down.

The frequency of stomach acid reflux varies from one person to another. The risk rises with age and may significantly decrease quality of life and overall well-being. 

Risks associated with heartburn or acid reflux

If left untreated the stomach acid can irritate the inner lining of the esophagus. This may lead to esophagitis. In more severe cases this may lead to open sores or ulcers within the esophagus. This is called erosive esophagitis. Over time in rare cases this may turn into cancers (esophageal cancer).

Treatment of heartburn

Treatment of acid reflux needs to include a major component of lifestyle change. Once this fails, therapy is stepped up to include antacids that help to neutralise effects of stomach acid. Lifestyle changes include:-

  • quitting smoking
  • reducing alcohol intake
  • losing weight
  • exercising regularly
  • avoiding fatty and spicy foods etc.

Medications that reduce the secretion of the stomach acid called Proton Pump Inhibitors are one of the mainstays of therapy in acid reflux. Treatment of acid reflux is usually successful but relapses are common. Nearly half of the treated individuals experience a return of symptoms after a year.

Heartburn (Acid Reflux) Diagnosis

Heartburn is a symptom that is often indicative of an underlying condition of acid reflux or Gastro-esophageal reflux disorder. Diagnosis of heartburn is vital as it may mimic a heart attack or other chest pathologies.

Diagnosis of heartburn or acid reflux disorder includes the following.

Medical history

This involves taking a detailed assessment of the condition in the past of its presence in the family. History of intake of certain drugs (like pain relievers) or other conditions that may raise the risk of acid reflux like smoking and alcoholism is important.

Factors that aggravate the condition including lying down, taking spicy or fatty foods etc. are noted. Factors that relieve the condition like intake of food or water are also enquired of.

Physical examination

Physical examination looks for features like anemia, weight loss and malnutrition due to difficulty in swallowing. Reflux of acid may also result in complications of lungs like lung abscess, pneumonia and interstitial pulmonary fibrosis.

Ruling out other conditions

Heartburn may also be caused by heart attacks, rib injury, esophagitis due to swallowed corrosives or drugs like NSAIDS, peptic ulcer, infections in HIV positive and other immune-suppressed patients due to herpes, candida, cytomegalovirus etc. These need to be ruled out.

Endoscopy

Endoscopy is the next step. In this an instrument called the endoscope examines the insides of the esophagus. This is a long thin flexible tube with a camera on its tip. The camera sends images of the examined area to the external monitor.

The endoscope is inserted into the mouth and passed into the esophagus. The endoscope checks the insides of the esophagus for possible irritation and inflammation caused by the refluxed acid.

Manometry

Acid reflux may also be diagnosed using manometry. Manometry is suggested if endoscopy does not find any evidence of damage to the esophagus. This test assesses the strength of the lower esophageal sphincter (LES). It measures the pressure levels inside the sphincter muscle.

A small tube is passed into the esophagus up to the LES. The tube contains a number of pressure sensors that are connected to an external computer. The patient is then given some food and drink to swallow and the pressure at the LES is recorded.

pH monitoring

A 24 hour pH monitoring may be recommended. The lower the pH level within the esophagus, the greater is the acid content.

Barium swallow test

A Barium swallow test may be advised to check on the blockages or problems with the muscles used during swallowing.

Routine blood tests

Routine blood tests are prescribed. This helps to detect anemia caused due to malnutrition.

Heartburn (Acid Reflux) Prevention

Heartburn and acid reflux can be prevented by several simple lifestyle changes. Some of these include:-

Smoking cessation

Complete cessation of smoking. Smoking is one of the major risk factors for heartburn. Stopping smoking helps prevent frequent attacks of heartburn.

Eating smaller and more frequently

Large meals bloat the stomach leading to a greater risk of back seepage of the acid into the esophagus. Large meals also lead to back pressure on the lower esophageal sphincter (LES).

Avoiding certain foods

Some foods naturally cause increased acid secretions. Those prone to acid reflux need to avoid these foods to prevent attacks of heartburn. These include:-

    • fatty meats
    • fried and spicy foods
    • citrus fruits and juices like lemons, oranges etc. - these contain citric and other acids
    • tomatoes, sauces, tomato based food products like tomato juice
    • chocolates and caffeine containing foods like coffee - caffeine weakens the lower esophageal sphincter leading to reflux
    • peppermint
    • excessive alcohol consumption - red wine especially in excess is bad for those with heartburn
    • carbonated beverages - these are bad for reflux both due to the gases produced also due to the high caffeine contents
    • chillies and peppers
    • garlic and onions

Healthy eating

Meals should be healthy and balanced with plenty of fresh fruits, vegetables, water and fresh fish. Obesity increases pressure within the abdomen. This can push the stomach contents up into the esophagus. At least 10% of weight loss may help in reduction of heartburn symptoms. All individuals with heartburn need to try and maintain normal body weight.

Avoiding lying down after meals

After every meal at least a two to three hour break should be allowed before lying down. Lying down immediately after eating a heavy meal increases risk of reflux. Staying upright helps gravity work to keep the stomach juices from seeping back into the esophagus.

Avoiding lying flat

On lying down, it is advisable to elevate the head a few inches above the rest of the body. Lying down flat presses the stomach onto the lower esophageal sphincter and this leads to acid reflux. If the head is higher than the stomach, the gravity can act to reduce this pressure. The elevation of the head end may be achieved by placing blocks or bricks under the legs of the bed at the head end or a wedge shaped pillow may be used under the head.

Avoiding tight clothing

Too tight clothes, corsets and belts should be avoided especially after food. Clothing that fits tightly around belly squeezes the stomach and presses against the lower esophageal sphincter.

Relaxation and meditation

Stress is one of the important factors that lead to acid reflux and heartburn. Relaxation and meditation helps prevent attacks. Relaxation should include a 7 to 8 hours sleep a night as well.

Maintaining a record of aggravating factors

A record of aggravating factors that trigger an attack should be maintained. This helps in prevention of future attacks by avoidance of the triggering factor.

Heartburn (Acid Reflux) Treatments

Treatment of acid reflux mainly relies on lifestyle changes that prevent attacks. Acid reflux is one of the commonest digestive disorders affecting millions of people worldwide at some point in their lives.

Lifestyle changes to relieve and prevent heartburn

Some of the lifestyle changes that can relieve and prevent attacks of heartburn and acid reflux include:-

  • Eating small and frequent meals
  • Eating a healthy, non-spicy, non-fatty and balanced meal. The last meal of the day should be taken at least 4 hours before bed. Lying down immediately after a meal may aggravate heartburn.
  • Avoidance of food and beverage triggers of heartburn including alcohol, coffee, chocolate, tomatoes, citrus fruits etc.
  • Maintaining a normal body weight.
  • Quitting smoking.
  • Avoidance of wearing tight clothes especially around the abdomen.
  • Raising the head end of the bed by about 20 cm (8 inches).

Medications for heartburn

For patients who do not respond to these measures diagnostic methods to evaluate the extent of esophagitis or esophageal damage and gastroesophageal reflux should be employed. Medication may be required in these patients.

Medications help in neutralizing the gastric acid or by reducing the acid production. There are another group of agents called prokinetics that increase the motility of the gastrointestinal system and thus allow food to be transmitted through the esophagus and gut faster.

Drugs used in acid reflux include:-

Antacids

These agents are available over the counter. They work by neutralizing the gastric acid and relieve the symptoms of heart burn and acid reflux. These drugs, however, cannot be taken along with other medications that reduce acid reflux and there may be significant interactions leaving these agents ineffective.

Alginates

These agents are also available over the counter without prescription. These agents work by producing a protective coating that shields the lining of the stomach and esophagus. This protects the vulnerable linings of mucosa from the acid.

Proton-pump inhibitors (PPIs)

These are prescription medications like Omeprazole, Pantoprazole, Rabeprozole and Lansoprazole. These work by reducing the acid produced by the stomach. Patients with gastroesophageal reflux disorder may require PPIs for a long duration.

H2-receptor antagonists

These include Ranitidine, Cimetidine and Famotidine. These agents block the effects of the chemical histamine that helps produce stomach acid. Thus these agents reduce the acid production.

Prokinetic agents

These include Bethanechol and Metoclopramide. These agents hasten movement of food via stomach to the intestines and reduce the risk of reflux.