Heartburn – What are the symptoms and how can it be best treated?

Heartburn is a symptom of an underlying condition such as gastroesophageal reflux disease (GERD) or lifestyle where the stomach contents travel up the oesophagus because of the lower oesophageal sphincter’s inability to close properly.  Burning pain and discomfort is experienced in the chest. The condition may be exacerbated by meals, bending or recumbency. It affects approximately 20% of the adult population.

The presence of reflux implies that the lower esophageal sphincter (LES) cannot close properly. Transient relaxations of this sphincter are triggered by stomach distention or pharyngeal stimulation. Hiatal hernias are found in one quarter of patients with non-erosive GERD, three quarters of patients with severe erosive oesophagitis and over 90% of patients with Barret’s esophagitis, a precursor of esophageal carcinoma emphasizing the seriousness with which one should look at this symptom. Hiatal hernias are caused by movement of the sphincter above the diaphragm, resulting in reflux.

Factors that contribute to the malfunction of the oesophageal junction include the action of the diaphragm and the posture of the patient. Other factors contributing to reflux include weight gain, fatty foods, caffeinated or carbonated drinks, alcohol, tobacco smoking and certain drugs that can lower the LES pressure such as decongestants used for flu, antihistamines, certain antidepressants, calcium-channel blockers used for blood pressure, and progesterone hormones. The refluxate may also irritate the oesophagus, depending on the duration of contact. In the case of diminished clearance of the acid, a lack of the neutralizing effect by the saliva, oesophageal peristalsis or delayed gastric emptying, there may be greater damage to the mucosa.

The most prominent symptom of gastroesophageal reflux disease is caused by acid reflux or heartburn which is a feeling of warmth, discomfort or burning in the chest and throat.

The symptoms may be described as:

• a burning sensation in the middle of the chest
• a burning, indigestion-like pain
• a foul, acrid taste in the mouth

Treatment

The goal of the treatment is to provide symptomatic relief, to heal oesophagitis (if present) and to prevent complications. Mild to intermittent symptoms can be treated by lifestyle modifications with medical interventions as needed. Patients may find that eating smaller meals and elimination of acid foods (citrus, tomatoes, coffee, spicy foods), foods that precipitate reflux (fatty foods, chocolate, alcohol) and ceasing of cigarette smoking may reduce symptoms. Weight loss is recommended to patients who are overweight or recently gained weight. Patients who experience infrequent heartburn may be treated on demand with antacids or oral acid inhibitors available without a prescription from your local pharmacy for people who is experiencing troublesome symptoms of a short duration. Patients with long-term symptoms should visit their medical doctor as it may be associated with more severe underlying conditions. Anti-reflux surgery is performed on patients with serious oesophagitis, rectal bleeding, a stomach ulcer or intractable symptoms.

• If conditions which could have similar symptoms such as angina, esophagitis, dyspepsia or a peptic ulcer are a possibility, a visit to the doctor is a must if the condition does not improve within a six-week period.
• Patients with typical GERD whose symptoms do not resolve with over-the-counter medication.
• Patients with suspected extraoesophageal GERD symptoms that do not resolve within three months on twice daily doses of prescribed medicine.
• Patients with significant painful swallowing or other alarming symptoms.

Non-medicinal treatment should always be the first line of treatment, like raising the head of the bed, avoiding foods that increase acid secretion, or is known to one to cause heartburn (most people are usually very familiar with what those foods are) like alcohol (especially beer) white bread, pea soup, starchy food etc. One should concentrate on one’s posture – especially when eating (eating while driving or in a slouched position usually aggravates the condition). A large meal should not be eaten at least three hours before bedtime.

Medicine that prevents acid secretion (PPI’s) should be taken one hour before breakfast and an antacid can be taken directly after a meal. Treatment is long-term unless an operation is scheduled, for example to repair the lower esophageal sphincter. Patients should be aware of the consequences of not following the non-pharmacological as well as the pharmacological treatment regime.

Heartburn caused by gastroesophageal reflux disease is a common annoyance that is usually harmless, but it could be a sign of a more serious medical problem. If there is a constant heartburn or if it is interfering with the one’s daily lifestyle, ask your pharmacist to advise on treatment options or a referral for further testing.

Article by: Johann Kruger M.Pharm., M.Phil., PhD., FPS – Director Medwell SA (Home Health Care Specialists) and the Head of EDNA Medical Distributors (an incorporated company at Medwell SA). 
For more information visit www.edna.co.za or www.medwell.co.za