I have heartburn! What is this caused by?
Heartburn is a symptom whereby patients feel a burning sensation in the middle of the chest, sometimes rising from the upper abdomen into the chest. It can be severe enough to be painful. Often heartburn occurs after eating or when lying down to sleep.
The commonest cause of heartburn is acid reflux. This means that the acid that is normally produced by the stomach refluxes into the oesophagus. Normally there is a muscular valve at the junction between the oesophagus and stomach. Whether the valve is too weak, thus allowing more acid to rise up, or the lining of the oesophagus is too sensitive, or a combination of both, acid causes inflammation and therefore heartburn. Heartburn is often associated with regurgitation of acidic fluid into the mouth.
Is heartburn dangerous?
Acid that refluxes into the oesophagus can sometimes cause much inflammation, damage and scarring of the oesophagus. Most often though, the acid causes either minimal inflammation or even no visible inflammation, but just causes symptoms.
The dangers of acid reflux damage to the oesophagus are:
- There might be erosions, or shallow ulcers at the lower end of the oesophagus and if deep enough, these ulcers could burrow into blood vessels and cause bleeding.
- The damage might be so bad that the oesophagus is scarred and narrowed (stricture) and swallowing becomes difficult, with food becoming stuck on the way down (dysphagia) with pain or discomfort (odynophagia).
- The lining of the lower oesophagus might be so scarred as to cause a change in the cells to a type called Barrett’s Oesophagus. This poses a risk of developing oesophageal cancer.
Are there hints as to how badly affected I am?
There is little correlation between the severity of heartburn and the damage seen in the oesophagus. Some patients have terrible heartburn but there is little visible inflammation. Others have minor symptoms but their oesophagus is already badly scarred. Therefore the actual severity of symptoms is not very helpful. However there are some symptoms that would be worrying (alarm symptoms), such as extreme pain, difficulty swallowing or painful swallowing, regurgitating or vomiting blood, loss of weight, loss of appetite or anaemia (low haemoglobin). If there are alarm symptoms such as these, there is a higher suspicion of possible serious consequences of acid reflux, as described above.
Can’t I just take medicine for heartburn without undergoing any tests?
If the symptoms are mild, a GP might offer a trial of empirical treatment of medicine to lower the acid production of the stomach. Such medicines are usually Proton Pump Inhibitors. If it works and patients are relieved, they should be monitored to see if the symptoms recur. If they do keep recurring, get worse, or some alarm symptoms appear, then it would not be reasonable to continue empirical treatment and patients should undergo further tests by a Gastroenterologist.
How can I get a diagnosis?
Besides taking a good history of the symptoms and doing a thorough clinical examination, a Gastroscopy might be offered. This is examination by a long thin instrument called a Gastroscope, which is gently inserted through the mouth into the oesophagus, stomach and first part of the small intestine (duodenum). The degree of damage to the oesophagus due to acid reflux might be visible and biopsies can be taken to check the cells. If there is oesophagitis, it can be classified into Los Angeles Grades A-D depending on severity. If there is no visible inflammation but the symptoms are typical, it might be “Non Erosive Reflux Disease”. If deemed necessary to get further confirmation of acid reflux, tests such as oesophageal pH (acidity) monitoring or manometry (checking the pressure at different parts of the oesophagus), or pH-impedence monitoring (detecting fluid shifts in the oesophagus), could be offered.
Some medicines such as anti-high blood pressure pills, asthma medicines or anti-depressants may relax the valve between oesophagus and stomach, leading to heartburn. You should always tell your doctor what medicines you are on.
What if I already have complications?
If you have narrowing of the oesophagus due to scarring, the narrowed segment can be dilated by means of hydrostatic (water filled) balloon dilators passed through the Gastroscope. This can stretch open the narrowed part. There is a small risk of bleeding and even perforation of the oesophagus.
If there is evidence of change of cells of the lower oesophagus to Barrett’s Oesophagus, then biopsies should be taken to see whether they are already progressing towards cancer. If not, then a surveillance programme can be offered whereby patients will have Gastroscopy and biopsy every one or two years so that any change towards cancer in the cells can be picked up early.
Can I be cured?
There are two objectives of treatment: Relieve symptoms, heal oesophagitis, restore quality of life, prevent relapse of symptoms and prevent complications. The medicines most commonly used are those that either neutralise stomach acid (antacids) or reduce acid production (typically Proton Pump Inhibitors) depending on degree of symptoms and how bad the oesophagitis is. Generally, patients are given a course of medication, then it is gradually withdrawn until the very smallest dose that keep patients symptom free. If possible, patients are taken off medicine or asked to take only “on demand”, that is when symptoms occur and stop when they are relieved. Some patients need continuous maintenance medicine to stay well. The worse the oesophageal erosions, the more likely that maintenance therapy is needed.
In the worst cases, or when it is poorly responsive to medicine, surgery to tighten the valve between oesophagus and stomach may be offered. This is highly specialised surgery and it only offered for the most difficult cases as all surgery carries risks which are not justified to take if medicine works. There are newer methods using special endoscopes and these are under development.
What about lifestyle?
There are only a few lifestyle changes that may be helpful: If obese, lose weight. Refrain from taking large meals, late at night near bedtime and don’t lie down for at least 3 hours after eating. Avoid alcohol and cigarettes. If you find specific foods bothersome, then take less of these, but there is no standard list of foods to avoid.