Heartburn and Gastro-oesophageal Reflux
Heartburn and Gastro-oesophageal Reflux explained
When you have something to eat or drink, it passes down the oesophagus (gullet) into the stomach. The flow of traffic should definitely be one-way. However, reflux occurs when whatever happens to be in your stomach travels in the wrong direction back up into the oesophagus. Unlike vomiting, which is quite a violent activity, reflux mostly occurs without us being aware that it is happening.
There is a ring of muscle around the lower end of the oesophagus which is there to stop reflux. When we eat or drink, the muscle relaxes but it then tightens up when we have finished. If the muscular ring gets too slack, reflux can occur.
Certainly not. Almost all of us have a little reflux from time to time, but we just don’t know that it’s happening. However, if reflux happens more often than normal, this may well lead to symptoms developing.
The most frequent symptom is heartburn which is a burning sensation in the chest. Run your hand down your breastbone. Heartburn is often most noticed at the lowest end of the bone and the discomfort rises upwards to an extent that varies from individual to individual. Sometimes the burning feeling can reach all the way up to the throat. Heartburn often seems worse after rich meals, citrus fruits, hot beverages or alcohol. Occasionally it can be felt deeply within the chest – almost within the back. Some patients notice reflux when some of the contents of their stomach ‘repeat’ by coming back up the oesophagus as far as the throat or even the mouth. A few patients notice discomfort or pain as they swallow. It is quite common for these symptoms to be worse at night or at other times when patients lie down.
Sometimes, even in people who have quite marked symptoms, the oesophagus may look entirely normal. However, some patients can develop oesophagitis. Whenever you see a medical term ending in -itis, this indicates inflammation. When inflammation occurs, this suggests that there is damage to that part of the body. Quite simply, oesophagitis means that there is inflammation within the oesophagus. The lining of the inflamed oesophagus looks red and sore. If the inflammation is severe, ulcers can form. Much the commonest cause of oesophagitis is reflux of acid from the stomach.
The stomach makes acid which helps start off digestion by mixing with whatever we have to eat or drink. The acid is very strong so if it refluxes in sufficient quantities and often enough, it will begin to cause damage to the lining of the oesophagus. At first the lining may just appear rather more red than normal. Later on the lining of the oesophagus may begin to wear away and, in severe cases, an ulcer may form.
Heartburn is very common. Most people who have symptoms can help themselves a lot by being sensible about what they eat and drink, and maybe also by taking antacids or other indigestion remedies. But if these do not work or if you are worried, it would be a good idea to seek medical advice. It is also appropriate to consult your doctor if you have begun to have symptoms that just don’t seem to settle down. You should definitely see your doctor if you are having trouble swallowing and food seems to get stuck on its way down.
In many cases we just do not know why the muscular ring that prevents reflux is not working properly. Some people do seem prone to getting reflux – especially those who smoke, drink excess alcohol, women during pregnancy or those who put on weight. Wearing tight clothes, stooping or bending forwards and eating rich, fatty foods all seem to increase the tendency to reflux. There are individuals who seem to lead healthy lives and have none of the above ‘risk factors’ yet experience troublesome symptoms. It is quite common for people to develop symptoms as a result of reflux when there are no signs of oesophagitis. Doctors believe that, in such cases, the lining of the oesophagus is unusually sensitive to reflux of acid.
A doctor may diagnose reflux just by listening carefully when you describe your symptoms and may treat you without the need for any tests. If they are not sure however or if the treatment does not work well, it is probable that they will arrange investigations.
The first investigation that doctors usually perform if they suspect you might have reflux oesophagitis is endoscopy. This involves passing a thin, flexible tube through the mouth and down into your oesophagus. The doctor will be able to get a really good look at your oesophagus and stomach and check whether there are signs of inflammation. Although it sounds unpleasant, your doctor will take care to explain how the discomfort of the procedure will be minimised. Although not used routinely, some specialists will choose to measure the amount of acid you are refluxing. This can be done by measuring the amount of acid in your oesophagus over a 24 hour period using a very narrow tube passed through the nose.
No-one is going to make you have tests although it is reasonable for the doctor to explain why it is important that you should do so. An alternative to an endoscopy is the barium meal test which will show up your oesophagus and stomach on x-ray. It does give less information than endoscopy but is good at showing up whether you have a hiatus hernia or whether your oesophagus is narrowed for any reason. It is worthwhile knowing that up to half of all patients with symptoms that suggest they have reflux turn out to have only mild inflammation or an oesophagus that looks quite normal.
The short answer is ... not much. Instead of staying entirely in the belly as it should do, it is possible for part of the stomach to slide upwards into the chest. It does this by pushing itself through a hole (called the hiatus) in the diaphragm muscle. The hernia itself rarely causes any symptoms but it does seem to make reflux more likely. Do note (1) that hiatus hernia is very common, (2) that you can certainly have reflux without one, (3) that many people who have one do not get reflux. The importance of having a hiatus hernia can certainly be overrated.
Because the severity of the condition varies from being just an occasional nuisance for some people while others are quite seriously troubled, so the intensity of treatment varies from one individual to another. There may well be changes in your lifestyle that you can make to help. There are also medicines – either bought over the counter or prescribed by your doctor – that can help your symptoms. There is no simple ‘cure’.
Your symptoms are likely to lessen if you take measures to reduce the amount of reflux that you have. It is a bad idea to eat large, rich meals – especially late in the evening. Eat little but more often if necessary. If you are carrying extra pounds, losing weight is usually very helpful. If you indulge, cut down on alcohol and stop smoking. Do eat early enough in the evening so as to avoid going to bed with a full stomach. It may help to prop up the head of the bed. Try to avoid bending forward or wearing tight clothes as this can put extra pressure on your tummy. There are a variety of useful medicines that you can buy. Many contain antacids which neutralize the acid in your stomach. Ask your pharmacist for advice about medicines that help reflux symptoms.
If your symptoms are mild, they may suggest you follow the above advice. If this does not work or your symptoms are more troublesome, they will probably prescribe a medicine for you. Ideally, they would choose to prescribe a drug that prevented you from having reflux in the first place – but there are no medicines that do that effectively. Fortunately there is a wide choice of drugs that cut down the amount of acid that gets to your oesophagus. These vary in their power so the doctor will try to choose the one that is best for you. The goodnews is that, for nearly everyone, there is a drug that is both very safe and really effective.
Many people find their symptoms improve greatly if they change their lifestyle to reduce reflux. Others may need to take medicines from time to time if their symptoms return. Some just cannot manage without taking drug treatment most of the time. It is very reassuring that taking extremely safe. There is a small number of people for whom drug treatment is not suitable for one reason or another. In such cases, surgery is definitely an option.
For most people with the condition, reflux is just a nuisance and little more than that. In a few people, especially where there is severe inflammation of the oesophagus, there is a risk of complications which can include internal bleeding and narrowing of the gullet. If you are worried about these complications, it is best to have a chat with your doctor.
It would be a major advance if we could work out what precisely is going wrong for reflux to occur. We don’t really understand why it happens so commonly and why some patients seem to have such unpleasant symptoms. Although treatment is effective, many patients notice their symptoms return soon after stopping their medicines. If we could work out what precisely is going wrong, we might then have a good chance of giving our patients lasting relief, prevent complications from happening and maybe even cure this condition.