Fighting against heartburn

Ever had that burning sensation in your chest right after enjoying a delicious meal you can’t help but wonder what is this strange feeling in the chest which only gets worse at night. You may think it's a heart attack and if the chest pain is spreading towards the neck and the left arm then indeed it is, and you must visit the nearest hospital but if these are not your symptoms then it’s likely you’re suffering from Heartburn, a very common condition and over 25 million adults worldwide experience it.¹

Heartburn is an unpleasant state of burning sensation in the chest which is caused by backflow of the acidic stomach content to the throat, called acid reflux. If acidic reflux occurs frequently it is called Gastroesophageal Reflux(GERD), a very serious condition, which needs medical attention right away.

It can affect a person in his day-to-day life or cause trouble sleeping at night and this way the cycle continues and makes the person weak and more prone to diseases. But the good news is, if diagnosed early it can be treated with medications and proper care.

Signs and symptoms²

• The feeling of burning in the chest after eating food
• Intense burning sensation when lying down or when bending
• Regurgitation of swallowed food into the mouth 
• Difficulty in swallowing the food
• Hiccups
• Bloating and feeling sick
• Salivation

Causes of heartburn³

Diet

• Spicy food
• Fatty meal
• Citrus fruits
• Coffee
• Carbonated Beverages
• Chocolates

Lifestyle

• Smoking
• Alcohol  
• Eating at midnight
• Sleeping or lying down right after eating  
• Stress
• Obesity      

Use of medications

Non-steroidal anti-inflammatory drugs (NSAIDs)

NSAIDS e.g. Ibuprofen destroys the protective lining of the stomach so when a patient suffering from heartburn is administered, the harsh acid will directly come in contact with the stomach lining and will result in lesions and develop ulcers.

Benzodiazepines 

They cause relaxation of the lower esophageal sphincter which causes increased backflow of the acidic stomach content back into the esophagus causing heartburn.⁴

Calcium channel blockers

They also cause relaxation of lower esophageal sphincter muscle due to which its functionality decreases and it fails to hold back the acidic content in the stomach which then ultimately travels to the esophagus and mouth causing heartburn.

Physiologic factors

• Hiatal Hernia: A condition where the upper part of the stomach bulges towards the chest causing acid reflux
• Poor lower Esophageal sphincter: responsible for preventing stomach-content food from entering back into the mouth

Diagnosis

You visit your nearby doctor and after taking history they prescribe you medications which resolve heartburn. But what if you want to make sure it is nothing serious and will be treated? In that case, there are some diagnostic procedures which will help in making proper diagnosis and prescribing of the correct medications.

Upper GI endoscopy

The person is firstly relaxed by Intravenous administration of Midazolam. The area behind the throat is numbed by Anesthesia and a flexible rod with a camera is inserted to view the concerned area of the stomach, esophagus and intestine. It is performed to locate any lesions or scars, ulcers and bleeding. ⁵

Esophageal pH monitoring

It is also called catheter monitoring. It consists of a flexible tube whose one end is inserted via the nose to check the presence of acid in the oesophagus. It is a less common test and is mostly used to figure out the reason behind the symptoms. This test can also help tell the effectiveness of the medications and help devise a plan to switch to alternatives.

Treatment and management⁶

Medications

Antacids

It consists of calcium, magnesium, and aluminium which are basic in nature. They come in contact with acid in the stomach and form water and neutral substances resulting in decreasing acidity. You may feel instant ease after taking the medication as they are most effective for mild heartburn.

H2 blockers

Parietal cells present in the stomach secretes acid which is important for the digestion process, however, an excessive activity of these cells causes increased acid production resulting in heartburn.H2 blockers show their effects by binding to the parietal cells in the stomach and inhibit acid secretion especially after meals and at night. H2 blockers take about 1 hour to show their action, but their effects last longer than antacids. 

Some Commercially available H2 Blockers include:

• Ranitidine
• Famotidine
• Cimetidine

 H2 blockers are taken on an empty stomach in the morning at least 30 minutes before breakfast. They are usually indicated for 8 weeks or less depending on the severity of the condition.

Proton pump inhibitors (PPIs)

If the H2 blockers have not been successful in treating Heartburn within 8 weeks then Proton Pump inhibitors are used. They inhibit the proton pumps present in the stomach which is responsible for the production of acid in the stomach. PPIs inhibit acid production and treat Heartburn. PPIs show more therapeutic action than H2 blockers.

Some proton pump inhibitors available are:

• Omeprazole
• Lansoprazole
• Esomeprazole

Persons suffering from this condition are directed to administer PPIs once daily on an empty stomach before breakfast or twice daily in case of severe Acid reflux, especially for patients suffering from night-time acid reflux. The dose can be adjusted according to the condition by consulting with the physician or local pharmacist.

Lifestyle modifications

• Avoid Heavy meals
• Avoid citrus fruits, alcohol and carbonated beverages
• Avoid spicy foods
• Eat Food in small portions
• Elevate your head with a pillow while sleeping 
• Avoid smoking 
• Manage your weight
• Take alternatives to NSAIDS or consult the pharmacist for dose adjustment

Surgical options

Fundoplication or anti-reflux surgery

It is a simple surgery process where the upper part of the stomach is stitched with the lower part of the esophagus which increases the pressure at the lower stomach part, thus decreasing the acid reflux and heartburn. The surgery takes around 2-3 hours under general anaesthesia. It is a complicated procedure which may lead to some complications if not taken care of. After the procedure has been successful the patient is required to stay at the hospital for monitoring and follow-up. The patient is asked to switch to a solid diet slowly to ensure full recovery.⁷

When is surgery recommended?

Surgery is not always the first line of care recommended by physicians, it is only recommended when it is of utmost importance, Surgeries are only performed when the medications are not effective the lifestyle modifications are also not working and there is an urgent need for medical attention. Thus, surgery is only performed when:

• If the use of medications does not improve the symptoms
• If there is ulceration, scarring and bleeding of the oesophagus
• If suffering from respiratory problems and trouble eating food

Complications of untreated heartburn

Chronic GERD (Gastroesophageal reflux disease)

If the heartburn is left untreated it will result in GERD. The symptoms may worsen with frequent burning sensations and pain. The long-term exposure will further weaken the sphincter and cause increased reflux. Urgent medical attention at the right time can be very lifesaving.

Esophagitis

If left untreated, it will cause inflammation of the esophagus and patients may suffer from difficulty swallowing food and the pain will increase to an extreme extent.

Barrett’s esophagus

It is a condition where the normal cells of the esophagus are replaced with abnormal cells which can ultimately lead to the risk of developing cancer. However, this can be prevented with proper monitoring and routine checkups at the hospitals.

Summary

Heartburn is also called “Acid reflux”, It occurs due to the regurgitation of acidic stomach contents back into the esophagus and mouth. This condition normally occurs because of the weakening of the lower oesophagal sphincter, where the sphincter fails to hold back the acidic stomach content; it results in a burning sensation, bad breath nausea or simply “heartburn”.

Individuals having lifestyles such as eating spicy food, citrus fruits, coffee, alcohol, smoking and taking medications such as NSAIDs have an increased risk of developing this condition, Heartburn when left untreated and prolonged can result in GERD and complications for e.g. Esophagitis. It can be managed by improving lifestyle choices which include increasing physical activity, eating vegetables and fruits and drinking herbal teas. It is treated with medications as prescribed by the doctor which include Antacids, Proton pump inhibitors and Histamine antagonists.

Proton pump inhibitors are very effective and usually successful in treating the condition. In severe cases, if the medications do not work, then the last option is to opt for surgery. The most common surgery performed is Fundoplication where the doctor simply ties the upper part of the stomach around the lower esophageal sphincter to increase the pressure. Surgeries are often used as a last resort since they can lead to many complications.

Heartburn can be managed by improving lifestyle choices and by proper care, it can be easily managed although it is important to be aware of the signs and symptoms since it can be extremely life-saving at times of need.

FAQs

Does drinking water help heartburn?

Water, low-fat milk and herbal teas can help manage the burning sensation in the throat and chest. However, beverages other than this can exaggerate the condition.

How to treat heartburn at night?

• Take a meal 2-3 hours before bedtime
• Eat in small portions
• Drink plenty of water
• Elevate your chest and neck
• Take prescribed antacids

Can heartburn be harmful?

If you are experiencing heartburn once or twice a year then there is nothing to be worried about, However, if the episodes are frequent then it may be concerning and you must make an appointment with a physician.