Heartburn and Acid Reflux

This factsheet is about Heartburn & Acid Reflux

Heartburn is extremely common, affecting up to 1 in every 4 of UK adults. It is a chest pain that occurs after eating, lying down, or bending over and is most usually described as ‘burning’. The pain is located at the lowest end of the breastbone in the centre of the chest. The discomfort often rises upwards and outwards.

Acid reflux is the regurgitation of some stomach contents including gastric acid (gastric reflux) into the oesophagus. Itis the major symptom of gastroesophageal reflux disease (GORD). Reflux mostly occurs without us being aware that it is happening.

Causes of Heartburn & Acid Reflux

When food or drink is consumed, it passes from the mouth, down the oesophagus (gullet) into the stomach. A muscular ring (lower oesophageal sphincter) which joins the oesophagus to the stomach should ensure that this flow is one way. Acid reflux occurs when this one-way system fails. Then whatever happens to be in your stomach travels in the wrong direction back up into the oesophagus. The stomach makes acid, which aids digestion by breaking down food and drink. Whilst the stomach can resist acid, if it refluxes in sufficient quantities into the oesophagus, it will cause pain (heartburn). Sometimes the lining of the oesophagus can become inflamed (called oesophagitis). If the inflammation is severe, ulcers can form.

Lifestyle Factors: There are certain factors which appear to increase the risk of heartburn and reflux. These include:

• Smoking
• Drinking excess alcohol
• Pregnancy
• Stooping or bending forwards
• Excess Body weight.

Pregnancy: Many women can develop heartburn during the later stages of pregnancy as the growing baby pushes upwards on the stomach. The symptoms will often go once the baby is born but can continue afterwards.

Hiatus Hernia: A hiatus hernia is when part of the stomach slides upwards into the chest by pushing itself through a hole (called the hiatus) in the diaphragm muscle (sliding hiatus hernia). The hernia itself rarely causes any symptoms but it does seem to make reflux more likely. For those people who have a large hiatus hernia, surgery may be required.

However, many people can suffer from heartburn when there is no apparent lifestyle or other factor. It is also quite common for people to develop symptoms because 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.

What are the usual symptoms of Heartburn & Acid Reflux?

Heartburn often seems worse after rich meals, citrus fruit juice, hot beverages or alcohol. Occasionally it can be felt deeply within the chest, almost within the back although sometimes the burning feeling can reach all the way up to the throat².  Some patients notice acid 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 and may often experience frequent throat clearing, coughing and choking. It is quite common for these symptoms to be worse at night or when lying down.

For most people with the condition, heartburn and 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. These can include internal bleeding and narrowing of the gullet. One in ten people with acid reflux have Barrett’s Oesophagus^{12, 13}. This is a condition that can, very rarely, progress to cancer of the lower oesophagus. If you are worried about these complications, discuss them with your GP.

You must always see your GP if:

• You have symptoms like food getting stuck in your oesophagus, frequently being sick or unintentional weight loss
• Lifestyle changes and pharmacy medicines aren’t helping.
• You have heartburn most days for three weeks or more.
• You have difficulty or pain when swallowing food.
• You have heartburn, indigestion, hiccups or an unpleasant taste in your mouth for three weeks or more.

How is Heartburn & Reflux diagnosed?

Your doctor will ask you to describe your reflux symptoms and the length of time you have had them and review the need for prescribing you acid-suppressant medication. Should you require such medication long term or the treatment is not working, and your symptoms continue or return, your GP may request an endoscopy. This will ensure there are no underlying problems with your oesophagus or stomach. 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.

Cytosponge: This is a new test that is available in some areas of the UK to identify Barrett’s oesophagus in people who have persistent heartburn and reflux symptoms. For the Cytosponge test you swallow a small capsule with a sponge inside, which is attached to a piece of thread. Approximately 7 min after swallowing it, the capsule dissolves in the stomach, and the sponge inside is released and then a nurse removes the sponge by pulling on the thread. On the way out the sponge collects cells from the oesophagus lining so that the laboratory can check if there are any changes in the cells.

Endoscopy: This test is conducted at a specialist unit and involves passing a thin, flexible tube through the mouth or nose and down into your oesophagus, stomach and start of small intestine⁹. It is usually carried out as an outpatient and takes less than 15 minutes. The endoscopist will take small tissue samples (biopsies) for analysis in the laboratory. You can choose to have a local anaesthetic throat spray and/or a sedative. The endoscopist can guide you in this decision. The procedure is not painful, but it may be uncomfortable at times.

Barium Meal: An alternative to a gastroscopy is a Barium Meal¹⁰. This involves drinking some barium liquid, which will show up your oesophagus, stomach and first part of the small intestine on x-ray. It gives less information than an endoscopy but is good at showing whether you have a hiatus hernia or whether your oesophagus is narrowed for any reason.

What treatments are available for Heartburn & Acid Reflux?

Most treatments revolve around lifestyle changes as your symptoms are likely to lessen if you take measures to reduce the amount of reflux that you have. For example, stopping smoking and drinking less alcohol can all make a big difference to the discomfort you experience.

Alcohol

Check your alcohol intake and reduce if needed to within healthy guidelines, if you do have a large intake it might be better to discuss your intake with your GP before reducing it. You can use the online calculator here https://www.drinkaware.co.uk/ to work out how many units you are having. Healthy advice is not to have in excess of 14 units per week with some alcohol free days during the week.

Smoking

Ask you GP about NHS stopping smoking services where you live. There are a number of different methods to use and stopping can have other benefits to health. See here for more information https://www.nhs.uk/live-well/quit-smoking/nhs-stop-smoking-services-help-you-quit/

Some foods are more likely than others to trigger reflux symptoms so you may find it helpful to look at how you eat as well as what you eat. Avoid late night, high fat meals so you don’t go to bed with a full stomach. Eat your main evening meal three hours before going to bed³. Propping up your head when you sleep may also alleviate symptoms³. Eat little but more often, if necessary. Try to avoid bending forward or wearing tight clothes as this can put extra pressure on your tummy.

Being overweight.

Being overweight can put additional pressure on the stomach making reflux episodes more likely. Review your weight, as excess body weight can create upward pressure from the stomach. If you are overweight taking steps to reduce your weight can be helpful, speak to your GP about what weight management services are available to you in your area. You might also find this NHS free weight loss programme useful https://www.nhs.uk/live-well/healthy-weight/start-the-nhs-weight-loss-plan/

Reduction of intake of fizzy drinks may help reduce symptoms but this has not been conclusively proven³, and drinks containing caffeine (tea, coffee and some energy drinks) have been shown to cause heartburn evidence is again inconclusive with respects to the benefits of reduction. People can find that spicy food, food higher in fats and tomato are more likely to trigger symptoms² Reduction of these foods might be helpful. There is no one approach to diet and reflux and triggers can be very individual.

There are also a variety of medicines you can buy at your local pharmacy to help lessen your reflux symptoms.

Antacids: alkaline liquids or tablets that reduce the amount of stomach acid. They usually work immediately. They are best taken after meals and before going to bed.

Alginates: These are products that form a thick protective layer on top of the stomach contents and help reduce reflux symptoms. These can be useful to take after meals and before going to bed to reduce night-time symptoms. Some medications are a combination of both antacids and alginates.

Acid-supressing medications: capsules or tablets which reduce the amount of acid produced by the cells in your stomach.

These are split into 2 groups:

• Histamine H2-receptor antagonists(H2 blockers). These include, Cimetidine, Famotidine and Nizatidine. These can be taken prior to bedtime.
• Proton pump inhibitors(PPIs). These include Omeprazole, lansoprazole, Pantoprazole, Rabeprazole and Esomeprazole. These are best taken 30 minutes prior to breakfast or evening meal.

The most effective therapies are Proton Pump Inhibitors (PPI) in managing the symptoms of heartburn and reflux. These are remarkably safe and among the most commonly taken medicines worldwide. There is a slightly increased risk of bowel infections while taking them but no other proven side effects from long term consumption.  Your doctor may initially prescribe up to 8 weeks of a PPI depending on the severity of your reflux and how quickly the symptoms reduce.

It is recommended that PPIs are taken for the shortest time at the lowest dose. So your doctor may advise coming off the medication. If your symptoms return the doctor may adjust your dose to the lowest effective dose to manage your symptoms. Exceptions to this are those patients who have confirmed (at endoscopy) to have severe gastro-oesophageal reflux disease, an oesophageal stricture or Barrett’s oesophagus. Speak to your GP, Pharmacist, Endoscopist or Gastroenterology Specialist they will be able to discuss with you any concerns you have regarding your acid medication.

Does Heartburn & Acid Reflux need to be monitored and, if so, how?

Many people find their symptoms improve greatly if they change their lifestyle. Others may need to take medicines from time to time or long-term, depending on the results of an endoscopy. There are some people for whom drug treatment is not suitable for one reason or another. In such cases, your GP may then refer you to your local hospital’s Gastroenterology Department for their advice. The specialist may choose to measure the amount of acid you are refluxing over a 24-hour period. This is called pH monitoring. The test is often useful when considering if anti-reflux surgery would be appropriate.

What to ask your doctor?

• Do I need an endoscopy?
• What can I do in terms of my lifestyle to reduce gastro-oesophageal reflux?
• How should I take my medications?

Where can I get more information?

The following are charities who you can contact to find out more information.

Action Against Heartburn

https://www.actionagainstheartburn.org.uk/

Nice guidelines for treatment of reflux in adults.

Tosetti C, Savarino E, Benedetto E, De Bastiani R; Study Group for the Evaluation of GERD Triggering Foods. Elimination of Dietary Triggers Is Successful in Treating Symptoms of Gastroesophageal Reflux Disease. Dig Dis Sci. 2020 Jun 24. doi: 10.1007/s10620-020-06414-z. Epub ahead of print. PMID: 32578044.

Kaltenbach T, Crockett S, Gerson LB. Are Lifestyle Measures Effective in Patients With Gastroesophageal Reflux Disease? An Evidence-Based Approach. Arch Intern Med. 2006;166(9):965–971. doi:10.1001/archinte.166.9.965

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