This factsheet is about Heartburn & Reflux
Heartburn is extremely common, affecting up to 25% of UK adults1 . 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 with the discomfort often rising upwards and outwards.
Reflux is the regurgitation of some stomach contents including gastric acid (gastric reflux) into the oesophagus and is the major symptom of gastroesophageal reflux disease. Reflux mostly occurs without us being aware that it is happening.
Causes of Heartburn & Reflux
When food or drink is ingested, 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. Reflux occurs when this one-way system fails and 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) and sometimes the lining of the oesophagus can become inflamed ie oesophagitis. If the inflammation is severe, ulcers can form.
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. Between 15%-25% of people suffer from a hiatus hernia with it being more common in the male population.3 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 oesophagitis2. Doctors believe that in such cases the lining of the oesophagus is unusually sensitive to reflux of acid.
There are certain factors which appear to increase the risk of heartburn and reflux.
- Drinking excess alcohol
- Stooping or bending forwards
- Weight gain
What are the usual symptoms of Heartburn & Reflux?
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 although sometimes the burning feeling can reach all the way up to the throat2. 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 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 that can include internal bleeding and narrowing of the gullet. One in ten people with acid reflux have Barrett’s Oesophagus12, 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 taken acid suppressant mediations, purchased from the pharmacy, for four weeks or more
- lifestyle changes and pharmacy medicines aren’t helping
- you have heartburn most days for three weeks or more
- you have other symptoms like food getting stuck in your oesophagus, frequently being sick or unintentional weight loss
How is Heartburn & Reflux diagnosed?
Your doctor will ask you to describe your reflux symptoms and the length of time you have had them8 and review the need for prescribing you acid-suppressant medication. Should you require such medication long term or the treatment is not working, your GP is likely to request a gastroscopy. This will ensure there are no underlying problems with your oesophagus or stomach8. 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.
Gastroscopy: This involves passing a thin, flexible tube through the mouth and down into your oesophagus, stomach and start of small intestine9. The endoscopist will be looking for signs of inflammation. It is usually carried out as an outpatient and takes less than 15 minutes. You can choose to have a local anaesthetic throat spray and/or 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 a gastroscopy 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 & 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. 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.4 Avoid late night, high fat meals so you don’t go to bed with a full stomach. Propping up your head when you sleep may also alleviate symptoms. Eat little but more often if necessary. Try to avoid bending forward or wearing tight clothes as this can put extra pressure on your tummy4.
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 work immediately and last for four hours. They are best taken after meals and before going to bed5.
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)6. These include Ranitidine, Cimetidine, Famotidine and Nizatidine. These can be taken prior to bedtime.
- Proton pump inhibitors (PPIs)7. These include Omeprazole, Pantoprazoleand Esomeprazole. These are best taken 30 minutes prior to breakfast or evening meal.
Proton Pump Inhibitors are very effective in managing the symptoms of heartburn and reflux. However, like many other medicines, they have potential adverse effects. These include Clostridium difficile infection in patients in hospital, bone fractures, hypomagnesaemia (low magnesium level) and vitamin B12 deficiency11. However, the participants in the research studies supporting these adverse effects were not randomly allocated to either the group receiving the treatment under investigation or to a group receiving standard treatment as the control. It is therefore difficult to establish whether PPIs were the cause of these adverse effects.
It is recommended that PPIs are taken for the shortest time at the lowest dose. Exceptions to this are those patients who have confirmed (at gastroscopy) severe reflux disease.12 Your GP, Pharmacist, Endoscopist or Gastroenterology Specialist will be able to discuss with you any concerns you have regarding your acid medication.
What to ask your doctor?
- Do I need a gastroscopy?
- Are PPIs safe for me?
- What monitoring will I need?
Does Heartburn & 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 a gastroscopy. 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 advice9. 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.