Heartburn (reflux oesophagitis) is an inflammation of the oesophagus (gullet) resulting from a failure of the valve (lower oesophageal sphincter) between the oesophagus and the stomach. In health, the valve prevents the back flow of gastric juices.
The symptoms of heartburn are common, often considered trivial, and frequently managed by simple home remedies or over-the-counter antacids. Untreated it can progress to serious disease in some people.
This fact sheet provides information on the causes, symptoms, treatment, and longer-term complications of heartburn (reflux oesophagitis).
Gastro-oesophageal reflux is the back flow of stomach contents into the oesophagus.
Normally the lower oesophageal sphincter opens to allow food and fluid to pass into the stomach and then closing to prevent food and acidic gastric juices flowing back into the oesophagus. Reflux occurs when the lower oesophageal sphincter is either weak or relaxes inappropriately allowing corrosive gastric contents to flow backcausing inflammation of the oesophagus.
A small tube which measures acidity when placed in the oesophagus shows that everyone has short periods of reflux. These are usually of short duration lasting a minute or two, with a total time of less than half an hour in a 24 hour period.
Inflammation occurs when the exposure to stomach contents is prolonged and the stomach juices refluxed have a high acid and pepsin content.
An important function of the stomach is to produce and store very strong acids. Acid have roles in breaking down food for digestion, and killing unwanted infectious organisms. In order to store the juices which would digest other organs and tissues, the stomach evolved a very effective barrier layer which protects it almost as well as if it were ceramic bowl. The uniqueness that in spite of this remarkable protective layer it is still able to allow passage of those foods and fluids required by the body.
The barrier layer over the oesophagus is much weaker and not designed to resist the aggressive stomach juices. The barrier is sufficient to provide temporary protection but long exposure results in inflammation with swelling, redness and sometimes pain – the hallmarks of oesophagitis.
The causes may be divided into two groups – those with a normal lower oesophageal sphincter and those with poorly functioning oesophageal sphincter.
Increases in the pressure in the abdomen can overcome the strength of a normal valve. Such pressure increases may be associated with pregnancy, obesity, bending when the stomach is full, large amounts of free fluid in the abdomen (ascites), physical exertion including coughing, vomiting, or straining, and sometimes very tight clothing.
Impairment of sphincter pressure function can be caused by some foods including coffee, chocolate, peppermint, fried and fatty foods, and alcohol; some pharmaceutical medications. Cigarette smoking relaxes the valve. The importance of hiatus hernia is controversial.
When the upper part of the stomach moves up into the chest through the diaphragm, the person is said to have a hiatus hernia. In its normal position the gastro-oesophageal valve has additional support from the muscles of the diaphragm. When the stomach is not in its preferred position with loss of diaphragmatic support there is lowering of the pressure available to prevent reflux.
Many healthy people have a small hiatus hernia. Hiatus hernia is more common as we age and it can be shown by x-ray examination in most people over 50. Many with a hiatus hernia have no symptoms and are unlikely to ever have symptoms. It is argued that hiatus hernia is a normal aging change and not a disease.
However, hiatus hernia is associated with more reflux oesophagitis than would be expected suggesting that the loss of the effect of the muscles in the diaphragm and the change of the angle in which the oesophagus enters the stomach, sufficiently weakens the effect of the sphincter mechanism to play a significant part in many with oesophageal reflux disease.
Heartburn is the characteristic symptom. Described as a burning pain behind the breastbone, it most commonly occurs after eating. It can, however, occur on bending, lying down, straining, after coffee, and even with emotional stress. It may last up to two hours and is often relieved by taking an antacid.
While heartburn means reflux oesophagitis, it can occur with spasm of the oesophageal muscle without inflammation. It can be confused with heart pain. There are differences between heart pain and oesophageal pain. Heart pain usually is associated with exercise and the pain radiates into the left arm.
Other symptoms are a feeling of food coming back into the mouth, leaving an acid or bitter taste. There may be a feeling of delay in the passage of food with discomfort associated with swallowing. Waking at night with coughing, a feeling of tightness in the chest and a wheeze may occur due to refluxed stomach contents being inhaled.
Endoscopy is the gold standard for diagnosis. The appearance can be photographed and a biopsy obtained.
Because the symptoms are characteristic, and providing heart disease can be reasonably excluded, some argue that for milder symptoms, treatment on the history alone is safe and cost effective. This advice can be endorsed providing if treatment is unsatisfactory, the endoscopy is then done.
Treatment should consider lifestyle factors, consideration of drug treatment, and surgery.
Antacids taken regularly can neutralise acid in the oesophagus and stomach. For very mild symptoms this is the simplest satisfactory medication. Usually the relief is temporary and too much antacid can have its own side effects.
More specific is to reduce the acid production of the stomach. Histamine 2 receptors antagonists are capable of reducing the gastric acid output by 70 or 90 percent. Four members of this group are available – Cimetidine, Ranitidine, Famotidine, and Nizatidine. These can be used intermittently or for long maintenance programmes.
Almost total suppression of acid can be obtained by using a proton pump inhibitor. These are used almost exclusively for the very severe diseases. There are three proton pump inhibitors in New Zealand – Omeprazole, pantopraxole, and lansoprazole.
Other treatments which may be considered are prokinetic agents which aid clearance of fluid from the oesophagus and improve the strength of the lower oesophageal sphincter. There are three of these agents available – metoclopramide, domperidone, and cisapride.
Surgery for reflux oesophagitis has been controversial. Surgeons have always had a place in the management of disease unresponsive to drug treatment and disease with complications. The recent advances in laproscopic surgery techniques – a less invasive procedure than open surgery – have renewed interest in surgery for the less severe forms of the disease. A procedure known as fundoplication, modifies the angle between the oesophagus and the stomach, making it more acute thus creating a valve action which closes when pressure in the stomach is increased.
A feeling of fullness (early satiety), abdominal distention, and food sticking in the gullet (dysphagia) are early symptoms with surgery. These settle quickly in most, but a small number may continue with distension, some difficulty in swallowing, and occasional diarrhoea.
Sometimes serious complications develop. Bleeding may occur. Ulcers can develop leading to scarring and narrowing (stricture) of the oesophagus. Cancer is a remote possibility which cannot be ignored.
Reflux oesophagitis is a disorder with a wide spectrum of symptom intensity which spoils quality of life and which, for a few, can cause severe life threatening illness. Because of the potential for serious complications the symptoms should never be ignored as trivial. The treatment options usually advance along the lifestyle, pharmaceutical drugs and finally to the surgical options. Laparoscopic fundoplication surgery is being considered earlier than in the recent past.