Reflux / Heartburn

Dr Cameron Schauer

What?

When stomach contents back up into the oesophagus (food tube) or mouth. Most people experience a few reflux events from time to time, and many may not even notice it.

People with GORD (gastroesophageal reflux disease) have events which cause symptoms which are frequent and troublesome.

Symptoms

Classically this is a rising, burning discomfort, but may also include:

• Regurgitation
• Bad breath
• Sore throat
• Nausea and/or vomiting
• Chest pain (some people mistake it for a heart attack, or vice versa)
• Abdominal pain
• Trouble swallowing (dysphagia)
• Sense of lump in the throat
• No symptoms at all (“silent reflux”)

Why?

There are many different causes.

One of the more common causes is that the junction of the oesophagus and stomach is lax. This area usually is able to tighten and contract, via a sphincter (muscle) mechanism, which prevents the food or fluid you eat coming back up from the stomach. In addition, acid which is produced in the stomach will also reflux up, which causes the classic burning sensation.

In patients with a hiatus hernia (where the stomach is elevated about the breathing muscle or diaphragm) this sphincter mechanism is not able to contact and pinch off efficiently because of the displacement of the stomach.

Why me?

We are not sure why some people develop reflux and some don’t. It is a common condition, affecting up to 30% of the population, with an increasing prevalence including younger patients. Symptoms have been shown to have significant impact on quality of life and productivity with considerable economic burden.

Risk Factors for reflux include:

• Overweight – a higher weight will increase abdominal pressure which pushes things back the wrong way
• Pregnancy – there is a similar mechanism as those with higher weight
• Hiatus hernia

Diet:

• Fatty foods, especially chocolate
• Caffeine
• Alcohol
• Fizzy drinks
• Smoking

Diagnosis:

The history you provide of your symptoms is very important. Sometimes a trial of PPI (see below) medication is given to see if this improves things outright.

If there is concern or otherwise, I may suggest  a gastroscopy (flexible camera down the food tube) which can be very useful. This can also provide information about anatomy (i.e. hiatus hernia) or if there are complications as a result of the reflux.

This may include:

1. Oesophagitis: this is inflammation as a result of reflux. There can be ulcers, erosions and bleeding.
2. Stricture: this is when there is repeated and prolonged oesophagitis, with intermittent healing which causes scar tissue formation and subsequent narrowing. Food may even become stuck at the narrowing.
3. Barrett’s oesphagus: This is when the normal cells (‘squamous’) in the lower part of their oesophagus are replaced by a different type of cell (‘columnar’). Some people with acid reflux never get Barrett's oesophagus, but some do. We are not sure why this is the case. If you have had acid reflux for a long time, it's important to know if you have this condition. This is because the cells have a small risk of transforming into pre-cancerous cells over time, which if detected early, can be treated before they become oesophageal cancer. We perform surveillance (repeated tests every few years) to assist with this.
4. Lung and throat problems – Acid may be refluxing up to the vocal cords and you get a sore throat or raspy voice. It can also tip into the lungs, which can cause coughing, infection or shortness of breath. Over time, acid in the lungs can lead to permanent lung damage.
5. Dental problems— Repeated episodes of acid reflux can erode the enamel of the teeth over time.

Treatment:

• Lifestyle changes:
  • Lose weight
  • Raising the head of the bed: this uses gravity to help food and fluid stay in the stomach as opposed to come back up when lying flat. Using extra pillows does not work (this raises the neck only). You can use blocks of wood under the legs or a foam wedge over the mattress. 
  • Avoiding trigger foods (see above)
  • Stop smoking
  • Avoid lying flat after meals, avoiding late night meals
  • Eating smaller meals
  • Avoid wearing tight fitted clothing

• Medications: These are generally effective at improving symptoms in over 80% of patients.
  • Proton pump inhibitors (PPI) – these reduce the amount of acid. This includes medications such as omeprazole, pantoprazole, lansoprazole.
    • These are most effective if taken 30 minutes prior to a meal, when acid is being generated.
  • Histamine receptor antagonists – this includes ranitidine or Famotidine. They may lose their effectiveness over time.
  • Ant-acids like Mylanta, acidex – these reduce symptoms by adding a soothing coating over the acid-burn, but do not really treat the underlying cause.

• Surgical treatment:
  • There are some endoscopic (interventions through the camera) and surgical options (i.e. laparoscopic fundoplication) for trying to improve or restore the function and strength of the junction. I generally suggest these to people who have ongoing symptoms despite medication, or you are unable to tolerate the medication (adverse effects or difficulty remembering to take them). I will speak to you about options and pros and cons of these and what is involved.