More than 40% of all adults experience this uncomfortable, burning sensation at least once a month. For most, it is an occasional occurrence that is easily relieved with an over-the-counter antacid. But for others, heartburn is a daily struggle that has changed the way they live. Their lives, from what they eat to how they sleep, to the type of clothes they can wear.

What Really Is Heartburn?

Heartburn is frequently referred to as acid indigestion. It is generally described as a burning sensation in the chest, usually felt behind the breastbone and sometimes moves upward to the neck and throat. Heartburn may last as long as two to three hours and can occur after eating a large meal or when you bend over or lie flat. Smoking, caffeine and alcohol may increase the level of acid in your stomach, causing even more heartburn. While heartburn is typically not serious, but when accompanied by a sour-tasting fluid in your throat and difficulty swallowing, it can be more serious. Although “heartburn” is often used to describe a variety of digestive problems, in medical terms, it is actually a symptom of gastro-oesophageal reflux disease (This also is known as reflux disease). Other symptoms may also include regurgitation, difficulty swallowing and chronic coughing or wheezing. Occasional heartburn is common but does not necessarily mean one has GORD. Heartburn that occurs more than twice a week may be considered GORD and it can eventually lead to more serious health problems.

So what is gastroesophageal reflux?

Gastro-Oesophageal reflux disease, or GORD, is a chronic disease that occurs when the lower oesophageal sphincter does not close properly and stomach contents leak back, or reflux, into the oesophagus. Anyone, including infants, children, and pregnant women, can have GORD.

Is Your Heartburn Really Gastroesophageal Reflux Disease?

Persons with GORD or reflux disease often complain of having:

• Painful heartburn (indigestion).
• Pain in the middle of the chest.
• Coughing and/or choking while lying flat.
• Increased salivation.
• Regurgitation.
• Difficulty in sleeping after eating.
• Asthma-like symptoms may occur.

What Causes Heartburn?

The burning feeling of heartburn is caused by acid that escapes from your stomach through a weakened one-way valve near the top of your stomach called (lower oesophageal sphincter). The acid can travel or reflux upwards into the oesophagus as far as the throat causing painful heartburn and indigestion. The food is propelled from the mouth into the oesophagus, which is a muscular tube, approximately 10 inches long that leads directly into the stomach. The food automatically travels through the oesophagus as a result of wave-like muscular contractions called peristalsis. When you swallow, the lower oesophageal sphincter opens, allowing food to enter the stomach before it quickly closes. But when it fails to close effectively the fluid and juices in the stomach wash back into the oesophagus. This stomach acid irritates the oesophagus and can cause it to become inflamed, scarred or even ulcerated.That is why people with severe GORD may have difficulty swallowing or often have the sensation that food is stuck in their throats. The swelling and inflammation in the oesophagus can lead to pain, pressure and burning in the chest and throat. The scarring which develops in the oesophagus will narrow it and make it harder to swallow. If an ulcer develops in the lining of the oesophagus, it can produce pain and bleeding, as well as difficulty in swallowing. If untreated, reflux can lead to respiratory problems or even oesophageal cancer. The increase of the pressure in the stomach and/or relaxation of the muscle tone of the valve can precipitate GORD. Loosening of the muscle tone of the valve with aging, pregnancy, as well as fatty foods, alcohol, coffee, and nicotine (cigarettes). Medications, especially smooth muscle relaxants, such as theophylline, oral bronchodilators, calcium channel blockers and diazepam can cause reflux. Usually foods such as chocolate, peppermint, fried foods, coffee, alcohol and cigarette smoking are involved.

Is Heartburn a Sign Of Heart Disease?

Heartburn pain can also be mistaken for a heart attack or heart disease. But there are major differences. Usually heartburn pain is not associated with any physical activity, while exercise can increase the pain resulting from heart disease or the onset of a heart attack, and rest may temporarily relieve the pain. Chest pain from hiatus hernia and/or oesophageal spasm may be extremely difficult to distinguish from chest pain of cardiac origin. The symptoms of pain spreading from below the sternum (breastbone) to the neck, jaw, and arms can mimic those of coronary artery disease.This situation is complicated by the fact that persons who have both heart disease and reflux may experience acid reflux that increases the workload of the heart and brings on angina. Severe reflux may also cause acid to bubble up from the stomach into the windpipe and lungs, causing respiratory difficulty such as wheezing in an asthma-like attack. If you experience any of these symptoms, it is best to immediately seek medical care to evaluate your problem.

What are the Symptoms of GORD?

The main symptoms are persistent heartburn and acid regurgitation. You may feel like you have food stuck in your throat or like you are choking or your throat is tight. GORD can also cause a dry cough, bad breath and damaged teeth.

Is my Reflux Caused By a Hiatus Hernia?

Another cause of GORD or reflux is a hiatus hernia. This is an opening in the diaphragm (a flat muscle that separates the thorax from the abdomen). When this occurs, the top of the stomach slips through the enlarged hiatus hernia and bulges into the chest cavity. While some people are born with a hernia, factors such as stress, heavy lifting, or the normal wear and tear of life can cause the opening to enlarge, allowing the stomach to protrude into the chest. This can cause the valve between the stomach and the oesophagus to fail, causing severe heartburn.

What are the Symptoms of Reflux Disease (GORD)?

• Burning sensations in the chest. These may start in the upper abdomen & radiate into the neck
• Regurgitation of sour/bitter-tasting material into the throat & mouth.
• Regurgitation when lying down/ sleeping.
• Heartburn 1-4 hours after eating or immediately after drinking orange juice.
• Excessive Belching.

Some people have GORD without heartburn. Instead, they experience chest pain, hoarseness in the morning, or trouble swallowing, bleeding. Occasional choking sensation (your throat is tight). GORD can also cause a dry cough, bad breath and damaged teeth.

How would you diagnose GORD?

The above history of heartburn, followed by an upper GI endoscopy and possibly a pH manometry (A study to define whether or not and how much a patient refluxes acid). The patient attends an out patient clinic, where a naso-gastric tube is inserted and a small, portable monitor is given to wear around the waist. They then go about their normal activity for a full 24 hours, returning the next day for the equipment to be removed and the data interpreted).

When to See a Doctor?

• If your heartburn persists with bleeding, pain and difficult swallowing.
• If you’re having symptoms you can’t distinguish from heart problems.
• If you’re having “wheezing” symptoms that don’t respond to medication.

Click here for Treatment of heartburn & Gastroesophageal reflux disease

This is information about the treatment of Gastro-oesophageal reflux disease (GORD) and hiatus hernia.

General Changes You Can Make

• Lifestyle changes can make a difference in relieving your symptoms. Raising the head of the bed (about six inches) and avoiding heavy lifting reduces heartburn by allowing gravity to minimize reflux of the stomach’s contents into the oesophagus. You can slide blocks or books under the legs at the head of the bed or sleep on a specially designed wedge. Tilting the bed is better than trying to sleep on several pillows, which can increase pressure or even make GORD worse.
• Reducing weight and stopping smoking are recommended because both weaken the LOS, (lower oesophageal sphincter) and increase stomach acid production and irritation.
• Avoid wearing tight garments.
• Avoid lifting heavy objects or bending forward if possible.
• Avoidance of certain foods & drinks that can weaken or reduce LOS pressure such as citrus and tomato products, caffeine, chocolate, carbonated drinks, fatty foods, spicy foods, onions, mint, nicotine, alcohol especially spirits and red wine.
• Eating smaller, more frequent meals rather than three large ones a day and avoid eating close to bedtime (usually 2-3 hours).

Medical Treatment:

Medications include those which neutralise the acid or reduce its effect, reduce acid production, increase gastrointestinal motility and those which protect the mucosa. Over-the-counter medications such as antacids (Rennie) may offer some comfort. They are usually taken after meals or at bedtime. Antacids, if taken regularly, can neutralize acid in the oesophagus and stomach and provide at least temporary or partial relief. If an antacid has not provided relief in several weeks, it probably won’t. Alginates (Gaviscon) are compounds that form a “raft” that floats on the surface of the stomach contents to reduce reflux. Long-term use of antacids can result in side effects, including diarrhoea, constipation, changes in the way your calcium metabolizes, and a build-up of magnesium in the body. Those with kidney disease or high blood pressure should consult their GP first. Similarly, if antacids are needed for more than 3 weeks, then your doctor should be consulted. If the symptoms continue, then acid reducing drugs are used. These include H-2 blockers (such as cimetidine, ranitidine). Another type of drug, the proton pump (or acid pump) inhibitor (PPI) such as Omeprazole and Lansoprazole. H-2 blockers may cause confusion in elderly patients, can increase the effects of alcohol. Antacids and cimetidine should be taken one hour apart because antacids reduce the drugs effectiveness. Other medical approaches include increasing the strength of the LES and quicken emptying of stomach contents with motility drugs that act on the upper gastrointestinal tract. These drugs include Motilium and Metoclopramide. Still, these drugs can have serious side effects. These drugs are usually prescribed for short-term use. Their side effects include stomach or abdominal pain, diarrhoea and nausea. Aspirin and anti-inflammatory drugs like ibuprofen? reduce the protective lining of your stomach, which can lead to more irritation.

Surgical Treatment

There are several types of surgical procedures now available for treating hiatus hernias and Gastroesophageal reflux disease. The traditional surgical procedure, known as Nissen fundoplication, involving a single long incision, a hospital stay of 4-6 days. Because the abdominal muscles must be cut to perform the surgery, you probably will experience more pain and discomfort in the hospital and later at home. The recovery period is 6 to 8 weeks. As a result, surgery has typically been limited to those patients with extreme or life-threatening conditions. Now a laparoscopic technique makes it possible to perform the same operation in a minimally invasive manner. Most patients go home in 1 or 2 days with only 5 tiny marks and, in most cases, can return to work and other normal activities within a week or two.

With either method, the hernia is repaired based on the “traditional” procedure developed by Dr. Nissen in 1948. The upper portion of the stomach is wrapped around the intersecting area where the oesophagus opens into the stomach like ?a Sausage in a bun?. This strengthens the area and prevents acid and food from refluxing up into the gullet. Studies have shown that more than 93% of patients who undergo the procedure say their symptoms are cured or improved after 10 years.

Laparoscopic Fundoplication

Involves having a laparoscope (slender tube, with a special system of lenses, a light source and a tiny video camera which transmits an image of the organs being inspected) in addition to special surgical instruments which are inserted through small abdominal incisions. These usually heal fairly quickly with less discomfort than with the traditional open Fundoplication.

Should I be concerned that the laparoscopic technique is new?

Laparoscopy has been used in gynaecological surgery for nearly 3 decades, and today, more than 97% of all gallbladder surgery is performed laparoscopically. More recently general and thoracic surgeons have applied the laparoscopic technique to a broad range of surgical procedures including appendectomy, hysterectomy, and lung and bowel surgery.

What are the side effects and what can go wrong?

The procedure is generally safe and there has been a low or zero mortality in most? ? experienced surgeons’ hands.

Side effects include:

• Short term difficulty swallowing especially white bread or lumpy foods. This is due to bruising of the lower oesophagus. It can last up to 3 months. It usually settles in due course.
• Bloating and increased flatulence. This is due to the inability to burp up swallowed air. It slowly improves with time.
• Diarrhoea can rarely occur in patients with large hernias caught in the chest as damage to the vagus nerves can occur in reducing the hernia out of the hiatus.

Complications include:

• General anaesthetic complications such as heart irregularities, chest infection, deep venous thrombosis and pulmonary embolism… etc.
• Bleeding from the spleen or gastric vessels.
• Tearing of the oesophagus resulting in leakage.
• Slippage of the wrap or breakdown of the hiatus resulting in pain or difficulty swallowing.
• Recurrence of the reflux or the associated hiatus hernia.

The incidence of serious problems is very small and patients in the vast majority of cases are very happy with the outcome of their surgery. If anything goes wrong at surgery the patient may require an open procedure to repair the damage.

Am I a candidate for laparoscopic Nissen fundoplication?

Although the majority of patients are eligible for a laparoscopic procedure, it may not be appropriate for some patients, including those who have had previous abdominal surgery on the stomach or the diaphragm or who have some pre-existing medical conditions. A thorough medical evaluation by your surgeon at the consultation, can determine if laparoscopic antireflux fundoplication is an appropriate procedure for you.

Click here for Gastro-oesophageal Reflux Disease (GORD)