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AUSTRALIAN GASTROENTEROLOGY INSTITUTE
(educational arm of the Gastroenterological Society of Australia)
Website: www.gesa.org.au... Copies reviewed January 2006

HEARTBURN - A Guide to Reflux Disease

What is reflux disease?

Gastro-oesophageal reflux disease is a common cause of indigestion. It is caused by the washing back (reflux) of food and stomach acid into the gullet (oesophagus). This occurs because a muscular valve (sphincter) at the junction of the oesophagus and stomach fails to work properly.

What are the symptoms?

The stomach contents irritate the oesophagus and cause a painful burning sensation in the chest rising up to the throat (heartburn). Sometimes this is accompanied by a bitter taste in the mouth. These symptoms typically occur after food.

Large meals and fatty or spicy foods are most likely to cause problems. Lying down or bending over may cause or worsen symptoms.

Stomach contents may rise as far as the throat (often described as repeating) and be experienced as regurgitation. When severe, it may resemble vomiting. Occasionally they may irritate the breathing passages and cause cough, hoarseness, sore throat and asthma. If this happens at night it may cause awakening with choking attacks.

Is reflux the same as a hiatus hernia?

No.

Hiatus hernia is protrusion of the top of the stomach through the diaphragm up into the chest cavity. Although a hernia helps to cause reflux disease, many people have a hiatus hernia but no reflux problems because their sphincter functions properly.

Is reflux serious?

Not usually.

In most sufferers reflux disease is no more than a nuisance, bothering them only on some occasions, eg. after large spicy meals. In some people it causes regular discomfort that disrupts their lives.

Most people with reflux disease do not have any significant damage to their oesophagus. In severe cases irritation caused by the refluxed stomach juices damages the lining of the oesophagus, causing oesophagitis and stricture.

• Oesophagitis is inflammation and ulceration of the lining of the oesophagus. This ulceration can cause painful swallowing and also bleeding.
• Stricture is narrowing of the oesophagus caused by scarring because of longstanding oesophagitis. Stricture causes difficulty with swallowing because food sticks at the narrowing.

Is it my lifestyle?

Reflux can be made worse by things you do or have some control over.

• Diet. Heartburn is typically more frequent after large, fatty or spicy meals. Many people find that specific foods provoke symptoms, eg. curries, fish and chips, pasties, roasts and chocolate.
• Eating habits. Eating just before you go to bed or before you exercise can lead to symptoms.
• Smoking may aggravate reflux.
• Alcohol may make reflux more irritant and so provoke symptoms.
• Pregnancy is often associated with troublesome reflux, probably due to hormonal factors and the pressure of the baby. It resolves as soon as the baby is born.

Is there something I can do?

The occasional heartburn episode is often diet related. Simple self-help measures are worth trying first. If these give adequate relief you do not need to do anything further.

• Avoid eating large or fatty meals, and any foods that aggravate your symptoms.
• Avoid eating within two hours of lying down or before going to bed.
• Lose weight if you are overweight.
• Limit alcohol consumption.
• Stop smoking.
• Prop up the head of the bed ten centimetres (one housebrick) or use a wedge pillow, particularly if your symptoms bother you at night.
• Try an antacid when heartburn occurs. Tablets are most convenient as they are easily carried. Choose an antacid form and flavour that appeals to you. Only low or sodium-free antacids should be used by people who must limit their salt intake.

When should I consult my general practitioner?

You should see your G.P. without delay if:

• food sticks on the way down
• swallowing is painful
• you vomit blood
• choking attacks occur.
•  

In these circumstances you may have complications of reflux disease that need diagnosis and stronger treatment than self-help measures.

You should see your G.P. if the self-help measures do not relieve your symptoms.

How can the doctor help me?

Your doctor can check your self-diagnosis. After this check, your doctor may try a course of prescription treatment, or determine a need for tests or evaluation by a specialist.

Special tests and reflux

Your local doctor may ask a specialist to give advice on your symptoms and organise some tests.

Endoscopy. Under sedation, the inside of your oesophagus and stomach is examined directly with a flexible telescope to see if there is any oesophagitis. Endoscopy also excludes any other problem such as a stomach ulcer.

Barium meal or swallow. X-ray pictures are taken as you swallow a thick liquid which outlines the oesophagus and stomach. It is most useful for seeing why food sticks.

Other special tests

• Oesophageal acidity or pH monitoring. A fine wire is passed through the nose into the gullet to record acidity in the oesophagus, usually for 24 hours at home. A small box, carried on a belt, makes the recordings. It is especially useful when the diagnosis is still uncertain, even after endoscopy.
• Oesophageal pressure testing or manometry measures how the muscles of the oesophagus work. This information is sometimes useful in people with reflux symptoms.

What prescription treatment is available?

There are several types of medication that prevent reflux symptoms and heal oesophagitis. These usually need to be taken regularly rather than only when you get your symptoms.

• Stomach acid suppressants: (a) H-receptor antagonists - cimetidine, famotidine, nizatidine and ranitidine. (b) Prostaglandins - misoprostol (c) Proton pump inhibitors - lansoprazole, omeprazole and pantoprazole all reduce the amount of acid that the stomach produces.
• Muscular stimulants, such as cisapride, aim to tighten the sphincter and improve the return of refluxed juices back to the stomach.
• Lining (mucosal) protectants such as sucralfate, stick to the ulcerated lining of the oesophagus and help to protect it from the stomach juices.

Medication can relieve symptoms and heal oesophagitis in almost everyone. In some people several adjustments to treatment may be needed.

Strictures are stretched (dilated) at the time of endoscopy.

Will reflux disease go away?

Not usually.

Medication has no permanent effect on the abnormalities that cause reflux. Thus it usually recurs if treatment is stopped.

What long term choices are there?

Recurrent reflux problems can usually be prevented by continuous medication. Sometimes an operation which improves the function of the valve (sphincter) may be appropriate. The merits of these two choices should be discussed with your doctor.

AUSTRALIAN GASTROENTEROLOGY INSTITUTE

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