Most of the population of Australia will, at some time in their life, experience heartburn; yet we don’t think about its effects until it is happening to us. Dr Alan Thomas from Upper GI West answers our questions on this common condition.

What exactly is heartburn?
Heartburn is a symptom that patients complain of when the oesophagus is exposed to abnormal amounts of acid coming up (refluxing) from the stomach. Sometimes people experience heartburn with normal levels of acid refluxing from the stomach because the oesophagus is extra sensitive. The most common cause for heartburn is an abnormally functioning valve between the stomach and the oesophagus and/or the presence or a hiatal hernia. A hiatal hernia is an abnormal protrusion of the top of the stomach through the natural opening in the diaphragm. Hiatal hernias can be as small as 1-2cms and may be present in 20% of the population; or large enough for the whole stomach and other organs to pass through.

What does heartburn feel like?
Heartburn can present as a sharp burning sensation, pain or discomfort in the lower chest that moves upward toward the neck area and is often accompanied by an acidic or metallic taste at the back of the throat. When liquid or food is present in the mouth this is called volume reflux.

How long does heartburn usually last?
When acid hits the oesophagus, usually symptoms are experienced quickly, often within a few seconds. The acute discomfort or pain usually lasts no more than a few seconds to a few minutes at one point in time but some individuals can continue to reflux for many hours at a time, especially after a big meal and when lying flat.
If there is acid in the mouth or throat voice changes, then sore throats can occur. Also, the refluxed liquid or food in the throat can be inhaled into the lungs. This can cause a worsening of asthma, recurrent chest infection or pneumonia, which can be life threatening.

How do I know when I should see a professional about my heartburn?
Around 30-40% of the adult population in Australia will experience heartburn at some point during the year. There is no definitive set of criteria that determine when you should see a GP, rather it is really an individual’s decision as to whether they consider their symptoms to be significantly affecting their quality of life. If it does, then by definition they have a disease process. They can then be said to suffer from Gastro oesophageal reflux disease (GORD). So, if you are significantly troubled go and see your GP.

Are there certain food and drinks I should avoid?
The foods or drinks precipitating heartburn varies quite considerably between individuals. The more common culprits include:
• fatty foods
• tomatoes
• pastries
• chocolate
• alcohol
• caffeine-based products.
Many of these tend to cause heartburn as they cause a relaxation of the valve at the top of the stomach between the stomach and oesophagus.

What are some lifestyle changes I can make to improve my symptoms?
Firstly, try and avoid the foods and drinks mentioned above as much as possible. Secondly, leave as much time as possible between eating and drinking and going to bed at night. As people lay flat in bed at night, the effect of gravity is lost. Imagine acid going up to the oesophagus while you’re standing up, gravity helps the natural rhythmic movement in the oesophagus move the acid back down. If you’re lying flat, the additional effect of gravity is lost.

Added to this is the fact that the natural rhythmic movement in the oesophagus, as well as the amount of mucous produced in the mouth and oesophagus, are also reduced at night so this further reduces the dilution and movement of acid back into the stomach and worsens symptoms.

How do I know if the pain in my chest is heartburn and not something more serious like heart trouble?
As heartburn symptoms are experienced in the chest and the oesophagus is supplied by the same nerve that supplies the heart, the symptoms can be very similar to heart-related pain. If you are under 40 years old, with the typical heartburn type pain described above and who has no risk factors of cardiovascular disease, diabetes, no history of smoking and no family history of heart disease then you are unlikely to have a heart related issue.

The chances are the symptoms are due to GORD. If you are over 40 years old or have any of the additional risk factors mentioned above or have other symptoms such as shortness of breath, tightness in the chest after exertion or palpitations then conditions other than GORD are likely and an urgent consult with your GP or Emergency Department may be advised.

The safest and advisable course of action is to always get checked out by your GP or emergency physician. I have a simple philosophy; if in doubt get checked out.

Putting a brick or a couple of books under the head end of the bed brings gravity back into play and can help reduce heartburn at night. It is better propping the bed end up rather than trying to sleep on lots of pillows because most people sleep on their side and pillows simply cause uncomfortable bending of the spine. Thirdly, as obesity is a large risk factor of the heartburn symptom, weight loss can improve symptoms dramatically.

Why is my heartburn worse during pregnancy?
Obesity can worsen heartburn due to increased pressure in the abdomen. In the same manner as the foetus grows in the uterus, there is an increase in pressure in the abdomen so heartburn can ensue.
There is a possibility of direct pressure on the stomach pushing more up into a hiatal hernia as well. Towards the end of pregnancy, hormonal changes in preparation for delivery cause tissues to relax. Tissue relaxation causes the valve at the top of the stomach to open more often and it can allow more of the stomach up into a hiatal hernia as well. Both of these mechanisms can make pregnant women even more susceptible and symptomatic with volume reflux and heartburn when they occur.

What are some treatment options?
As with most treatments, they range from the simple to the complex. Everyone should start with the simple lifestyle recommendations as far as practical, then add on medications and lastly consider surgical options. Over-the-counter medication can be a quick fix for someone experiencing mild heartburn symptoms. These can help to neutralise the acid or coat the lining of the oesophagus.

Stronger over the counter medications are also available now. These
are the Histamine type 2 (H2) antagonists and the Proton Pump Inhibitors (PPI’s).
The H2 antagonists reduce the acid in the stomach by about 60% whilst the PPI’s reduce the acid by 90-95%. The H2 antagonists and PPI’s are also available at higher doses and for longer duration on the PBS.

Lastly, there are surgical options to reduce symptoms. These procedures include the tightening of the hiatus and/or fundoplication surgery. A fundoplication involves wrapping the top part of the stomach around the bottom of the oesophagus to mechanically assist the valve keep acid, liquid and food in the stomach. Also, if there is a hiatal hernia then this is repaired. These operations are performed by keyhole surgery through five tiny incisions and an in-patient stay of two to three days. The aim of treatment is to improve symptoms and hence the quality of life whilst minimising side effects.

Can I permanently get rid of heartburn?
The short answer is yes (but it comes with some caveats)! The aim of all treatment is to alleviate
symptoms permanently. However, a sad fact of life is that all tissues relax and weaken as we get older. Muscle strength also deteriorates even in the oesophagus! We also tend to gain more fat mass as we age. As such treatments which may have held symptoms at bay for years may fail to do so as time goes by. Reherniation through the hiatus can occur.

The principles of all treatment remain the same: Control of symptoms with minimal side effects to optimise quality of life, starting with the simplest and moving up the treatment ladder to surgery.

Similarly, the aim of surgery is to be a once-in-a-lifetime procedure but again as tissues and circumstances change, symptoms may recur. If they do, then lifestyle changes and medications may again prove beneficial but occasionally surgery is required again.

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