Heartburns: Commonest Symptom of Gastro-Oesophageal Reflux Disease

What is heartburn?

Heartburn refers to a feeling of burning sensation within your chest just behind the breastbone which makes you feel as if your heart was by a burning flame. This happens to be the commonest symptom of Gastroesophageal Reflux Disease (GERD).

What is GERD?

Gastroesophageal Reflux Disease is a common condition which results from a backward flow of acids from the stomach to the upper part of the gastrointestinal tube usually going past the lower esophageal  sphincter into the oesophagus.

The heartburns felt from GERD are as a result of the acids burning or eroding the membranes of the esophagus. People occasionally experience heartburns which may be transient and may not require treatment. This can be the case when you lie down immediately after eating. 

However, a persistent feeling of heartburn which likely affects your daily activities may point to Gastro-oesophageal Reflux Disease and may need treatment to resolve.

Untreated GERD can lead to complications which may include narrowing of the esophagus, ulceration, strictures, and adenocarcinoma.

What causes heartburns and GERD

The esophagus is a tube joining the throat and the stomach. Beneath the oesophagus is a ring of muscle called the lower esophageal sphincter which is supposed to open to allow the passage of food bolus and close after its passage.

Heartburns or GERD develop when that ring of muscle becomes defective. That is to say, it is likely to get the stomach content moving backwards into the oesophagus when the lower esophageal sphincter becomes weak or malfunctional. The backflow of acid is intensified upon bending down or lying down.

Stomach content is acidic in nature and may be very corrosive. Unfortunately, unlike the stomach, the oesophagus does not have an acid-resistant lining and hence is exposed to the destructive nature of the acid. This is responsible for the burning sensation (heartburns) that is felt.

Who is at risk of getting heartburns or GERD?

• People who are obese: This usually leads to an increase in abdominal pressure (Read more about it here)
• Pregnant women
• Smokers
• People who drink alcohol, carbonated drinks and caffeine a lot
• People who use  medications that decrease the lower esophageal sphincter pressure e.g. anticholinergics (like hyoscine butylbromide), morphine, diazepam, pethidine, calcium channel blockers
• Children with chronic neurological disease (e.g. cerebral palsy)

What are the symptoms of GERD in adults?

• Burning sensation or discomfort in the middle of your chest just behind the breastbone (heartburns)
• Bitter taste in the mouth
• Epigastric pain which worsens on bending down
• Nocturnal regurgitation (wakes you up in the middle of the night with cough, choking and filling of the mouth with saliva)
• Sore throat, hoarse voice, and cough
• Pain on swallowing or difficulty swallowing

What are the symptoms of GERD in children?

• Refusing to eat
• Coughing
• Vomiting
• Wheezing
• Forceful regurgitation which may lead to aspiration pneumonia

Which tests will be done to diagnose GERD?

It is common practice to diagnose GERD using the symptoms but aside from that there are a number of laboratory investigations that can be carried out to diagnose GERD or any complication that may be present. Some of these tests include:

• Endoscopy of the upper gastro-intestinal tract (looking into the esophagus with the aid of a flexible tube and camera)
• Barium swallow fluoroscopy
• Lower esophageal sphincter manometry (testing to see if the ring muscle at the end of your esophagus is working well)
• Esophageal pH monitoring (measuring the amount of acids in the esophagus using a thin, flexible tube with a sensor at the end of it )
• Chest x-ray (to rule out other causes of chest pain)
• Abdominal ultrasound (also to exclude other possible diseases)

What can you do to relieve or prevent heartburns or GERD?

Lifestyle changes may help relieve or prevent GERD or heartburns. Some of the things recommended include:

• Supporting your head with pillows when sleeping or elevating the head of your bed to about 30 degrees
• Do not eat heavily prior to sleeping or do not sleep immediately after eating
• Avoid wearing tight clothes, corsets and the likes. Instead wear loose clothes
• Lose weight if you are overweight (check this out: Natural ways to lose weight without medicines)
• Avoid smoking and excessive alcohol intake
• Undertake moderate exercise regularly
• Avoid foods that may aggravate symptoms e.g. spicy foods, coffee, chocolate, carbonated drinks
• If there are any medicines that you are taking, mention them to your pharmacist or doctor since some may contribute to the condition

How is GERD or heartburn treated?

Medications used to treat heartburns may fall into the following categories:

• Antacids
• Acid suppressive agents
• Promotility agents

Antacids

These are medications that are able to decrease the acidity nature of the stomach content and hence help reduce the pain. Examples of such medications are Magnesium trisilicate, Aluminium hydroxide, and other combined products of aluminium and magnesium salts. Some of the common brands out there include: Nugel, Nugel-O, Stomocaine, Gastrone.

In very mild cases of GERD, the use of antacids alone may be enough to resolve the heartburns.

Acid suppressive agents

These are agents that act on certain cells in the stomach to prevent the secretion of acids. This decreases the acidity of the stomach content and may make room for injured esophageal tissues to heal fast. They may be required to be used for an extended duration (a minimum of one month).

Two main classes of medications fall under this category of drugs used to treat GERD. They are:

• Proton pump inhibitors: Examples include omeprazole, pantoprazole, rabeprazole and esomeprazole 
• H2- antagonists: Examples include cimetidine, ranitidine

Promotility agents

These agents primarily increase the rate at which food passes through the gut thereby decreasing transit time. Since food doesn’t stay in the gut for long, the tendency of a backward flow (reflux) is reduced. Also some act by increasing the lower esophageal sphincter pressure, making it stronger to prevent reflux. 

Examples of such agents include metoclopramide and domperidone. They are, however, not recommended for use as single agents in the management of GERD. Meaning, you have to use them as add-on to the other medications and unlike the others they shouldn’t be used for long.

When should you see a pharmacist or doctor about your GERD?

Chest pain may be a sign of a more serious condition and hence the presence of any of the following should push you to seek medical advice.

• Experiencing heartburns more than twice in a week despite taking antacids
• Results in shortness of breath
• There is difficulty swallowing or severe pain on swallowing
• Persistent vomiting and nausea
• Excessive weight loss

References

1. Heartburn – Symptoms and causes. (2021). Retrieved 13 July 2021, from https://www.mayoclinic.org/diseases-conditions/heartburn/symptoms-causes/syc-20373223
2. Quick Facts: Gastroesophageal Reflux (GERD) – MSD Manual Consumer Version. (2021). Retrieved 13 July 2021, from https://www.merckmanuals.com/home/quick-facts-digestive-disorders/esophageal-and-swallowing-disorders/gastroesophageal-reflux-gerd?query=heartburn
3. Heartburn. (2018). Retrieved 13 July 2021, from https://www.mydr.com.au/gastrointestinal-health/heartburn/
4. Smith, L. (2005). Updated ACG Guidelines for Diagnosis and Treatment of GERD. American Family Physician, 71(12), 2376. Retrieved from https://www.aafp.org/afp/2005/0615/p2376.html
5. Standard Treatment Guidelines, 2017 Ghana