What is Heartburn (Acid Reflux)?
Heart burn also commonly known as Acid Reflux is officially called gastro-oesophageal reflux disease (GORD or GERD if you live on the other side of the pond!!). In simple terms it means the stomach acid instead of staying in the stomach where its meant to be is tracking up the gullet (oesophagus). As the lining of the oesophagus is not designed to resist acid, the exposure to it literally causes chemical burns to the lining and pain. Prolonged exposure to gastric contents results in oesophagitis.
Typical symptoms include chest pain that may start in the top of the tummy and rises into the chest. This can be so severe that patients have been admitted with suspected heart attacks. Nausea, acid taste in the mouth (especially when bending over), bloating, belching, food sticking and pain when swallowing hot or cold drinks are also commonly seen in GORD. In severe cases patients may complain of a persistent cough, sore throat, hoarse voice, short of breath and even asthma-like symptoms (supra-oesophageal symptoms). Indeed some patients may have been mistakenly diagnosed to have asthma or referred for ENT consultation and undergone voice training.
Why do I get Bile tastes in my mouth?
In a subgroup of patients bile is also tasted in their mouth in addition to the acid taste. This is more evident when patients start taking medications to stop the acid production (eg. Omeprazole). This situation is sometimes referred as volume reflux. As the name suggest significant volume of gastric content (bile and acid) is refluxing back up the gullet and into the mouth. In addition to the symptoms of heart burn many patients also complain of food regurgitation or vomiting. Biliary reflux contains bile, enzymes and other chemicals found in the duodenum. These alkali agents, just like acid can cause damages to the oesophageal lining albeit insidiously with little or no symptoms at all.
Why do you get Reflux?
When food is swallowed it goes down the gullet (oesophagus) which starts from the back of your throat down the chest and through the hole (hiatus) in the diaphragm that separates the chest from your tummy (abdomen). At the lower end of the gullet together with the diaphragmatic muscles that surrounds it form the lower oesophageal sphincter mechanism that works mainly as a one way valve. This allows food to go into the stomach but restricts, most of the time, anything from going back up the gullet. This means you can belch and vomit when the need arises. Reflux occurs when this valve fails.
There are many reasons why this valve can fail. The most common causes include hiatus hernia, a wide cardia and poor gastric emptying. A hiatus hernia is when part or whole of the stomach slips into the chest through the hiatus. A widened cardia is when the lower end of the gullet remains wide open. In both cases the lower oesophageal sphincter mechanism loses its ability to close and this enables stomach content to reflux up the oesophagus. In about 20% of patients with GORD their stomachs emptying is delayed after meal. This prolonged period of stomach distension encourages reflux.
What is Barrett's Oesophagus?
Barrett's esophagus refers to the replacement of the normal lining of the oesophagus with a mixture of gastric and intestinal cells (lining of the stomach) from chronic GORD. In simple terms the oesophagus simply changes its lining into something that can resist gastric contents. And perversely people who have had longterm reflux symptoms may find themselves becoming symptom-free when Barrett's oesophagus develops. This may seem a good thing if you are a GORD sufferer. The problem with Barrett's oesophagus is that this is associated with increase risk of developing oesophageal cancer. Thankfully this is rare with the risk being between 1 in 200 to 300 patients per year.
What investigations do I need?
The gold standard is an upper gastrointestinal endoscopy
(AKA oesophagogastroduodenoscopy or gastroscopy). This is when a thin flexible tube with a camera on its end is swallowed. This allows us to see any damages or changes in the lining of the oesophagus, stomach and duodenum. It will also allow for taking biopsies. It is likened to you walking into a house and see the wall colourings and decor. This is done either with sedation or with the throat numbed with a throat spray.
In rarer incidence when an endoscopy is not possible you may have a barium swallow/meal. This is done with X-rays when you drink a milky drink (barium). The disadvantage of this test was its inability to detect mild to moderate changes in the oesophagus.
Oesophageal pH and manometry study is used to measure the amount of acid the oesophagus is exposed to. A manometry test will also check how well the oesophagus is contracting. This test is particularly useful in people who have symptoms of GORD and a normal gastroscopy. Recently a new gadget (BRAVO capsule) was developed to allow for measurement of oesophageal pH for 48hrs. this involves clipping a small electronic capsule just above the lower end of the oesophagus. The measurement is downloaded onto a computer and the capsule detaches itself after 3-5 days and passed in the stool.
How can GORD be treated?
Treatment of GORD consists of lifestyle modifications, medical and surgical treatment.
Lifestyle modifications include weight loss, stop smoking, avoidance of caffeine, chocolate, fatty foods, alcohol, spicy foods, regular meal times and avoid eating before bedtime. The head of the bed should be raised to utilise gravity to minimise night time reflux.
Medical treatments essentially aim to suppress gastric acid with proton pump inhibitors (eg. Omeprazole, lanzoprazole) and facilitate clearance of acid from the oesophagus with prokinetic agents (eg. Metoclopramide, domperidone). As for Barrett's oesophagus this will require regular gastroscopy and biopsies to monitor any changes with a view of intervention before cancer develops.
Lifestyle changes and medical therapy are effective at controlling reflux symptoms in many patients. However, the vast majority of patients will have relapses and may require long-term medical treatment to control symptoms. Proton pump inhibitors do not have any effect on biliary reflux. Additionally, many patients on medication will continue to demonstrate reflux on pH testing even though they are not symptomatic. This may contribute to the progression of the disease from simple oesophagitis to Barrett's oesophagus, to the development of dysplasia (cell changes) and cancer.
Surgical treatment (anti-reflux surgery) is aimed at repairing the hiatus hernia and creating a high pressure zone in the lower oesophagus. This artificial high pressure zone acts as a one way valve repelling gastric content (acid, bile, air) from refluxing up the oesophagus. These procedures are done laparoscopically (keyhole).
A number of anti-reflux procedures have been described. All these involve repairing the hiatus hernia when present and using the upper part of the stomach to create a wrap around the lower oesophagus. The wrap may be partial or a full 360º wrap. Surgery is very effective at relieving symptoms and treating the complications of GORD. Side-effects of surgery are dependent on the type of wrap and they include transient swallowing difficulty, inability to belch, gas bloat, unable to vomit and increase flatulence. Swallowing usually recovers about 6 weeks after the operation and may take three to six months before returning to normal.
What is Dyspepsia?
'Dyspepsia' is a general non-specific term and is often interchanged with indigestion. Dyspepsia is very common, it is estimated to affect some 25% of the population and everyone at one time or another will experience this. People generally describe a discomfort, pain or a burning sensation in the upper part of your tummy that may go into the chest. This may be accompanied by bloating, nausea and excessive belching. The pain may sometimes be so severe that it is mistaken for a heart attack!
What causes Dyspepsia?
Dyspepsia can be caused by gastritis (inflammation of the stomach lining), gastric ulcers, bile reflux, aspirin or similar type of medicines (non-steroidal anti-inflammatory drugs), gallstones and sometimes stomach cancer. The stomach may also be infected by bacteria called Helicobacter Pylori which damages the lining of the stomach by weakening the protective mucous and thereby letting acid damage the lining resulting in gastritis and ulcers.
Ulcers not only cause pain but it may also bleed resulting in anaemia (slow bleed) or it can be life threatening by bleeding torrentially. Although much less common nowadays, ulcers can perforate or cause strictures that block the stomach.
The best way to investigate dyspepsia is a gastroscopy (aka endoscopy). This procedure involves placing a flexible camera into the stomach where the lining of the oesophagus and stomach can be examined directly and biopsies taken at the same time.
The second best option is to have a barium meal. This involves drinking barium while X-ray pictures are taken. Unfortunately barium meal can miss subtle changes and treatment may be delayed.
Ultrasound scan is used to look for gallstones if they are suspected. Depending on the circumstances a CT scan may be required to look at the internal organs in more detail.
Treatment of dyspepsia like GORD (see Heartburn) involves lifestyle modifications and medicines. For the majority of sufferers taking anti-acid medicine (eg. omeprazole, lanzoprazole) to reduce the acid output in the stomach will allow for the stomach lining to heal. However, you may also need antibiotics if Helicobacter pylori infection is present. In patients whose ulcers are caused by aspirin or aspirin-like drugs (eg. brufen, ibuprofen), they will need to stop these ulcer causing medicines in addition to taking anti-acid medications. A prokinetic medicine (metoclopramide, domperidone) may reduce bile reflux in biliary gastritis.
Lifestyle modifications include giving up smoking, avoid spicy foods or any foods that upset your stomach, reduce stress although this is easier said than done in the modern hustle and bustle life that we lead. You can do quite a bit to help yourself feel better.
With the advances in medical treatment, surgical procedures like vagotomy for dyspepsia are resigned to historical textbooks. Modern surgical treatment for dyspepsia is restricted to treating complications like ulcer perforation or relieving strictures caused by of ulcers. Surgery with or without chemotherapy remains the mainstay for treatment of gastric cancers.