Persistent Heartburn

An extremely common condition, affecting up to 1 in 4 adults in the UK, heartburn is described as a burning sensation in the chest.  It is caused by acid reflux - stomach acid passing up from the stomach into the oesophagus toward the throat.  Persistent reflux is known as gastro-oesophageal reflux disease or GORD.

While most attacks occur during the day, some people experience problems at night. These people often have a chronic cough which would not usually be associated with a gastro issue.

Some people may experience some or all of the following.  If you experience any of these symptoms persistently for more than 3 weeks, you should consult your GP.

• Burning sensation or pain behind the breastbone.
• Sour taste in the back of your mouth and/or bad breath.
• Food coming back up into your mouth or ‘repeating’ (regurgitation) after eating, on bending or exercising.
• A hoarse voice or sore throat.
• A cough or hiccups that does not go away or keep coming back.
• Difficulty swallowing including frequent throat clearing, coughing or choking.

Food and drink, once swallowed, travels down the oesophagus and into the stomach.  At the bottom of the oesophagus is a muscular ring – a sphincter – which acts as a one-way valve.  When this valve fails acid reflux occurs.  Although the stomach lining is designed to withstand the acidity in your stomach, the irritation in your oesophagus can cause inflammation (oesophagitis) and, in severe cases, can cause Barrett’s oesophagus.

Lifestyle factors which can increase the risks of heartburn and reflux include:

• Overeating (this increases pressure in the stomach and can cause the sphincter to relax).
• Certain medications (specifically non-steroidal anti-inflammatory drugs like aspirin or ibuprofen; bisphosphonates; muscle relaxants and calcium channel blockers. Please speak to your doctor if you have concerns with any of the medications you are taking).
• Smoking
• Excessive alcohol consumption.
• Being overweight
• Posture (If you spend a lot of time bending, stooping, or hunched this can put extra pressure on your stomach).
• During pregnancy many women find they develop heartburn during the later stages as their growing baby increases pressure on their stomach. Although they symptoms usually disappear once baby is born, some women find they continue to experience discomfort.

If you have a hiatus hernia you may be more likely to experience reflux.

Diagnosis will be based on the description of your symptoms and the length of time you have been experiencing them.

Sometimes, these symptoms may be caused by other medications you are taking and therefore you will be prescribed extra medication to take alongside in the form of proton pump inhibitors (PPIs).

You may be referred for any of the following medical tests:

The Capsule Sponge Test - known as the Cytosponge™ or EndoSign®:

This test involves you swallowing a capsule the size of a large vitamin tablet. The capsule is on a fine thread which you hold onto while the capsule goes down into your stomach. After a few minutes of being in the stomach the outer capsule dissolves and the thread is used to gently but quickly retrieve the now exposed tiny sponge which collects millions of cells to be sent for analysis. There is no need for any anaesthetic or sedation for this procedure.

Endoscopy:

A thin, flexible tube will be passed down through your mouth or occasionally through your nose into the oesophagus into the stomach and start of the small intestine. The tube will have a camera for the endoscopist to take images as well as biopsies to be sent for analysis. The procedure is usually carried out under sedation or with a local anaesthetic in the form of a numbing spray. Occasionally, a general anaesthetic may be necessary. These options will be discussed with your doctor.

Barium Meal:

This is done less often these days as an endoscopy is usually preferred. You will be asked to drink some barium liquid which will show up in your oesophagus, stomach and the first part of your intestine on x-ray. This procedure can highlight a hiatus hernia or narrowing of the oesophagus.

Depending on the severity, medication such as proton pump inhibitors (PPIs) may be prescribed or H2 receptor antagonists. These suppress acid before it can cause damage.

If medication is required long term or your symptoms do not improve, your doctor may refer you to check for any underlying cause.

In some cases, when medication is not effective at controlling your symptoms, your doctor may refer you for an operation called Laparoscopic Nissen Fundoplication. 

The keyhole surgery, carried out under general anaesthetic, involves wrapping the top end of the stomach around the bottom of the oesophagus to form a new valve which stops acid travelling back up into the oesophagus. 

Contact your GP immediately if you have ANY of the following:

• Pain or difficulty when swallowing.
• Food getting stuck in your oesophagus.
• Frequently being sick.
• Unintended weight loss.
• Persistent heartburn despite medication.

It may be useful to track the food, drink and activities which trigger your symptoms.  This can help you to avoid them and it can also help you keep a record for your GP appointments.

The following are often the most common triggers although they vary from person to person:

• Drinks such as coffee, fizzy drinks, acidic juices, and alcohol.
• Foods such as tomatoes, citrus fruits, chocolate, fatty foods and spicy foods.
• Large meals
• Eating late at night – try and eat at least 3 or 4 hours before you go to bed and don’t lay down after you have eaten. If you are having trouble at night, try sleeping with extra pillows to prop yourself up.
• Smoking
• Being overweight – excess weight causes upward pressure from the stomach which can trigger symptoms of heartburn and acid reflux. If you are overweight, speak to your pharmacist or GP about what weight management services are available to you in your area.
• Stress and anxiety
• Changes in hormones
• Some medications, such as anti-inflammatory painkillers (i.e. ibuprofen, naproxen).