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Sunday, August 24, 2025

Acid reflux,Heartburn


Introduction

  • Heartburn is the burning sensation behind the breastbone, usually after meals or when lying down.

  • Acid reflux is the backward flow of stomach acid into the esophagus, which causes heartburn and other symptoms.

  • If reflux is frequent and persistent, it is classified as Gastroesophageal Reflux Disease (GERD).

Prevalence:

  • Affects about 20% of adults in Western countries.

  • Risk increases with obesity, smoking, pregnancy, and poor diet.

Pathophysiology

  • The lower esophageal sphincter (LES) normally prevents stomach acid from entering the esophagus.

  • In reflux, LES tone is reduced or intra-abdominal pressure is increased, allowing acid to rise.

  • Prolonged exposure damages the esophageal lining, causing inflammation (esophagitis).

Causes and Risk Factors

1. Lifestyle Factors

  • Large/fatty meals, spicy foods, citrus, chocolate, caffeine, alcohol.

  • Smoking.

  • Obesity, central weight gain.

  • Eating before bedtime.

2. Medical Conditions

  • Hiatal hernia.

  • Pregnancy.

  • Connective tissue disorders (scleroderma).

  • Gastroparesis (delayed stomach emptying).

3. Medications

  • NSAIDs (ibuprofen, aspirin, naproxen).

  • Calcium channel blockers (amlodipine, nifedipine).

  • Nitrates.

  • Anticholinergics.

Clinical Features

Typical Symptoms

  • Heartburn (burning chest pain, often after meals, worse lying down).

  • Regurgitation of sour fluid into mouth.

  • Difficulty swallowing (dysphagia).

Atypical / Extra-esophageal Symptoms

  • Chronic cough.

  • Hoarseness, sore throat.

  • Asthma-like symptoms.

  • Dental enamel erosion.

Alarm Features (Red Flags)

  • Dysphagia or painful swallowing.

  • Unexplained weight loss.

  • Gastrointestinal bleeding (vomiting blood, black stools).

  • Persistent vomiting.
    * These require urgent investigation for cancer or strictures.

Diagnostic Approach

1. Clinical Diagnosis

  • In young patients with typical symptoms, diagnosis can be made on history alone.

2. Investigations (if severe, atypical, or refractory)

  • Endoscopy (EGD): detects esophagitis, strictures, Barrett’s esophagus, cancer.

  • 24-hour pH monitoring: measures acid exposure.

  • Esophageal manometry: assesses sphincter function, motility disorders.

  • Barium swallow X-ray: structural abnormalities.

Management and Treatment

A. Lifestyle and Non-Pharmacological Measures

  • Weight reduction.

  • Avoid large, fatty, or spicy meals.

  • Avoid lying down within 2–3 hours after eating.

  • Elevate head of bed by 15–20 cm.

  • Stop smoking and alcohol.

  • Avoid tight clothing.

B. Pharmacological Treatment

1. Antacids (for quick relief)

  • Neutralize stomach acid.

  • Aluminum hydroxide + Magnesium hydroxide suspension 10–20 mL orally as needed after meals and at bedtime.

2. H2 Receptor Blockers (reduce acid secretion)

  • Ranitidine 150 mg orally twice daily (less used due to safety concerns).

  • Famotidine 20–40 mg orally once or twice daily.

3. Proton Pump Inhibitors (PPIs) – first-line for moderate/severe GERD

  • More potent acid suppression, healing esophagitis.

  • Omeprazole 20–40 mg orally once daily before breakfast.

  • Esomeprazole 20–40 mg orally once daily.

  • Pantoprazole 40 mg orally once daily.

  • Usually given for 4–8 weeks; long-term if recurrent.

4. Prokinetic Agents (increase LES tone, gastric emptying)

  • Metoclopramide 10 mg orally three times daily before meals.

  • Domperidone 10 mg orally three times daily.

  • * Use short-term due to side effects.

5. Mucosal Protectants

  • Sucralfate 1 g orally four times daily (before meals and at bedtime).

C. Surgical / Endoscopic Treatment

For severe, refractory GERD or complications:

  • Nissen fundoplication: stomach fundus wrapped around esophagus to strengthen LES.

  • LINX device: magnetic ring placed around LES.

  • Endoscopic techniques (radiofrequency, plication).

Complications of Untreated GERD

  • Esophagitis.

  • Peptic strictures (narrowing, dysphagia).

  • Barrett’s esophagus (precancerous condition).

  • Esophageal adenocarcinoma.

  • Chronic respiratory problems (aspiration, asthma).

Prognosis

  • Most patients respond well to lifestyle + PPIs.

  • Relapse common if risk factors persist.

  • Complications rare if treated early.

  • Barrett’s esophagus requires surveillance endoscopy.

Patient Education

  • Heartburn is common but frequent symptoms (>2 times per week) suggest GERD.

  • Lifestyle changes are as important as medications.

  • Long-term PPI use may increase risk of fractures, vitamin B12 deficiency, kidney disease — use lowest effective dose.

  • Seek medical review if:

    • Symptoms persist despite treatment.

    • Alarm features (weight loss, vomiting blood, difficulty swallowing).




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