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Tuesday, August 12, 2025

Heartburn and acid reflux


Definition

  • Heartburn is a burning sensation felt behind the sternum (retrosternal area), often rising toward the throat.

  • Acid reflux (gastroesophageal reflux) is the backflow of stomach contents, including acid, into the esophagus.

  • Persistent or troublesome reflux is termed Gastroesophageal Reflux Disease (GERD).

Pathophysiology

The lower esophageal sphincter (LES) is a muscular ring at the junction of the esophagus and stomach. Normally, it prevents reflux by remaining contracted except during swallowing. In acid reflux:

  • LES tone is reduced or transiently relaxes inappropriately.

  • Gastric contents escape into the esophagus, irritating its lining.

  • Acidic exposure leads to symptoms (heartburn, regurgitation) and, in chronic cases, esophagitis or complications.

Contributing factors include:

  • Increased intra-abdominal pressure (obesity, pregnancy)

  • Hiatal hernia

  • Delayed gastric emptying

  • Reduced esophageal clearance

Risk Factors and Triggers

  • Large or fatty meals

  • Spicy, acidic foods, chocolate, caffeine, alcohol

  • Carbonated drinks

  • Smoking

  • Lying down soon after eating

  • Tight clothing

  • Certain medications: calcium channel blockers, nitrates, anticholinergics, NSAIDs, bisphosphonates

Clinical Features

  • Heartburn: burning discomfort behind the breastbone

  • Acid regurgitation: sour/bitter taste in the mouth

  • Dyspepsia: upper abdominal discomfort, bloating

  • Symptoms often worse after meals, when bending over, or at night

  • Alarm features: dysphagia, odynophagia, persistent vomiting, weight loss, gastrointestinal bleeding – warrant urgent evaluation

Diagnosis

Usually clinical, based on characteristic symptoms.
Investigations are indicated if:

  • Alarm symptoms present

  • Symptoms persist despite empirical therapy

  • Diagnosis uncertain

Possible investigations:

  • Upper gastrointestinal endoscopy (esophagogastroduodenoscopy)

  • 24-hour esophageal pH monitoring

  • Esophageal manometry (assesses LES function)

  • Barium swallow (less commonly used)

Management

1. Lifestyle Modifications

  • Eat smaller, more frequent meals

  • Avoid trigger foods and beverages

  • Lose weight if overweight

  • Avoid lying down for at least 2–3 hours after eating

  • Elevate the head of the bed by 15–20 cm for nocturnal symptoms

  • Stop smoking and limit alcohol

  • Wear loose-fitting clothing

2. Pharmacological Treatment

A. Antacids – For rapid short-term relief of mild, occasional symptoms

  • Aluminium hydroxide + magnesium hydroxide: 10–20 mL orally as needed after meals and at bedtime

  • Calcium carbonate: 500–1000 mg orally as needed

B. Alginates – Form a protective raft on stomach contents to reduce reflux

  • Sodium alginate + potassium bicarbonate: 10–20 mL orally after meals and at bedtime

C. H₂ Receptor Antagonists (H₂RAs) – Reduce gastric acid secretion

  • Famotidine: 20 mg orally twice daily or 40 mg once daily at bedtime

  • Nizatidine: 150 mg orally twice daily or 300 mg at bedtime

D. Proton Pump Inhibitors (PPIs) – Most effective for frequent symptoms or confirmed GERD

  • Omeprazole: 20 mg orally once daily before breakfast

  • Lansoprazole: 30 mg orally once daily before breakfast

  • Pantoprazole: 40 mg orally once daily before breakfast

  • Esomeprazole: 20–40 mg orally once daily before breakfast

  • Duration: Usually 4–8 weeks; long-term use may be needed in chronic GERD but requires monitoring for adverse effects (e.g., vitamin B12 deficiency, hypomagnesemia, bone fracture risk)

E. Prokinetic Agents – Enhance gastric emptying and LES tone (less commonly used, reserved for selected patients)

  • Metoclopramide: 10 mg orally 3 times daily before meals (short-term use only due to risk of extrapyramidal effects)

  • Domperidone: 10 mg orally 3 times daily before meals (use restricted in some countries due to cardiac risk)

3. Surgical and Endoscopic Options

For patients with:

  • Severe reflux not controlled by medication

  • Preference to avoid long-term medication

  • Large hiatal hernia

Procedures:

  • Laparoscopic Nissen fundoplication – wraps gastric fundus around LES to strengthen the barrier

  • Magnetic sphincter augmentation – magnetic ring device placed around LES

Complications of Chronic Untreated GERD

  • Reflux esophagitis

  • Esophageal strictures

  • Barrett’s esophagus (metaplastic change with risk of adenocarcinoma)

  • Respiratory complications: chronic cough, laryngitis, asthma exacerbations

Prognosis

  • Many patients achieve symptom control with lifestyle changes and intermittent or continuous medication

  • Relapse is common when therapy is stopped, especially in chronic GERD

  • Early treatment reduces risk of complications




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