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Dictionary The Gastrointestinal System

Heartburn

Synonyms : Esophageal Reflux, Gastroesophageal Reflux, GERD - Gastroesophageal Reflux Disease, Pyrosis

Clinical features, Diagnosis, Management, Prognosis,

Gastro-oesophageal reflux disease (GERD) is a regurgitation of gastric contents into the oesophagus which takes place after mechanisms which normally prevent this fail (most important is the lower oesophageal sphincter). This condition is closely related to sliding hiatus hernia but can happen without the hiatus hernia, and the hiatus hernia doesn’t always include reflux. 

Hiatus hernia is a sliding of the gastro-oesophageal junction through the diaphragm into the thoracic cavity. The aetiology is unknown but obesity, pregnancy and occasionally ascites (fluid accumulated in the abdominal cavity) may be important factors. The condition is common, occurring in up to 30% of normal adults and 50% of aged individuals. The majority of individuals with a hiatus hernia have no symptoms and the hernia is of no clinical significance. In a minority (about 10%) however the hiatus hernia appears to facilitate gastro-oesophageal reflux presenting with relevant symptoms. 

Persistent exposure of the lower oesophagus to acid and pepsin results in oesophagitis with the damage to the superficial mucosa, when it is called erosive oesophagitis. Peptic stricture results from fibrosis (scarring) that causes narrowing of the oesophageal lumen. Replacement of the normal squamous epithelium of the oesophagus by columnar intestinal epithelium containing goblet (mucus producing) cells (Barrett’s oesophagus) occurs in 2-10% of patients with reflux oesophagitis. This process is known in pathology as metaplasia and is important because in 2-5% of cases it can progress to adenocarcinoma (30% of all oesophageal cancers are adenocarcinoma, the rest being squamous cell carcinoma). 

Several factors may promote gastro-oesophageal reflux, such as pregnancy, obesity, ascites, heavy lifting and straining, smoking, alcohol, fatty foods, caffeine, large volume meals.

Clinical features:  < BACK TO TOP >

  • Malfunction of the anti-reflux mechanism of the gastro-oesophageal junction allows gastric acid and pepsin to reflux into the oesophagus, causing damage to the mucosa, reflex muscle spasm and pain felt behind the sternum. Most people have experienced heartburn: the pain is a scalding or burning sensation behind the sternum and radiates towards the throat. An acid or bitter taste may develop in the mouth and reflex salivation may cause it to fill with saliva ('water brash'). The patient's description is often accompanied by a hand gesture that illustrates the upward radiation of the pain behind the sternum. Heartburn is rapidly relieved by antacids. Retrosternal chest pain caused by reflux may occasionally mimic the pain of myocardial ischaemia (angina) and in this situation the distinction between them is essential.

    A common cause of heartburn is a hiatus hernia, in which the oesophagogastric junction prolapses into the chest through the oesophageal hiatus. The heartburn is often provoked by postures which raise intra-abdominal pressure such as bending or lying down. The diagnosis may be suspected in overweight patients but confirmation relies on visualising the hernia, either by barium meal or endoscopy and assessing the response to treatment.

    Heartburn may result from a particular diet and lifestyle: chocolate and alcohol consumption and cigarette smoking relax the lower oesophageal sphincter allowing reflux to occur. It is a common symptom in the later months of pregnancy. This is due both to the increase in intra-abdominal pressure and the loss of sphincter tone caused by high oestrogen levels.


  •        Heartburn (pyrosis), deeply placed burning pain behind the sternum often radiating to the throat, is a characteristic symptom and is produced by the contact of corrosive refluxed material with the inflamed oesophageal mucosa.

           It characteristically occurs after meals and is aggravated by bending and straining; can occur on lying down in bed at night.

           Regurgitation of gastric content to the mouth during bending, after a large volume meal may also occur.

           Patients experience transient dysphagia for solids and fluid, usually due to reflex spasm. More persistent dysphagia for solids suggests development of a peptic stricture (scarring).

           Rarely there may be pain on swallowing (odynophagia), which is consistent with more serious oesophagitis.

           In long standing cases oesophageal ulcers may occur and iron deficiency anaemia due to chronic unnoticed blood loss.

Diagnosis:  < BACK TO TOP >

           Barium swallow with fluoroscopy (real-time X-ray) is the most widely used initial test for the diagnosis of oesophageal disease.

           The presence of hiatus hernia is shown by a barium meal fluoroscopy when the patient is placed in a lying position with the head down; a leakage of barium from the stomach into the oesophagus can be seen.

           The diagnosis of oesophagitis is made on the visual and biopsy findings at endoscopy; this procedure is especially important to confirm the presence of Barrett’s oesophagus.

Management  < BACK TO TOP >

           The patient should avoid the precipitating factors, and this together with weight reductions, corrections of diet and stopping smoking alone will relieve symptoms in about 75% of patients.

           The patient should sleep in a more upright position (e.g., on two pillows), and late night meals avoided to reduce reflux during sleep.

           Antacids, preferably liquid preparations, will reduce the heartburn, and can be used as needed; however they are unsuitable for regular prolonged treatment due to possible role of aluminium from antacids in degenerative brain disease (dementia) and osteoporosis.

           Histamine H2-receptor antagonists (ranitidine [Zantac], nizatidine [Tazac] and famotidine [Pepcidine, Amfamox]) or proton pump inhibitors (omeprazole [Losec] and lansprazole [Zoton]) will reduce acid and pepsin secretion in the stomach, but do not prevent the reflux.

           Dopamine antagonists (metoclopramide [Maxolon, Pramin] and domperidone [Motilium]) increase the contraction of the lower oesophageal sphincter as well as promote gastric emptying.

           Surgical treatment (antireflux surgery) is carried out in selected cases of sliding hiatus hernia with severe symptomatic reflux oesophagitis that does not respond to above-mentioned measures.

Prognosis  < BACK TO TOP >

  • - - 

Nutrition  < BACK TO TOP >

Nutrition that alleviate or prevent heartburn :-
C

Herbs  < BACK TO TOP >

Herbs that alleviate or prevent heartburn :-

Aloe vera (Aloe)
Anethum graveolens (Dill)
Berberis vulgaris (Barberry)
Cinnamomum zeylanicum (Cinnamon quills)
Gentiana lutea (Gentian)
Hydrastis canadensis (Golden Seal)

Mentha piperita (Peppermint)

Chillis help to alleviate Heartburn. research


Mastic (gum) alleviates Heartburn when the underlying cause of Heartburn is Helicobacter pylori infection. research

Neem (leaf extract consumed internally) alleviates Heartburn.
Slippery Elm (9 - 30 grams) alleviates Heartburn (by coating and “smoothing?the irritated upper Gastrontestinal Tract). research


(source : -)

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