Health Guide

Heartburn: Upset Stomach

Other names :
Reflux oesophagitis.


Introduction :
Burning pain behind the breast bone caused by reflux of acid from the stomach into the oesophagus.


Types :
May be caused by over indulgence, weakness of the diaphragmatic sphincter of the stomach, a hiatus hernia or other causes of excess acid production.


Cause :
Heartburn is caused by the reflux of hydrochloric acid from the stomach into the lower part of the gullet (oesophagus). If the patient has a hiatus hernia, where part of the stomach slips through into the chest cavity, acid can more easily escape up into the gullet to cause heartburn. A hiatus hernia and heartburn may occur during pregnancy because of the pressure of the enlarging womb and the hormonal effect on muscle tissue in the oesophagus and stomach. The oesophagus (gullet) runs from the throat to the stomach through the back of the chest. At its lower end, it passes through the diaphragm, which is a sheet of muscle that separates the chest from the belly. At the point where it passes through the diaphragm, there is a muscle ring (sphincter), which opens when you swallow food, but remains closed at other times to prevent the concentrated hydrochloric acid in the stomach from coming back up (refluxing) (Upset Stomach ?) into the oesophagus when lying down or bending over. The cells lining the inside of the stomach are made acid resistant by a thick layer of mucus, but those lining the oesophagus lack the protective mucus. If acid (along with food) is able to flow back up into the oesophagus, the acid will attack the unprotected cells, to cause inflammation, ulceration, pain and scarring. This is heartburn or reflux oesophagitis. There are two types of hiatus hernia. In some patients the hernia remains fixed in the one position, but in others, the hernia may slide up and down, depending on the patients position or activity. A large meal may be sufficient to push the overloaded stomach up into the chest. Some babies are unlucky enough to have a defect or temporary weakness in the muscle ring at the bottom of the oesophagus. The reflux of acid into the oesophagus causes considerable pain to the infant. Most children will grow out of the problem, but medication must be given in the meantime to prevent the burning and pain. In adults, factors such as obesity, smoking, over eating, rapid eating, alcohol, stress and anxiety, and poor posture may cause the excessive production of acid in the stomach or slackness in the muscle ring.


Incidence :
Probably five percent of adults suffer from heartburn at least once a week, often following dietary indiscretions. Babies and overweight elderly men are the two groups who are most likely to suffer from reflux oesophagitis.


Prevention :
Lying down, stooping and heavy lifting should be avoided after heavy meals. Meals should be kept small and frequent, rather than the traditional three large meals a day. Smoking will lower the tone of the muscles at the lower end of the gullet, and aggravate heartburn. Overweight patients should shed those extra kilograms to prevent the fat pressing on the stomach. If a hiatus hernia is present, raising the head of the bed is also useful.


Investigations :
When reflux oesophagitis and/or hiatus hernia is suspected, it will be proved by either gastroscopy, in which a flexible tube is passed down into the stomach, and through which a doctor can see exactly what is happening; or by a barium meal, in which a special fluid is swallowed, and its passage into the stomach (and sometimes its reflux back up into the oesophagus) can be followed by a series of x-rays.


Course :
Heartburn has absolutely nothing to do with the heart. The name derives from the sensation of burning pain or warmth behind the lower end of the breast bone. The pain may spread all the way from the top of the stomach to the back of the mouth. The patient may also experience a bitter taste on the back of the tongue, a feeling of fullness, burping as gas escapes easily from the stomach, difficulty in swallowing, bleeding from the damaged part of the stomach, pain from ulceration or pinching of a hiatus hernia, and palpitations if a large hiatus hernia pushes onto the heart. Heartburn is often worse at night, after a large meal and when the patient is lying down, as it is easier in these situations for the acid to flow up out of the stomach. If the attacks of acid reflux are intermittent and mild, the lower end of the oesophagus can recover between each episode, but if the attacks are regular or constant, the pain will become more severe, and significant damage may occur to the area. A hiatus hernia may may be present but cause no symptoms.


Treatment :
Treatment of reflux involves the appropriate advice with regard to losing weight, propping up the head of the bed, having the main meal in the middle of the day, avoiding bending and heavy lifting, stopping smoking and reducing alcohol (nicotine and alcohol relax the diaphragm muscle ring). Medication can be given to reduce the acid concentration in the stomach (antacids) and to act as a foam that floats on the stomach acid to protect the lower end of the oesophagus. Further treatment will involve the use of medication to drain acid out of the stomach, and reduce acid production (cisapride and other ulcer treatments - see Medication Table) Only in severe, resistant cases is it necessary to resort to quite major surgery to treat the problem. Gravity is the most important factor in keeping the stomach in the abdomen rather than the chest, and the acid in the stomach rather than the oesophagus. Bending over to garden or lift, and any heavy lifting are banned. The head of the bed should be elevated, and three or more pillows used to raise the chest higher than the abdomen. Lying on the right side rather than the left, to enhance the drainage of the stomach, can also be tried. In only a very small percentage of patients, who do not respond adequately to the above regimes, should surgery be contemplated. A number of different procedures can be performed. These are major operations, that require a significant time in hospital, but more than 80% of patients obtain a satisfactory result. Babies with reflux are treated with a mixture (eg: Gaviscon) which is given after every feed. More sophisticated treatments (eg: cisapride - see Medication Table) are available for the intractable cases.


Diet :
The pain can be brought on if certain foods are eaten to excess. Common offenders are salad dressings, peppermints, fatty or fried foods, pineapple, citrus fruits, coffee, alcohol and highly spiced foods. Medications such as aspirin and some arthritis treating drugs can also cause heartburn.


Complications :
If ulcers form in the oesophagus because of acid reflux, they may erode down to a vein or artery, and severe bleeding may occur, that in extreme cases may be life threatening. The other main complication is scarring and narrowing of the lower end of the oesophagus, to the point where it may be difficult, or even impossible, to swallow food. Rarely, if left untreated this process may continue to develop into cancer. Long before these advance stages, most patients have sought medical assistance for the problem. The symptoms of a heart attack may be neglected because the patient thinks it is heartburn. This may have fatal consequences.


Outcome :
The majority of patients can have their heartburn controlled if they follow a doctor's advice, and use the appropriate medication.


Medical curiosity :
In the past, patients with heartburn often got worse with treatment rather better because milk and cream soothed the burning, but increased the patient's weight, thus aggravating the heartburn.