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Heartburn and 'Indigestion'

What is Indigestion? Indigestion (and also 'dyspepsia') are not very useful medical terms as they are used by people to mean a variety of different forms of discomfort experienced almost anywhere in the body after eating food! 'Indigestion' can be caused by a variety of different underlying conditions including gastro-oesophageal reflux, peptic ulcers, gallstones and irritable bowel syndrome.

What is 'heartburn'? Heartburn is the name given to a burning discomfort felt behind the sternum (breastbone) and may be associated with an acidic or unpleasant taste in the mouth. It may occur after eating, or at night, lying down or bending over. Unlike 'indigestion' or 'dyspepsia' this symptom does closely correspond with a condition - gastro-oesophageal reflux.

What causes heartburn? Heartburn is caused by acid coming back up from the stomach (refluxing) and irritating the lining of the oesophagus. The commonest cause for this is a 'hiatus hernia'. A hernia is where the contents of a body cavity are pushed outside of that cavity - most people are familiar with hernias occurring in the groin through the abdominal wall. However, a 'hiatus hernia' is a hernia that occurs through the 'hiatus' or gap in the diaphragm - the muscle that separates the chest from the abdomen. The result is that a small amount of stomach is pulled up into the chest, and the usual valve mechanisms to control the reflux of acid into the stomach are negated. Hiatus hernias are extremely common - affecting up to 1 in 10 people - and may occur through congenital weakness of the diaphragm or due to increases in abdominal pressure as may occur with coughing, weightlifting or straining for example. Not all hiatus hernias cause problems, and most hiatus hernias do not need any treatment.

How is Gastro-oesophageal reflux diagnosed? The symptoms of gastro-oesophageal reflux are so clearly described that it is often enough to make the diagnosis on the basis of the story alone. However, in up to 40% of patients, all the features of heartburn may not be present and the major symptom may be a pain experienced at the top of the abdomen under the ribs. In such cases it may be important to establish the diagnosis - often by seeing how it responds to treatment - or excluding other causes such as gallstones. The definitive test is to measure directly the acid level in the oesophagus - this can be carried out with a very thin tube that is passed down the nose until the tip sits just above the junction of the stomach and the oesophagus. The tube stays in place for 24 hours and measures the acid over this period of time, allowing the patient also to record when they experience symptoms. Whilst it is not necessary for uncomplicated reflux symptoms, particularly if they respond well to treatment, gastroscopy may be required to look for signs of damage to the lining of the oesophagus or 'Barrett's oesophagus' (see below).

What treatment is available for gastro-oesophageal reflux? Sometimes simple measures that can be institued at home can avoid the need for medication. For instance, avoiding tight fitting clothing, straining, eating fatty or fried foods, refraining from smoking and cutting back on alcohol intake all reduce the symptoms of acid reflux. Some people find that losing weight helps to clear the symptoms, and those that experience the symptoms particularly at night may be helped by raising the head end of the bed in order to recruit gravity. This is best done by blocks or bricks under the head of the bed rather than using pillows to prop yourself up. If such measures (which usually have additional benefits for health as well) are unsuccessful then medication mya be required. Initially simple antacids such as 'Rennies' can help, but if symptoms are persistent or severe then medication may be required. Medications that reduce the acid secretion into the stomach - called 'proton pump inhibitors' or PPIs - are extremely effective at reducing the symptoms of heartburn and are extremely safe with few side effects. It is generally recommended to take a PPI tablet for 1 month to assess response and the effect of stopping, however there are few risks associated with long term use if required.

Is there an operation to treat heartburn? Occasionally patients with severe symptoms that cannot be managed with medications require an operation to reduce the hiatus hernia - moving the stomach back into the abdomen and tightening up the 'hiatus' or gap in the diaphragm through which it herniated. the operation can be done by keyhole surgery, but does potentially lead to additional complications such as an inability to burp, resulting in gas bloating. With modern techniques severe side effects are unusual but on balance it is still preferable and safer to use PPI therapy, even long term if necessary, than undergo surgery.

Are there any complications of gastro-oesophageal reflux? Whilst acid exposure in the oesophagus may show no signs at all, a variety of complications can be associated.
Peptic oesophagitis occurs when the acid causes a caustic burn to the lower oesophagus that can cause pain or bleeding. Severe oesophagitis can result in scarring that narrows the gullet and causes an inability to swallow food, or a feeling that food is stuck in the middle of the chest after eating. A narrowing -or stricture - can be stretched at the time of endoscopy to open it up and allow easier swallowing, but would also require long term use of acid suppressing medication to reduce the risk of recurrence.
'Barrett's Oesophagus' is a condition where the lining of the oesophagus changes to the type of lining normall found in the stomach, that is resistant to acid. Whilst it would seem to be a very wise act of nature to do so, such a change in the lining does increase the risk of cancer. The change in the type of lining can be visualised at gastroscopy and biopsies can be taken to see if there are any early cancerous changes. Some patients with Barrett's oesophagus may benefit from having a close eye kept on them with endoscopies every 2 years to sample the lining anc check for these precancerous changes. Long term acid reflux is a risk factor for oesophageal cancer.

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