Heartburn

“Doc, it’s my heartburn. I am getting sick and tired of this,” said Dave as I settled down on my chair. “Doc, can we get this under control?”

Sure Dave, we can. First, we should try and understand what is heartburn. What is the mechanism behind this symptom? Does it need any investigations? Then we can talk about treatment.

“Ok Doc, shoot!”

Esophagus is a long hollow muscular tube. It is about 40 cm long in an adult and crosses the chest behind the heart and in between the lungs. It connects two separate anatomical areas: mouth above the neck and the stomach below the diaphragm (in the abdomen).

Esophagus allows food, drinks and saliva to go down in to the stomach but prevents stomach contents to flow back. This control is achieved by the upper and lower esophageal sphincters.

Heartburn is a burning sensation felt behind the middle of the chest. It is worse in certain positions (bending, lying down). Certain foods, obesity and anxiety can aggravate the symptoms. The sensation of burning is created by the reflux of stomach contents – usually acidic – into the esophagus.

Why does the lower esophageal sphincter (LES) fail to prevent reflux? The mechanism is complex. But simply put, the LES tone may be decreased or there may be inappropriate relaxation of the sphincter. The normal anatomy of the LES may be disturbed by obesity or hiatus hernia.

Hiatus hernia is a condition where by the junction of the esophagus and stomach (site of LES) slides up into the chest through the opening in the diaphragm from its normal position in the abdomen.

Reflux or heartburn can occur with or without hiatus hernia. Hiatus hernia and heartburn each occurs in about 30 percent of the population. Therefore some overlap can be expected.

About 35 percent of the population have experienced heartburn in their lifetime and about 10 percent suffer from this at least once a week. Most people treat themselves with off the counter medications and do not even complain to their doctors.

Should we investigate all patients who complain of heartburn? Clinically uncomplicated heartburn does not require investigation to start with. This is first treated with advice on change in lifestyle (lose weight, reduce or stop smoking) and off the counter antacids. Elevation of the head end of the bed will help keep the acid in the stomach when lying down.

Dave follows this advice for six weeks and is no better. “Dave, let us try acid reducing medication. If this does not help in the next couple weeks then add a prokinetic agent. This will empty your stomach better and strengthen LES.”

Dave is no better. Now he has difficulty swallowing. He is anemic. He has pain in the middle of the chest. These are features of complicated gastro-esophageal reflux disease. He is booked for gastroscopy and biopsies to check for ulcer or cancer.

Gastroscope is a lighted flexible instrument to examine the lining of the esophagus, stomach and duodenum. This test is done under mild sedation. Dave has a moderate size hiatus hernia with inflammation and ulceration. Biopsy reveals no cancer.

Dave is given a new prescription with higher dosage for acid reducing and prokinetic pills. Iron pills are prescribed to correct anemia. Dave responds to this treatment very well. He is now on maintenance therapy.

Dave could have had gastroscopy earlier if he did not respond to medications prescribed or relapsed after initial positive response. But his symptoms advanced rapidly and cancer was strongly suspected.

“Thank you, doc,” said delighted Dave. “I am glad there is no cancer.”

(This series of articles explore the health problems of Dave and his family. They are composite characters of a typical family with health problems)

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