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Understanding Heartburn and Gastro-Oesophageal Reflux Disease (GERD)

Written By TheCRCS
January 17, 2025

Written by Dr. Ronnie Mathew, Senior Consultant Surgeon, CRCS

What is Heartburn, and how does it occur?

Heartburn is a burning sensation that rises from the stomach or lower chest towards the neck. It is essentially due to gastro-oesophageal reflux disease (GERD), also called reflux oesophagitis. 

The mouth and the stomach are connected by the oesophagus (food pipe).  At the end of the oesophagus, where the stomach connects, there is a valve called the lower oesophagus sphincter (LES). The LES is a circular muscle that only opens when you swallow, burp, or have hiccups. It closes again to prevent the stomach acid from coming back up again. Acid reflux occurs when the LES weakens or relaxes, such as after a heavy meal. While the LES usually relaxes temporarily, GERD happens when the LES is weakened. 

GERD is usually a chronic condition in which stomach contents (particularly acid, bile, and pepsin) reflux back into the oesophagus (food pipe) and irritate the lining of the lower end of the oesophagus. The predominant symptoms are heartburn and acid regurgitation. Atypical oropharynx and/or respiratory tract symptoms may occur, such as hoarseness, cough, asthma, and dental erosions.

Heartburn occurs when stomach acid irritates the lining of the oesophagus, causing inflammation and a burning sensation in the chest.

How common is Heartburn?

GERD affects 10-30% of the adult population in developed countries. Although heartburn/GERD can occur at any age, its prevalence increases with age, especially after age 40. It is slightly more common in women. 

What causes Heartburn or GERD? 

A certain amount of gastro-oesophageal reflux of acid is normal, and there is a natural protective mechanism of the lower oesophagus. Gastro-oesophageal reflux disease (GERD) describes prolonged or excessive reflux that may cause the breakdown of this protection with inflammation of the oesophagus (oesophagitis).

Several factors can predispose to reflux, including:

  • Increased intra-abdominal pressure
  • Smoking, alcohol, fat, chocolate, coffee
  • Pregnancy
  • Obesity
  • Stress and anxiety
  • Tight clothes
  • Big meals
  • Surgery in achalasia of the cardia
  • Systemic sclerosis
  • Hiatus hernia (this is a weakening of the sphincter at the lower end of the oesophagus/food pipe)
  • Family history
  • Drugs (examples include alpha-blockers, anticholinergics, benzodiazepines, beta-blockers, bisphosphonates, calcium-channel blockers, corticosteroids, nonsteroidal anti-inflammatory drugs, nitrates, theophyllines, and tricyclic antidepressants

Most of these predisposing factors increase intra-abdominal pressure. A fatty meal delays gastric emptying. The above-listed drugs and smoking relax the tone of the sphincter at the lower end of the oesophagus (also called the lower oesophageal sphincter or cardiac sphincter). Note that there is no proven relationship between Helicobacter pylori infection (which affects the stomach, causes gastritis, etc.) and GERD.

Bile is particularly caustic, and reflux of duodenal contents is more troublesome than reflux of gastric contents alone. There is little correlation between the severity of symptoms and findings on endoscopy.

What are the symptoms of Gastro-oesophageal Reflux Disease?

You may have GERD if you have experienced the following symptoms:

  • Heartburn
  • Backwash of food in the throat
  • Sensation of a lump in the throat
  • Nausea
  • Difficulty swallowing
  • Backwash
  • Breathing symptoms: chronic cough, shortness of breath, wheezing
  • Laryngitis
  • Sore throat
  • Chest pain not related to the heart
  • Upper abdominal pain/discomfort

How is GERD diagnosed?

A specialist (e.g., general surgeon/intestinal surgeon/gastroenterologist) will need to undertake a full assessment of symptoms and relevant history, followed by a physical examination. They then may decide to undertake diagnostic procedures like:

  • Upper gastrointestinal endoscopy (Oesophago-Gastro-Duodenoscopy, OGD): This diagnostic procedure involves inserting an endoscope through the mouth to examine the inside of the oesophagus, stomach, and part of the duodenum more closely.
  • Barium Swallow: This type of X-ray involves swallowing a chalky liquid (barium) and taking pictures of the oesophagus as you swallow.
  • Oesophageal manometry: This procedure uses pressure sensors planted in a nasogastric tube to measure the muscle activities in the oesophagus and determine whether the LES is functioning properly.
  • Oesophageal pH test: measures the acid content in the oesophagus.

Can certain foods cause worsening of the acid reflux?

In the presence of weakened LES (valve at the lower end of the oesophagus), certain foods can cause acid reflux. These foods include:

  • Certain beverages, like alcohol, coffee, carbonated beverages, and tea.
  • Certain fruits and vegetables include pineapple, citrus fruits, tomatoes, garlic, and onions.
  • High-fat foods 
  • Spicy food.

What lifestyle changes can help to reduce the symptoms of heartburn/GERD?

Certain lifestyle changes could help the heartburn/GERD symptoms:

  • Eat slowly and in smaller portions, but more frequently
  • Reduce the intake of above-mentioned foods
  • Elevating your head when you sleep. You can use additional pillows for this or raise the headend of your bed
  • Wear loose clothes when you sleep, so that it doesn’t constrict your tummy
  • Eat your last meal of the day at least three hours before you go to bed
  • Maintaining a healthy weight. Lose weight if you are overweight
  • Reduce alcohol intake 
  • Quitting smoking

How is GERD usually managed and treated?

There are various broad management approaches to help treat GERD symptoms:

Lifestyle changes

As mentioned above, adopting positive lifestyle changes, such as healthy eating habits and reducing alcohol can help manage GERD symptoms. 

Medications

  • Antacids: neutralizes the acid that is already present in your stomach
  • Alginates: help create a barrier between the stomach acid and the oesophagus as the contents of the alginates float on top of the stomach acid.
  • Proton pump inhibitors reduce acid secretion into the stomach.
  • Histamine receptor antagonists (H2 blockers) reduce acid secretion into the stomach.
  • Potassium-competitive acid blockers reduce acid secretion into the stomach.
  • Baclofen: to reduce muscle spasms and the frequency of lower oesophageal sphincter relaxation, thereby reducing the occurrence of acid reflux.
  • Prokinetics: to strengthen the lower oesophageal sphincter and help the stomach empty faster

Please note: Medications have side effects and also interactions with other medications. Please consult your healthcare provider before you take any medications.

Fundoplication is a surgical procedure for GERD that involves wrapping the stomach around the oesophagus — with different methods tailored to individual needs.

Operative management

If lifestyle management along with medications are unable to control GERD symptoms, then surgery for gastro-oesophageal reflux disease (GERD) may be considered. Surgical options involve a few different procedures, including:

  • Fundoplication: Operation where the top of the stomach is wrapped at the junction of the oesophagus and stomach. This creates a new valve-like mechanism that prevents stomach acid from flowing back into the oesophagus. This is often performed laparoscopically, which means through small incisions and with the aid of a video monitor. There are mainly three types of fundoplication:
    • Nissens fundoplication
    • Anterior/Dor fundoplication
    • Toupet fundoplication
  • Transoral incisionless fundoplication (TIF): A procedure that reconstructs the valve between the stomach and oesophagus.
  • LINX Reflux Management System: A minimally invasive procedure that involves placing a ring of magnetic beads around the lower oesophageal sphincter. The beads help keep the sphincter closed, preventing stomach contents from flowing back into the oesophagus.

If you have any questions regarding heartburn, acid reflux or GERD, then do get in touch with us today to have them answered. 

For further information on GERD: https://thecrcs.com/gerd/

Important: Please note: The information provided here is not specific and is meant for general information only. It does not constitute guidance for the management or treatment of any condition and does not replace information from your healthcare professional. Please consult your healthcare professional for more information and guidance.

Acknowledgement:

https://patient.info/doctor/gastro-oesophageal-reflux-disease

Further References:

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  2. Endoluminal gastroplication for gastro-oesophageal reflux disease; NICE Interventional Procedure Guidance, July 2011
  3. Feinle-Bisset C, Azpiroz F; Dietary and lifestyle factors in functional dyspepsia. Nat Rev Gastroenterol Hepatol. 2013 Mar;10(3):150-7. doi: 10.1038/nrgastro.2012.246. Epub 2013 Jan 8.
  4. Garg SK, Gurusamy KS; Laparoscopic fundoplication surgery versus medical management for gastro-oesophageal reflux disease (GORD) in adults. Cochrane Database Syst Rev. 2015 Nov 5;(11):CD003243. doi: 10.1002/14651858.CD003243.pub3.
  5. Gastro-oesophageal reflux disease and dyspepsia in adults: investigation and management; NICE Clinical Guideline (Sept 2014 - last updated October 2019)
  6. Gyawali CP, Yadlapati R, Fass R, et al; Updates to the modern diagnosis of GERD: Lyon consensus 2.0. Gut. 2024 Jan 5;73(2):361-371. doi: 10.1136/gutjnl-2023-330616.
  7. Laparoscopic Insertion of a Magnetic Ring for GORD; NICE UK Jan 2023
  8. Liu L, Li S, Zhu K, et al; Relationship between esophageal motility and severity of gastroesophageal reflux disease according to the Los Angeles classification. Medicine (Baltimore). 2019 May;98(19):e15543. doi: 10.1097/MD.0000000000015543.
  9. Katz PO, Dunbar KB, Schnoll-Sussman FH, et al; ACG Clinical Guideline for the Diagnosis and Management of Gastroesophageal Reflux Disease. Am J Gastroenterol. 2022 Jan 1;117(1):27-56. doi: 10.14309/ajg.0000000000001538.
  10. Krause AJ, Walsh EH, Weissbrod PA, et al; An update on current treatment strategies for laryngopharyngeal reflux symptoms. Ann N Y Acad Sci. 2022 Apr;1510(1):5-17. doi: 10.1111/nyas.14728. Epub 2021 Dec 17.
  11. Moayyedi P, Talley NJ; Gastro-oesophageal reflux disease. Lancet. 2006 Jun 24;367(9528):2086.
  12. Nencioni M, Asti E, Saino G, et al; Magnetic oesophageal sphincter for the treatment of gastro-oesophageal reflux disease: results of a prospective clinical trial. Chir Ital. 2009 Mar-Apr;61(2):187-92.
  13. Ness-Jensen E, Hveem K, El-Serag H, et al; Lifestyle Intervention in Gastroesophageal Reflux Disease. Clin Gastroenterol Hepatol. 2016 Feb;14(2):175-82.e1-3. doi: 10.1016/j.cgh.2015.04.176. Epub 2015 May 6.
  14. Sigterman KE, van Pinxteren B, Bonis PA, et al; Short-term treatment with proton pump inhibitors, H2-receptor antagonists and prokinetics for gastro-oesophageal reflux disease-like symptoms and endoscopy negative reflux disease. Cochrane Database Syst Rev. 2013 May 31;(5):CD002095. doi: 10.1002/14651858.CD002095.pub5.
  15. Yuan LZ, Yi P, Wang GS, et al; Lifestyle intervention for gastroesophageal reflux disease: a national multicenter survey of lifestyle factor effects on gastroesophageal reflux disease in China. Therap Adv Gastroenterol. 2019 Sep 25;12:1756284819877788. doi: 10.1177/1756284819877788. eCollection 2019.

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