What is reflux (heartburn)?
Heartburn or clinically known as “gastro-oesophageal reflux disease (GORD)” is a digestive disorder that affects the lower oesophageal sphincter (LES) – the muscle connecting the oesophagus with the stomach. This causes the regurgitation of acidic stomach contents back to the oesophagus causing substernal pain or burning sensation. In many patients GORD is a chronic relapsing disease and requires long term maintenance. All of us can have occasional heartburn but when it occurs more than two or three times a week regularly it is clinically defined as gastro-oesophagal-reflux-disease (GORD).
Who gets reflux and when?
Population studies indicate that about 10% of people suffer from reflux. There is a slight gender difference on the onset of reflux and men are expected to get it 5 years earlier than women. 25% of pregnant women experience heartburn daily. Although the incidence of GORD increases markedly after the age of 40 there is no particular age of onset and it is also found in infants and children.
Risk factors for heartburn
It is now known that cigarette smoking increases the incidence of heartburn by decreasing the lower oesophageal sphincter pressure and also decreasing the strength of the oesophageal valve. Pregnancy also contributes to GORD
Obesity is another predisposing factor although the exact mechanism is unknown. There are also certain foods that can increase the incidence of reflux of which the main ones are chocolate and peppermint due to relaxing effects of the “LES’. Other foods include oily fried food, citrus and fruit juices, alcoholic beverages, tomatoes and products with caffeine such as coffee.
The patient will report a burning pain behind the breastbone (a sub-sternal pain, the sternum being the breastbone) and it moves upwards to the neck and throat. A feeling of acid/bitter taste of food coming back to the mouth is common. The pain is unrelated to activity and can present anytime but certain conditions tend to make it worse – lying down or bending over and having more food, particularly after large meals. The pain can last up to around 2 hours.
Symptoms with severe untreated GORD include:
- Dysphagia – swallowing difficulties or feeling of food trapped in oesophagus
- Vomiting blood or having tarry black stool due to bleeding
- Weight loss
- Choking from acid refluxing onto the tracheal tract which may also cause shortness of breath coughing or hoarseness of voice.
What causes reflux?
A small ring of muscle situated where the oesophagus enters the stomach, helps prevent food from moving back up. When there is malfunction of this muscle, the lower oesophageal sphincter, it doesn’t close properly or closes infrequently. The acidic stomach contents then come in contact with the oesophageal wall. Prolonged contact with the oesophageal lining with acid and enzymes from the gastric juice will damage the wall causing burning discomfort.
If untreated this will lead to serious complications which include oesophagitis, very severe chest pain, bleeding, oesophageal stricture (narrowing or obstruction of oesophagus) or even pre-malignant change in the oesophageal lining (Barrett’s oesophagus). A vast majority of patients with complicated GORD will also have a hiatal hernia – this is an opening or weakness in the diaphragm and makes is easier for the stomach contents to pass upwards.
In infants or children a careful evaluation of the parents’ story is necessary .In adults diagnosis is generally made from the clinical history alone. In addition to that the following tests are available for both adults and children:
- Barium swallow or upper gastrointestinal (GI) series – an x-ray method involving barium where abnormalities of the GI tract are visible