Does this sound like a familiar scenario? Do you suffer from heartburn regularly, particularly if you eat certain foods? Then you are not alone. Heartburn is one of the most common problems seen in any general practitioner's office, and is really a problem of lifestyle.

What are the symptoms of heartburn?

Heartburn, or indigestion, feels like a burning sensation in the chest. It usually begins behind the sternum, or breastbone, and can move upward to the throat and mouth.

People describe it as feeling as though acid is coming back up the throat, and often complain of a bitter, or metallic taste in the mouth.

This pain can last from a few minutes to many hours. It is often worse after eating, and even worse when lying down. It may wake you at night.

Bending over can also precipitate the feeling of acid in the throat.

The symptoms of heartburn can be mistaken for those of a heart attack or angina, and the distinction is sometimes very difficult to make.

What causes heartburn?

There are a number of factors which contribute to this problem. In most cases, chronic heartburn is caused by a combination of gastro-oesophageal reflux and hiatus hernia.

Gastro-oesophageal reflux

Gastro-oesophageal describes the combination of the stomach, and the oesophagus, or gullet. Reflux means back-wash, or return. What is happening in gastro-oesophageal reflux (GORD) is that the stomach's contents are flowing back into the oesophagus.

Normally, something called the lower oesophageal sphincter, or valve, prevents this from happening. In GORD, this sphincter is weak, or relaxes at the wrong time. This allows the acidic stomach contents to flow back into the oesophagus, resulting in pain and spasm of the oesophagus.

Hiatus hernia

In many people a small hiatus hernia is the reason the lower oesophageal sphincter is weak.

A hiatus hernia results when the upper part of the stomach moves up into the chest through a small opening in the diaphragm, which is the muscle which separates the chest from the abdomen. The presence of a hiatus hernia results in acidic stomach contents being retained above this opening, within the lower part of the oesophagus.

Hiatus hernia is common, and does not always cause symptoms. Many people over the age of 50 have a hiatus hernia, although it can occur at any age. The hernia seems to be caused by coughing, straining, vomiting, or sudden physical exertion causing increased pressure in the abdomen. Hiatus hernia is also common in obese people and pregnant women.

Lifestyle and heartburn

There are definite lifestyle factors which cause heartburn. Certain types of food and drink can weaken the lower oesophageal sphincter, resulting in GORD, and heartburn.

Chocolate, peppermint, fried or fatty foods, coffee and alcohol contribute to GORD. Cigarette smoking relaxes the lower oesophageal sphincter, and contributes to heartburn. Obesity is a definite risk factor, as is pregnancy.

How is gastro-oesophageal reflux treated?

Since this is effectively a lifestyle problems, modifications of lifestyle will help control it.

Avoid foods which you know give you heartburn. You will have noticed that fried foods, and other fatty foods are prime culprits. Decrease your coffee and alcohol intake.

Decrease the size of your meal portions, and do not eat within two to three hours of going to bed.

Try to lose some weight if you need to. This often results in a dramatic reduction in symptoms.

Some people find that elevating the head of the bed on blocks, or sleeping on a wedge, reduces symptoms at night.

Over-the-counter antacids can provide temporary relief, but you need to see your doctor if you are taking these more than occassionally. If you need antacids for more than three weeks, see your doctor.

If you are suffering from chronic heartburn, your doctor may well prescribe medications which reduce the amount of acid in the stomach, and increase the speed with which your stomach contents are emptied. These are extremely effective, but should be combined with changes in lifestyle.

If symptoms persist in spite of treatment, then you will be sent for further investigations.

Long-term effects of gastro-oesophageal reflux

If you are suffering from severe heartburn and reflux over a long time, then you must seek treatment, and not continue to dose yourself with over-the-counter medication.

The combination of hiatus hernia and untreated gastro-oesophageal reflux will eventually result in damage to the lower part of the oesophagus from repeated acid exposure. This causes inflammation of the oesophagus, swelling of the whole area, bleeding, ulceration, and eventually a condition called Barrett's oesophagus. This describes severe damage to the lining of the oesophagus, which seems to predispose to a particular type of oesophageal cancer.

As with many health matters, prevention is better than cure. If you are finding that you are becoming more prone to heartburn, control your lifestyle, and don't get to the stage where you need medical intervention.

Stop eating fatty foods, give up smoking, limit your alcohol and coffee intake, and lose some weight.

Diet and reflux / hiatal hernia

Heartburn is a typical symptom of reflux and although almost everyone experiences transient reflux episodes, prolonged reflux poses difficulty.

During swallowing, the oesophagus functions as one tissue. As the food moves from our mouths toward the oesophagus, the upper sphincter relaxes, food moves into the oesophagus and the lower oesophageal sphincter (LES) relaxes to receive the food. By peristaltic (wave-like) motion, the food moves down the oesophagus and into the stomach.

Short-term episodes of reflux are caused by ingestion of an irritating food or viral inflammation. Recurrent reflux can be the result of a hiatal hernia, reduced LES pressure, increased abdominal pressure, recurrent vomiting or other factors. This type of reflux will ultimately cause oesophagitis or inflammation of the oesophagus. Hiatal hernia is an outpouching of a portion of the stomach into the chest through the oesophageal hiatus of the diaphragm. The pressure generated by the diaphragm forces acidic stomach contents up into the oesophagus causing reflux.

One of the determinants of reflux severity is the competency of the LES. The pressure of the sphincter is controlled by many factors, one of which is hormonal. LES pressures decreases during pregnancy, in woman taking progesterone-containing oral contraceptives and even in the late stage of the normal menstrual cycle. Helicobacter pylori bacteria and excessive use of aspirin and other non-steroidal anti-inflammatory drugs may cause oesophagitis in susceptible people.

Dietary modifications

Orange juice, and other citrus and tomato products can be irritating because of their acidity. Foods that include chilli powder and black pepper may be particularly irritating and should be limited. Certain foods and factors decrease LES pressure and should be restricted or omitted — the diet should be low in fat and exclude alcohol, carminatives (peppermint and spearmint), chocolate and caffeine-containing beverages — all of which lower LES pressure.

Because nicotine also decreases LES pressure, cigarette smoking is contra-indicated.

Timing of the evening meal is especially important and one should consume nothing but water for three hours before lying down. This also applies to an afternoon nap. Avoidance of food for three hours ensures an almost empty stomach which reduces the likelihood of gastric contents passing into the oesophagus when the person reclines. Obesity increases pressure on the stomach and is a contributing factor. Weight loss in overweight people should therefore be a priority.

In summary the person with reflux should:

Avoid cigarette smoking

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