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Indigestion and heartburn: a practical approach

Key learning points:

- The terms indigestion and heartburn can be broad, a clear history is required to ascertain their meaning to the patient

- Gastro-oesophageal reflux disease affects more than 40% of the population

- Eighty per cent of patients will respond to a two-week course of high dose proton pump inhibitor therapy, those not responding to treatment or those with alarm symptoms should be referred to a gastroenterologist for further investigation

Indigestion and heartburn are common symptoms reported to healthcare professionals that affect people of all ages. Indigestion is a broad term that is commonly used to describe a wide-variety of symptoms including abdominal pain, bloating, nausea and vomiting, belching and gas, acidic taste, growling stomach and heartburn. Heartburn itself is a term generally used to describe a burning sensation experienced by people in the upper abdomen or chest often; but not always, in relation to food. It is common for people to use these terms in relation to suffering with acid reflux. When these symptoms become frequent or troublesome then patients are referred to as having gastro-oesophageal reflux disease (GORD). (1) However, it is important to recognise that these symptoms can mimic potentially more serious diseases. Therefore, it is imperative to ascertain from the patient what they mean when using these terms.

Recognising the symptoms and signs

Symptoms of acid reflux are common. It is estimated that approximately 40% of the UK adult population will report some degree acid reflux symptoms each week with 24% having symptoms on two or more days. (1,2) The most common symptoms reported are abdominal or chest discomfort, often described as burning, particularly occurring after meals. This can cause odynophagia (painful swallowing) and these symptoms can be associated with regurgitation of food and fluids and acid brash. While there is an association with meals, patients often report symptoms that can be worse overnight when lying, due to both the impact of gravity and reduced overnight peristalsis. (1) In those whom acid reflux is more severe, patients can report symptoms due to the impact of acid on the throat or mouth. These include; a hoarse voice, sore throat, bad breath, the sensation of a lump in the throat, chronic sinusitis and even dental enamel erosion. Rarely, acid reflux can even affect the lungs leading to a chronic cough or recurrent lung infections. Patients presenting with ear, nose or throat (ENT) or respiratory symptoms should have diseases of these organs excluded prior to considering GORD.

As mentioned GORD can mimic other diseases and one must therefore, take a thorough history to ensure other potentially more serious conditions are not missed. Key conditions and their features are outlined in Table 1.

Why do people get acid reflux?

Following swallowing the oesophagus propels food or liquid into the stomach by muscular contraction known as peristalsis. At the lower end of the oesophagus a ring of muscle, aided by the diaphragm, known as the lower oesophageal sphincter (LOS) relaxes to allow the passage of the substance into the stomach before quickly contracting again to prevent this substance from “refluxing” back into the oesophagus. The LOS should remain closed unless swallowing, however, it can become weak or relaxed at inappropriate times causing it to be open and allow reflux to occur. Similarly the diaphragm aids in strengthening the LOS. Should it become weak, the stomach may be able to slide through the diaphragm, into the chest, causing reflux.

 

Diagnosing acid reflux

Diagnosis is generally based upon symptoms and thus obtaining a thorough history is key. However, this can be difficult as only 5-10% of acid reflux episodes produce heartburn. (1) Should the diagnosis be suspected then a trial of treatment, ranging from lifestyle measures to medication, is appropriate with the confirmation of the diagnosis made upon response to treatment. Eighty percent of patients with typical reflux symptoms will respond to a two week course of high dose proton pump inhibitor (PPI), 40mg omeprazole twice daily. (1) Further testing tends to be reserved for those not responding to treatment or those with more serious signs or symptoms.

An upper gastrointestinal (UGI) endoscopy is able to evaluate whether there is inflammation caused by acid reflux, or the presence of other conditions or complications of acid reflux including ulcers and cancer. A normal endoscopy does not mean the patient does not have GORD, it just means that no damage has been caused by acid reflux. Seventy percent of patients who report heartburn have no inflammation seen on an endoscopy. (1) Thus endoscopy tends to be reserved for those with alarm symptoms of UGI cancer (see Table 1).

Some patients undergo a 24-hour oesophageal pH study and manometry in order to ascertain whether there is abnormal acid reflux and whether the oesophagus is able to propel substances into the stomach through sufficient peristalsis, and if the LOS is functioning properly. However, this latter test tends to be reserved for cases that are more difficult to diagnose or are not responding to treatment.

The affect on quality of life

Indigestion and heartburn can have a significant impact on a person's quality of life. It can affect their dietary and eating habits, weight, mood, ability to sleep and even exercise tolerance. Studies have shown that the impact of GORD on quality of life is proportional to the severity and frequency of symptoms, and this detrimental impact exceeds the impact of those with back problems, diabetes, chronic lung problems, hypertension and arthritis. (4)

Treatment options

The aim of treating GORD is to achieve symptom control while preventing the potential complications of acid reflux. Mild symptoms can often be managed through lifestyle modification and antacid therapy. Moderate to severe symptoms will require medical therapy with surgery reserved for those with medication fails and symptoms greatly impacting their quality of life.

Lifestyle

Numerous lifestyle modifications have been recommended for years but few have been evaluated in clinical trials (see Table 2).

Medication

Antacids (e.g. gaviscon, tums, maalox etc) are effective for mild symptom relief but will not promote healing of inflammation in more significant GORD. They can be used in combination with stronger medication in moderate to severe GORD, and generally work by forming a pH neutral barrier preventing the symptoms caused by acid aggravating the oesophagus. Should symptoms not be or only partially be controlled by antacids then patients will need additional medication.

Proton pump inhibitors (PPI) (e.g. omeprazole, lansoprazole etc) are commonly prescribed in those suspected of having GORD and, as indicated earlier, are effective both as a treatment and a safe investigative test to confirm the diagnosis. Generally, patients will be given an eight-week course of a PPI as the healing rates have been shown to significantly improved from this (84%) compared to a four week course (68%). (1) In those patients where symptoms return following cessation of the PPI they may be required to take the medication long term. While there have been concerns over the long-term safety of PPI prescription, the risks are in fact low. There is a small increased risk of contracting infective diarrhoeas including clostridium difficile, and the slight increased risk of pneumonia and osteoporosis is still debated with conflicting studies. (5) It is generally accepted that the prescription of PPIs in the long term is safe and the aim should be to tailor the dosing to achieve symptom control on minimal dosage. Maximal benefit may be achieved if taken 30 minutes before food, however, this can be tailored to match the patient's symptom profile. Histamine-receptor-2 antagonists (e.g. ranitidine, cimetidine etc) are less effective than PPIs. These tend to be prescribed for those who are unable to tolerate PPIs or used in conjunction with PPIs to maximise medical therapy. It has been shown that a dose of a histamine antagonist last thing at night can minimise nocturnal symptoms when used in conjunction with PPIs. (1)

Conclusions

The impact of GORD on quality of life can be significant, therefore, recognition of symptoms and effective management can have a beneficial impact, while also avoiding the potential complications of untreated GORD including peptic ulcers, strictures, Barrett's oesophagus and oesophageal cancer.

References

1. Banks M, The modern investigation and management of gastro-oesophageal reflux disease (GORD). Clinical Medicine, 2009. 9(6): p. 600-4.

2. Issing W J, Karkos PD, Atypical manifestations of gastro-oesophageal reflux. Journal of the Royal Society of Medicine, 2003. 96(10): p. 477-80.

3. David G G, Al-Sarira AA, Willmott S, Deakin M, Corless DJ, Slavin JP, Management of acute gallbladder disease in England. British Journal of Surgery, 2008. 95(4): p. 472-6.

4. Shaw M J, Crawley JA, Improving health-related quality of life in gastro-oesophageal reflux disease. Drugs, 2003. 63(21): p. 2307-16.

5. Mohamed Z, Attwood SE, Oesophageal dysfunction and disease in obesity. British Journal of Medical Practioners, 2011. 4(2): p. 417.

6. Owen C, Marks DJ, Banks M, The dangers of proton pump inhibitor therapy. British Journal of Hospital Medicine, 2014. 75(7): p. C108-12.