Heartburn – gastric reflux

Summary

Generally

Heartburn is caused by the fact that the  upper abdomen cannot hold completely tightly but permits some gastric juice from the stomach up to the esophagus.

Heartburn is also called gastric reflux.

symptoms

Common symptoms are

  • acid reflux
  • pain in the upper abdomen
  • a burning sensation behind the sternum.

Treatment

Temporary mild heartburn often goes away by itself. If you have mild problems it can help if you

  • raises the head end of the bed about 15 centimeters and is on the left side, so that the contents of the stomach cannot reach the esophagus as easily
  • avoids food and drink that you know causes trouble
  • Avoid eating late meals
  • avoids bending forward and lifting heavy
  • lose weight if you are overweight
  • temporarily use non-prescription medicines for gastric juice reflux.

If you have long-term problems, the mucous membrane of the esophagus can be damaged and you get an inflammation, called esophagitis. Then you need treatment with medicines.

When to seek care?

You can contact a health care center if you are worried about your problems or have problems even though you have tried to treat yourself and if you feel that the problems interfere with everyday life.

You should contact a health care center if you need to

  • are older than 45 years and have not had the trouble of heartburn and acid reflux before
  • has major problems with heartburn
  • have difficulty swallowing or food gets stuck when swallowing, especially if the symptoms are new
  • have heartburn and lose weight
  • previously received treatment but the trouble does not decrease.

You can seek care at any healthcare center you want  throughout the country.

You should contact the healthcare provider immediately if you have heartburn and a lot of stomach or chest pain, or if the stools are black.

Important to understand

In order to be able to participate in the care and to make decisions, it is important to understand the information  you receive from the healthcare staff. You can ask questions if you do not understand, or ask to have the information printed to read it in peace.

You have the right to receive interpreting assistance. You may also have the right to receive interpreting assistance if you have a hearing impairment.

What happens in the body?

Heartburn is often due to gastric reflux

Heartburn usually means having acid rebounds, or some type of pain behind the sternum. The disease is also called gastric juice reflux. In the medical language it is called gastroesophageal reflux disease. Gastro stands for stomach and esophagus means esophagus.

The disease is almost always harmless and there is good treatment available.

If you have a lot of reflux problems, it is important to get treatment. Otherwise, you may get inflammation of the esophagus, which can, among other things, cause narrowing of the esophagus. Then it can be difficult to swallow and pain behind the sternum.

What is reflux?

Reflux means reflux and means that the upper stomach can not hold completely tightly but permits some gastric juice from the stomach up to the esophagus.

The esophagus transports the food

The esophagus is shaped like a soft tube and goes from the mouth through a hole in the diaphragm down to the stomach. The diaphragm is also called the middle nerve muscle. The most important task of the esophagus is to transport the food from the mouth to the stomach. In the transition between esophagus and stomach there is the upper stomach.

Fracture in the diaphragm

The upper stomach is a type of valve that allows the food to pass down to the stomach, but prevents the stomach contents from backing up to the esophagus. The upper gastric mouth is never completely dense, which means that stomach contents can still come back into the esophagus.

If you have a hernia in the diaphragm, it is common for the function of the upper abdomen to deteriorate. This can lead to reflux problems. A hernia is when the muscles in the diaphragm are weakened, which causes the hole in the diaphragm where the esophagus passes, to be enlarged. Then the lower part of the esophagus and part of the stomach can be pressed into the chest through the enlarged hole. The noise itself is harmless, and if it does not cause any trouble, you do not need to do anything about it. Diaphragmatic hernias are also called diaphragm hernias, hiatus hernias or sliding hernias.

Gastric juice reflux can cause mucosal damage

The mucous membranes of the esophagus are protected by a mucus layer and by bicarbonate because the stomach acid is highly corrosive. In addition, the esophagus is protected by the small amount of saliva that comes with each time you swallow.

The mucous membrane of the esophagus can be damaged if the upper stomach can not hold tightly and acid from the stomach goes up into the esophagus for a long time. Then you can get heartburn, acid reflux and aches or sweat in the middle of the upper abdomen. In addition to hydrochloric acid from the stomach, bile salts from the bile ducts can sometimes back up to the esophagus and cause problems.

Inflammation of the esophagus

If you have long-term reflux problems you may suffer from inflammation of the esophagus. This can lead to permanent damage, which can sometimes make it difficult to swallow food. Inflammation can also be caused by, for example, infection, allergies, certain drugs and poisons such as lye or acid that you have accidentally swallowed. In addition, the inflammation can be caused by having swallowed down an excessively large bite that has been difficult to pass through the esophagus and stomach.

Reflux problems can be hereditary

Reflux problems and hernias in the diaphragm can be hereditary. Gastric juice reflux is as common in non-pregnant women as in men. Heartburn is a common pregnancy problem . About one fifth of the population in Europe has recurring complaints that periodically require medication and some people have complaints every day. It is unusual to need treatment for a long time when you have heartburn.

You can get heartburn at any age. Infants easily gain stomach contents into the esophagus, which means that they sometimes vomit up food after being breast-fed or eating out of a bottle. This decreases by itself during the first few months. If the child is doing well otherwise and is gaining weight then there is no need to worry.

Toddlers can suffer from vomiting, asthma-like disorders and recurrent respiratory problems that may at some time be due to reflux disease. Heartburn or heartburn and acid reflux caused by gastric juice reflux are uncommon before adolescence.

Being overweight increases the risk of reflux problems

Research shows that being overweight leads to a greater risk of reflux. However, scientific studies have given contradictory results regarding the importance of exercise, coffee, smoking, alcohol, caloric intake and fiber content in food.

Prolonged reflux can increase the risk of cancer

Although cancer of the esophagus is uncommon, there is a slight increased risk of it if you have had gastric juice reflux for several years. The risk increases further if you are overweight and have severe problems. While smoking has a meaning.

A small increased risk of cancer also applies to some people who have so-called Barrett’s esophagus. This means that you have a type of mucous membrane in the esophagus that is usually not there. Gastroscopy examination shows whether Barrett’s esophagus is present. If you have Barrett’s esophagus, you can go on regular checks to find any cell changes early.

Symptoms and diagnosis

Common problems when having gastric juice reflux are

  • heartburn or heartburn
  • acid reflux
  • stomach ache, that is, in the middle of the upper abdomen.

It is often called heartburn, but the burning sensation is actually behind the sternum and radiates backwards towards the chest. Therefore, breast burn is an expression that better describes what it is about.

The reflux disease does not change for most people over the years. It is unusual for it to disappear completely or to go into some more serious form. Many people learn to live with the hassle and avoid things that cause trouble. This means that there is not always a need for continuous drug treatment.

Other symptoms

If you have gastric juice reflux you can also:

  • get difficult to swallow
  • cough at night
  • mucus in the trachea and throat
  • asthma-like symptoms
  • sore throat
  • prolonged hoarseness
  • get mouth damage to mucous membranes and teeth. 

Other diseases can cause reflux disorders

Sometimes it is another illness that is behind the trouble with reflux. Symptoms that may be signs of another disease are that

  • get reflux problems if you are older than 45 years and have not had it before
  • you have difficulty swallowing or food gets stuck when swallowing, especially if the symptoms are new
  • you lose weight
  • the trouble does not diminish from the treatment you have received.

Having difficulty swallowing may be a sign that there has been a narrowing of the esophagus. The narrowing can occur due to an inflammation that has healed with so-called scar shrinkage. Scarring can occur if there are several scars on the same level in the esophagus. You should always contact a health care center if you have difficulty swallowing.

The trouble can also be a sign of a malignant tumor in the esophagus or stomach.

Severe nocturnal problems can cause inflammation of the esophagus

If you have a lot of reflux during the day or if you have reflux even at night, the risk of inflammation in the esophagus is greater. This is because the acid remains in the esophagus for longer than during the day.

When you have had severe inflammation of the esophagus, a new examination is often needed to check that the injury has healed. It is the treating physician who decides on, how and when to be examined.

Doctors at the health center treat

Usually a gastric reflux is investigated and treated by a doctor at a health center.

If further research is needed, gastroscopy is done primarily. This is usually done at a special reception to which you are referred  . If you do not get well from the treatment or if there is some other reason, the doctor can write a referral to a gastroenterologist, who is a specialist in diseases of the stomach and intestines.

Various surveys

If you are young and have reflux problems, which are mild and that you have only had for a short time, it may suffice to describe the problems for the doctor to make an assessment.

If you have other problems that are not as typical, further investigation is needed, primarily through examination with gastroscopy. This is important, because even in the case of less obvious and rather mild problems, you can sometimes have severe inflammation of the esophagus.

Gastroscopy

If you have reflux problems that need to be investigated, you are primarily examined with gastroscopy. A doctor then brings down a tube with a camera in the end through the mouth in order to be able to examine the esophagus, stomach and duodenum.

With the help of the gastroscope, the person doing the examination can also take sample pieces from the mucous membranes, which are examined in a microscope to see if, for example, there are gastric ulcer bacteria in the stomach or cell changes. By means of an instrument brought down by the gastroscope, the doctor or nurse can also measure whether the gastric mucosa forms hydrochloric acid or not.

The acidity of the esophagus is measured

If you have typical problems, the doctor makes the diagnosis of reflux disease even though gastroscopy cannot show that you have gastric juice reflux. If the symptoms are unclear and the gastroscopy does not show any deviation, further studies may be needed to determine whether gastric juice reflux is the cause of the disorders.

With the so-called 24-hour pH measurement, the acidity of the esophagus can be measured. It is a fairly unusual examination, but it can be used if, despite medication, you have severe problems and the doctor does not find any explanation. At 24-hour pH measurement, a thin tube is inserted into the esophagus and stomach. Then you have to write down for a day when you have problems. For 24 hours, the acidity in the stomach and esophagus is measured via the thin tube. The pressure is usually recorded simultaneously in the stomach and esophagus.

There is also another technique where the doctor, using a gastroscope, glues a small capsule to the upper stomach. The capsule then transmits a radio signal that varies with the acidity for several days. The advantage of this technique is that you do not release the tube in the nose.

Usually the gastric juice is acidic in the stomach but neutral in the esophagus. If it becomes acidic, that is, the pH is low, in the esophagus for most of a day and it coincides with problems, the doctor can safely say that you have gastric juice reflux.

After the investigations

You should find out who to contact, and when, to find out the answers after the surveys. You should also find out where to turn if you get worse.

Care and treatment

The most common thing is that you get reflux problems on a few occasions and that the problems are mild.

If you have temporary problems that are not difficult, you should think about whether you have eaten or drank something that may have triggered the problems. For example, it can be fatty food, alcohol or coffee. It can be enough to avoid any of this in order to be trouble free again. If you are taking medicines, even prescription-free, and have reflux problems, you should consult your pharmacist or your doctor.

If you have gastric juice reflux for an extended period of time it means an increased risk of inflammation of the esophagus. Inflammation rarely heals by itself. It must be treated in order to avoid problems in the form of wound healing with scars in the future. Scars can cause difficulty swallowing.

Avoid the trouble

In addition to losing weight, there is not much scientific support for changing lifestyle to reduce the hassle. If you have mild problems it can sometimes help if you

  • raises the head end of the bed about 15 centimeters and is on the left side, so that the stomach contents cannot reach the esophagus as easily
  • avoids fatty foods, coffee, alcohol and nicotine  
  • don’t eat late at night
  • avoids working position in forward-bending position.

Some drugs can exacerbate the problems, especially painkillers and anti-inflammatory drugs, so-called NSAIDs. NSAIDs are available in both non-prescription drugs, such as Treo and Ipren, and in prescription drugs, such as Voltaren and Diclofenac. You should consult your doctor or pharmacist if you have gastric juice reflux and should start using a new drug.

Three different drug treatments

If you have severe reflux problems you may need treatment with medicines. There are three different types of anti-gastric reflux drugs:

  • So-called antacids that neutralize stomach acid.
  • Medicines containing alginic acid which form a protective layer in the stomach and which prevent reflux to the esophagus.
  • Histamine-2 blockers and proton pump inhibitors reduce hydrochloric acid formation in the stomach.

The trouble determines which drug you are given

If you do not have inflammation of the esophagus, the treatment is determined by how much reflux you have. If you have temporary problems, antacids can suffice for you to become trouble free. One advantage of antacids is that they work immediately, and make you feel better at once. They are therefore suitable for quickly relieving reflux symptoms.

Proton pump inhibitors are the most effective drugs if you have severe reflux problems. Next, histamine-2 blockers, antacids and alginic acid.

If you do not have inflammation of the esophagus and become trouble-free by histamine-2 blockers or proton pump inhibitors it is sometimes enough to use them only when the problems come. If you are trouble free, you usually do not need any medication unless you have been told otherwise by the doctor.

If the esophagus is inflamed, proton pump inhibitors are usually needed for two to four weeks, sometimes longer, for inflammation to heal. Treatment should be continued even if the symptoms disappear after a few days. In general, proton pump inhibitors are taken until a check with gastroscopy has shown that the inflammation has healed. If you have more severe inflammation you may need to be treated with proton pump inhibitors throughout your life.

antacids

Drugs that neutralize the acid are called antacids. Samarin is an example of antacids containing bicarbonate. Bicarbonate provides temporary relief of symptoms, but is also absorbed into the bloodstream and can affect the pH of the body if the drugs are used frequently. Therefore, antacids with bicarbonate should not be used more often than a few times a day, and not for longer than two weeks.

If you often have problems, you should primarily choose so-called buffering antacids over antacids with bicarbonate. The fact that it is buffering means that the drugs do not raise the pH of the stomach too much and that they are not absorbed into the blood. This makes it possible to take them up to 10-15 times a day. But you need to take drugs so often it is better to take proton pump inhibitors or histamine-2 blockers.

alginic acid

Alginic acid forms a kind of jelly-like mass that settles at the top of the stomach. It means that the stomach contents do not rise so easily in the esophagus. This reduces the risk of reflux. The effect lasts for about three hours. Alginic acid is not absorbed from the intestine but leaves the body with the stools. Alginic acid is found in the drugs Galieve and Gaviscon. Both are available for purchase without a prescription.

Alginic acid can be combined with antacids. Alginic acid needs hydrochloric acid to benefit. Therefore, it is important to take alginic acid first, about half an hour before taking antacids.

Histamine-2 blockers

Histamine-2 blockers, so-called H2 blockers, are a type of drug that blocks the nerve of the cells that produce hydrochloric acid in the stomach. In this way, the secretion of hydrochloric acid decreases.

Histamine-2 blockers get their maximum effect a little faster than proton pump inhibitors, but are not as effective. Thus, when choosing these drugs, it is important to make an assessment of what is most important – speed or efficiency. Histamine-2 blockers can be combined with antacids.

There are non-prescription drugs for the treatment of reflux disorders. Examples of histamine-2 blockers are drugs that contain the active substance famotidine, for example Pepcid.

Proton pump inhibitors

Proton pump inhibitors reduce hydrochloric acid production more strongly than histamine-2 blockers. There is no significant difference in effect between the various proton pump inhibitors in the treatment of reflux disorders. Examples of proton pump inhibitors are drugs that contain the active substance omeprazole, such as Omeprazole and Losec, or the substance pantoprazole, such as Pantoprazole and Pantoloc. Another name for proton pump inhibitors is the abbreviation PPI.

Some proton pump inhibitors can be purchased non-prescription in smaller packages. If you regularly need proton pump inhibitors, it will be cheaper per tablet if you get a prescription from your doctor on larger packages.

To get the best effect from proton pump inhibitors, you should take them half an hour before the first meal of the day, no matter when the day is at its worst. It takes one to three hours for the drug to start working, and a few days before getting full effect.

Therefore, if you want faster effect, antacids are better. If you want to take antacids at the same time to reduce the problems more quickly, then you are fine.

Most often proton pump inhibitors in severe problems

If you have mild and moderate symptoms, it is usually enough to take histamine-2 blockers and antacids to become trouble-free. The treatment depends on how much trouble you have. Therefore, you should be involved in the treatment yourself.

When you have severe reflux problems, the doctor usually prescribes a proton pump inhibitor. The trouble usually decreases or disappears in a few days. If you have very severe problems you may need regular treatment for a longer period of time. Once the trouble is gone, proton pump inhibitors can be used if needed. You do not generally need to take them regularly. It is good to consult the doctor about how often to take the medication.

If you have typical reflux problems that are not alleviated by proton pump inhibitors and histamine-2 blockers, it may be because bile salts from the bile ducts back up to the esophagus, but this is unusual. Antacids usually help. If you have reflux problems that are not alleviated by proton pump inhibitors or histamine-2 blockers, consult your doctor.

Higher dose in severe inflammation of the esophagus

If you get severe inflammation of the esophagus, high doses of proton pump inhibitors may be needed. Reflux problems are usually alleviated by proton pump inhibitors and if you do not get any effect you should investigate further, for example with so-called 24-hour pH measurement. The problems can, for example, be due to functional dyspepsia and there are no effect of acid suppressants.

Risks with treatment

There are no major disadvantages of using anti-gastric reflux drugs.

If you take histamine-2 blockers and proton pump inhibitors for two weeks or longer, you can sometimes get a so-called recoil effect. This means that you get increased production of hydrochloric acid and more symptoms when you stop taking the drug. If you experience a recoil effect, you may need to take half the dose every day or the same dose every other day for a couple of weeks before you can stop taking drugs. You should consult your doctor on how to do it.

Risk of trouble coming back

There is a great risk that the reflux problems will return despite being treated with drugs. Then you should avoid eating or drinking things that usually aggravate the problems. It is good to eat regularly. You should also start with medicines you have used before and that usually help. Treatment may take a few or a few days to get through without medication.

If you have had inflammation of the esophagus, regular treatment with proton pump inhibitors is sometimes required.

Alternative treatment methods

There are a variety of alternative treatments for reflux disorders within health food. There are no scientific studies on whether the treatments have any effect or not.

Pregnancy and breastfeeding

It is common to have reflux problems when you are pregnant. This is due to the increased pressure in the abdomen that arises during pregnancy and the fact that the upper abdomen becomes flaccid.

Proton pump inhibitors, antacids and alginic acid can be used during pregnancy. With regard to histamine-2 blockers, there is insufficient experience in the treatment of pregnant women and you should therefore consult a doctor if you need to use the medicine when you are pregnant. If you have not had reflux problems before pregnancy, it is advisable to consult a midwife or doctor at the maternity care center for appropriate treatment.

Histamine-2 blockers should be avoided when breast-feeding. The active substance passes into the breast milk and can affect the baby. The same applies if you use proton pump inhibitors and therefore you should consult a doctor if you need to use any of the medicines when breastfeeding.

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