Mild or intermittent heartburn can often
be relieved with lifestyle changes and over-the-counter antacids.
However, if heartburn has a negative
impact on your quality of life, you should seek treatment from a doctor. You
may have gastro-oesophageal reflux disease
(GORD), an increased risk for oesophageal cancer and/or be at risk for
large-volume reflux events, which may cause aspiration.
in 10-20% of people with GORD and refers to the inhalation of stomach contents
into the airways. When high volumes of acid are pushed up into the oesophagus,
frequent infections of the airways, and even life-threatening pneumonias, may
What are your treatment options?
Antacids help to neutralise the stomach acid that
causes heartburn, but these medicines can’t heal the underlying causes or
complications (e.g. inflammation).
Antacids combine with hydrochloric acid in the stomach to form salt and
water, and differ in their reaction times, neutralising capacity, side effects
and complications. These relatively inexpensive, widely
available medicines are good for treating infrequent heartburn, and are best taken before and after
meals. They work only for a short period of time (30 minutes or so).
There are three types of antacids: those
that contain calcium (e.g. Tums), those that contain magnesium, and those that
contain aluminium. Many brands (e.g. Gaviscon) also combine these ingredients
and add others. Alginates, for example, are sometimes added. These form a gel
that floats on top of the stomach contents, helping to control reflux.
Note that brands with magnesium may cause diarrhoea,
antacids with calcium or aluminium may cause constipation, and that taking
large amounts of antacids over a period of time can cause calcium loss. In this
way, antacids may contribute to osteoporosis.
Some antibiotics shouldn’t be taken in
conjunction with antacids – check with your doctor or pharmacist.
A note on sodium bicarbonate: Baking soda is commonly accepted as an effective way of providing
temporary, occasional relief of heartburn and reflux. The alkaline pH of baking
soda helps to neutralise stomach acid in a way that’s similar to
over-the-counter antacids. Half a
teaspoon of baking soda mixed with half a cup of water may provide relief.
Consult your doctor before using baking
soda regularly, as it can affect the absorption of other medicines. Baking soda
is also high in sodium, which could have a detrimental effect on your health.
Avoid using baking soda if you’re pregnant and opt for a safe antacid instead.
Once again, your doctor or pharmacist can assist.
2. Acid-suppressive therapy
antacids don’t control your heartburn sufficiently, medicines that reduce the
release of acid from your stomach are your next best option. Your doctor may
prescribe one of three types of medicines, or a combination of these drugs:
Proton-pump inhibitors (PPIs)
PPIs help to stop nearly all stomach acid production by blocking an enzyme needed for this process. They’re usually prescribed to people who experience heartburn more than 2 – 3
days a week, and provide 24-hour relief if taken as prescribed.
The PPIs available are omeprazole, lansoprazole, pantoprazole, rabeprazole, and esomeprazole, which are sold under different brand names. Many are available as generics and some PPIs are available over
the counter. Consult with your doctor before taking them, however, especially
if you have liver disease or if you’re taking other medicine.
Note that it may not be safe to take PPIs
for extended periods of time, as they’ve been linked to an increased risk of
hip fracture and certain bacterial infections. But these risks are small. If
you have Barrett’s oesophagus (see ‘Possible complications’), you might have to
take PPIs indefinitely. People with Zollinger-Ellison syndrome, a rare
condition in which a tumour leads to high levels of stomach-acid production,
may also have to take a PPI for an extended period of time.
Although this group
of drugs is considered to be the most effective medicine for relieving
heartburn, approximately 30% of
patients fail to respond to them, either partially or completely. If this is the case, you may have to
undergo further tests to see which other treatment options could work for you.
H2 receptor antagonists (H2RAs)
H2RAs also reduce stomach acid production. They stop the acid-making cells in the stomach from responding
to histamine – a natural chemical in the body that triggers acid production.
Although their effectiveness deteriorates with time, H2RAs are good for rapid relief of
symptoms. They should be taken just before the time you would usually expect to
Most H2RAs are only available on
prescription, but some can be obtained over the counter. The over-the-counter
varieties are usually somewhat weaker than those obtained on prescription. In
South Africa, the available H2RAs include cimetidine, nizatidine and
ranitidine, all of which are sold under a number of brand names.
H2RAs shouldn’t be taken without the
knowledge of your doctor, especially if you’re taking medication to control
chronic asthma or epilepsy, or if you’re on blood-thinning medication (e.g.
warfarin). Also note that side effects such as diarrhoea, dizziness and
headaches may occur.
Prokinetic agents (prokinetics)
Prokinetic agents (e.g. benzamide, bethanecol, metoclopramide, domperidone and
cisapride) are an older class of drugs that work
by strengthening the muscle tone of the lower oesophageal sphincter. In this
way, they reduce reflux into the oesophagus.
Although prokinetics are
as effective as H2RAs, they come with risks. For example, metoclpramide has
been linked to a muscle problem called tardive dyskinesia, while cisapride is
restricted in many countries because it’s been linked to a heart-rhythm
disorder. For this reason, they’re often only used if other forms of treatment
heartburn persists despite lifestyle changes and medication, surgery might be
the next step. Some of the types of surgery used to treat severe heartburn,
GORD, and its underlying causes, include:
This system helps to strengthen a weak lower oesophageal sphincter
(LES), one of the main causes of heartburn and GORD.
medical device is made up of a small, flexible band and a series of magnetic
titanium beads. The magnetic attraction between the beads helps to keep the LES
closed, unless food or liquid is ingested, when the LES will open. This helps
to prevent reflux of stomach acid into the oesophagus.
device is placed around the oesophagus, just above the stomach, during keyhole
In some people
with severe heartburn, high volumes of reflux or dangerous complications, a
type of surgery called Nissen fundoplication may be required. The aim of this
procedure is to strengthen the oesophageal sphincter, which will allow the
oesophagus to heal.
wrapping the top end of the stomach around the bottom of the oesophagus to form
a strong new “valve”. It can be done by traditional open surgery or with the
help of a laparoscope.
Surgery for early-stage cancer
If your doctor picks up that you
have early-stage oesophageal cancer, he or she might choose to remove the affected
sections of the oesophagus, and some of the tissue surrounding it. This can be
done via a scope, and is a minimally invasive operation.
An oesophagectomy is usually done
when cancer is affecting a significant portion of the oesophagus. This type of
surgery is used to remove some or most of the oesophagus and, sometimes, a
small part of the stomach as well.
How much of the oesophagus is removed, and
the surgical approach used, depends on the stage of cancer and where the tumour
is located. Lymph nodes are also often removed during the surgery to check if
they contain cancer cells, too.
Oesophagectomywith gastric pull-up
If tests indicate that you have
oesophageal cancer, your doctor may also recommend an oesophagectomy with
During this surgical procedure, the upper
part of the oesophagus is connected to the remaining part of the stomach – the
stomach is pulled up into the chest or neck to replace part of the oesophagus.
complications may occur, and patients tend to experience side effects shortly after surgery,
long-term survivors of oesophagectomy with gastric pull-up generally enjoy a good
quality of life.
Another surgical procedure that
may be done to treat a damaged oesophagus is colon interposition. This type of
surgery is usually performed when the stomach isn’t suitable or available to
use as a substitute for the oesophagus.
During this procedure, your doctor
will remove a section of your colon to reconnect the remaining oesophagus. He
or she may choose to preserve as much of the healthy, functioning sections of
the oesophagus as possible.
4. Chemotherapy and radiation
Apart from surgery to remove cancer, you might have to
be treated by means of chemotherapy and/or radiation therapy. In fact, if you have locally-advanced oesophageal
cancer, you may not have to undergo surgery at all, but chemotherapy or
radiation may be required.
involves the use of high-energy X-rays
or other particles to destroy cancer cells; with chemotherapy, drugs are used
to destroy cancer cells.
If you suffer from mild, intermittent heartburn, you may want to try natural
remedies to see if they make a difference. Some of the remedies used for
heartburn include calcium tablets, charcoal tablets, coconut water, angelica,
caraway, chamomile, milk thistle and fennel seeds. Note, however, that there
aren’t any good, evidence-based studies that support the use of these remedies.
Interesting new research has shown that, in
addition to other medical therapies, oesophageal-directed.
Hypnotherapy could possibly help to manage
disorders of the oesophagus. In this way, the therapy may help relieve
heartburn. Another alternative treatment that may help to treat heartburn and
GORD is acupuncture, although more research is needed to confirm that this
age-old Chinese therapy really works to relieve heartburn.
Getting a physiotherapist
to help you breathe via your diaphragm, a technique called “belly breathing”,
is another integrative treatment option that’s receiving attention around the
globe. Talk to your gastroenterologist to find
out if this is an option for you.
Remember to always contact your doctor before taking any natural remedies to
make sure they won’t interact with any other medications you’re taking.
- Reviewed by Dr
Estelle Wilken,Senior Specialist in Internal Medicine and Gastroenterology at
Tygerberg Hospital. - March 2017