Treating heartburn

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.

Aspiration occurs 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 occur.

What are your treatment options?

1. Lifestyle changes

The following lifestyle changes may be all that’s needed to relieve your heartburn:

• Lose weight, if necessary. Weight loss is associated with a significant improvement in heartburn and GORD. Exercise several times a week, reduce your portion sizes and eat healthy, balanced meals (include lots of fresh vegetables). Work with a registered dietician if you struggle to lose weight on your own.
  
• Eat small, frequent meals and don’t skip meals. Large meals put pressure on your stomach and lower oesophageal sphincter (LES). This could lead to reflux and heartburn.
  
• Eat slowly and chew your food properly. This will make the food easier to digest and pass through the digestive system.
• Avoid foods and beverages that make your heartburn worse. These differ from person to person, but may include:
  
  - Rich, fatty foods. These foods delay gastric emptying, prolonging the time stomach acid is in contact with the oesophagus.
  - Spicy foods, which may irritate the lining of the oesophagus and stomach.
  - Alcohol, which may irritate the lining of the oesophagus and stomach.
  - Caffeinated, carbonated beverages (e.g. Coca Cola), which could lead to belching.
  - Coffee, which may cause relaxation of the LES.
  - Chocolate, which may cause relaxation of the LES.
  - Citrus fruits and juices, which are very acidic.
  - Tomato sauce, which is also acidic.
  - Peppermint and spearmint, which may cause relaxation of the LES.
  - Refined starches (e.g. white bread, porridge, pasta), which tend to cause gas.
  - Onions, garlic, cucumber and peppers, which tend to cause gas.

• Don’t drink large amounts of fluid with your meals.
  
• Don’t eat late-night snacks and don’t lie down for 2-3 hours after eating a meal.
  
• Chew sugarless gum after meals. The saliva generated acts as a buffer to the acid in your digestive system.
  
• Avoid taking painkillers such as ibuprofen, aspirin and naproxen regularly or in large quantities, as they may irritate the lining of your oesophagus and stomach.
  
• Sleep on your left-hand side. Research shows that reflux occurs more frequently in people who sleep on their right-hand side.
  
• Elevate the head of your bed, e.g. put the top section of the bed on bricks or blocks, or sleep on a wedge-shaped pillow. Gravity helps to clear the refluxed stomach contents from your oesophagus. Also, reflux experienced during the night tends to be more damaging than reflux experienced during the day.
  
• Raising your torso might also help, as it reduces pressure on the LES. Use a cushion or a wedge.
  
• Don’t wear tight-fitting clothes, which can put pressure on your stomach.
  
• Monitor the effect of certain types of exercise. Bending over, doing heavy lifting, and doing intense physical activity may trigger reflux and heartburn, so it might be better to switch to different or more moderate activities. Note that exercise is extremely beneficial to your overall health, so try to exercise as often as possible. Avoid exercising on a full stomach, and drink a glass of water before and after exercise.
• Quit smoking. The nicotine in cigarettes causes the LES to relax, increasing the risk for reflux and heartburn.
  
• Keep a diary of what you eat, your activities and the symptoms you experience. This can help you identify which lifestyle factors contribute to your heartburn. There are great phone apps out there to make this process as easy as possible.

2. Antacids

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.

3. Acid-suppressive therapy

If simple 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 get heartburn.

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 fail.

4. Surgery

If your 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.

This 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.

The LINX device is placed around the oesophagus, just above the stomach, during keyhole surgery.

Nissen fundoplication

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.

Fundoplication involves 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.

Oesophagectomy

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 as well.

Oesophagectomywith gastric pull-up

If tests indicate that you have oesophageal cancer, your doctor may also recommend an oesophagectomy with gastric pull-up.

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.

Although serious 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.

Colon interposition

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.

5. 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.

Radiation therapy involves the use of high-energy X-rays or other particles to destroy cancer cells; with chemotherapy, drugs are used to destroy cancer cells.

6. Integrative care

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, the following treatments may be effective:

• 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 these treatments may be suitable 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.