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Heartburn

HeartburnSymptoms of heartburn are caused when there is reflux of gastric contents, particularly acid, into the oesophagus, which irritate the sensitive mucosal surface (oesophagitis). Patients will often describe the symptoms of heartburn – typically a burning discomfort/pain felt in the stomach, passing upwards behind the breastbone (retrosternally). By careful questioning, the pharmacist can distinguish conditions that are potentially more serious.

What you need to know

Age, Adult, child, Symptoms, Heartburn, Difficulty in swallowing, Flatulence, Associated factors, Pregnancy, Precipitating factors, Relieving factors, Weight, Smoking habit, Eating, Medication, Medicines tried already, Other medicines being taken, Significance of questions and answers

Age

The symptoms of reflux and oesophagitis occur more commonly in patients aged over 55 years. Heartburn is not a condition normally experienced in childhood, although symptoms can occur in young adults and particularly in pregnant women. Children with symptoms of heartburn should therefore be referred to their doctor.

Symptoms/associated factors

A burning discomfort is experienced in the upper part of the stomach in the midline (epigastrium) and the burning feeling tends to move upwards behind the breastbone (retrosternally). The pain may be felt only in the lower retrosternal area or on occasion right up to the throat, causing an acid taste in the mouth.

Deciding whether or not someone is suffering from heartburn can be helped by enquiring about precipitating or aggravating factors. Heartburn is often brought on by bending or lying down. It is more likely to occur in those who are overweight and can be aggravated by a recent increase in weight. It is also more likely to occur after a large meal. It can be aggravated and even caused by belching. Many people develop a nervous habit of swallowing to clear the throat. Each time this occurs, air is taken down into the stomach, which becomes distended. This causes discomfort which is relieved by belching but which in turn can be associated with acid reflux.

Severe pain

Sometimes the pain can come on suddenly and severely and even radiate to the back and arms. In this situation differentiation of symptoms is difficult as the pain can mimic a heart attack and urgent medical referral is essential. Sometimes patients who have been admitted to hospital apparently suffering a heart attack are found to have oesophagitis instead. For further discussion about causes of chest pain.

HeartburnDifficulty in swallowing (dysphagia)

Difficulty in swallowing must always be regarded as a serious symptom. The difficulty may be either discomfort as food or drink is swallowed or a sensation of food or liquids sticking in the gullet. Both require referral (see ‘When to refer’ box below). It is possible that discomfort may be secondary to oesophagitis from acid reflux (gastro-oesophageal reflux disease), especially when it occurs whilst swallowing hot drinks or irritant fluids (e.g. alcohol or fruit juice). A history of a sensation that food sticks as it is swallowed or that it does not seem to pass directly into the stomach (dysphagia) is an indication for immediate referral. It may be due to obstruction of the oesophagus, e.g. by a tumour.

Regurgitation

Regurgitation can be associated with difficulty in swallowing. It occurs when recently eaten food sticks in the esophagus and is regurgitated without passing into the stomach. This is due to a mechanical blockage in the oesophagus. This can be caused by a cancer or, more fortunately, by less serious conditions such as a peptic stricture. A peptic stricture is caused by long-standing acid reflux with esophagitis. The continual inflammation of the esophagus causes scarring. Scars contract and can therefore cause narrowing of the oesophagus. This can be treated by dilatation using a fibre-optic endoscope. However, medical examination and further investigations are necessary to determine the cause of regurgitation.

Pregnancy

It has been estimated that as many as half of all pregnant women suffer from heartburn. Pregnant women aged over 30 years are more likely to suffer from the problem. The symptoms are caused by an increase in intra-abdominal pressure and incompetence of the lower oesophageal sphincter. It is thought that hormonal influences, particularly progesterone, are important in the lowering of sphincter pressure. Heartburn often begins in mid-to-late pregnancy, but may occur at any stage. The problem may sometimes be associated with stress.

Medication

The pharmacist should establish the identity of any medication that has been tried to treat the symptoms. Any other medication being taken by the patient should also be identified; some drugs can cause the symptoms of heartburn, e.g. those with anticholinergic actions, such as tricyclic antidepressants and calcium channel blockers and caffeine in compound analgesics or when taken as a stimulant.

Failure to respond to antacids and pain radiating to the arms could mean that the pain is not caused by acid reflux. Although it is still a possibility, other causes such as ischaemic heart disease and gall bladder disease have to be considered.

When to refer

Failure to respond to antacids

Pain radiating to arms

Difficulty in swallowing

Regurgitation

Long duration

Increasing severity

Children

Treatment timescale

If symptoms have not responded to treatment after 1 week the patient should see a doctor.

Management

The symptoms of heartburn respond well to treatments that are available over the counter, and there is also a role for the pharmacist to offer practical advice about measures to prevent recurrence of the problem. Pharmacists will use their professional judgement to decide whether to offer antacids/alginates, H2 antagonists or the proton pump inhibitor omeprazole as first-line treatment. The decision will also take into account customer preference.

Antacids

Antacids can be effective in controlling the symptoms of heartburn and reflux, more so in combination with an alginate. Choice of antacid can be made by the pharmacist using the same guidelines as in the section on indigestion. Preparations that are high in sodium should be avoided by anyone on a sodium-restricted diet (e.g. those with heart failure or kidney or liver problems).

Alginates

Alginates form a raft that sits on the surface of the stomach contents and prevents reflux. Some alginate-based products contain sodium bicarbonate, which, in addition to its antacid action, causes the release of carbon dioxide in the stomach, enabling the raft to float on top of the stomach contents. If a preparation low in sodium is required, the pharmacist can recommend one containing potassium bicarbonate instead. Alginate products with low sodium content are useful for the treatment of heartburn in patients on a restricted sodium diet.

H2 antagonists (famotidine and ranitidine)

Famotidine and ranitidine can be used for the short-term treatment of dyspepsia, hyperacidity and heartburn in adults and children over 16. The treatment limit is intended to ensure that patients do not continuously self-medicate for long periods. Pharmacists and their staff can ask whether use has been continuous or intermittent when a repeat purchase request is made. The H2 antagonists have both a longer duration of action (up to 8-9 h) and a longer onset of action than do antacids.

Where food is known to precipitate symptoms, the H2 antagonist should be taken an hour before food. H2 antagonists are also effective for prophylaxis of nocturnal heartburn. Headache, dizziness, diarrhoea and skin rashes have been reported as adverse effects but they are not common.

Manufacturers state that patients should not take over the counter famotidine or ranitidine without checking with their doctor if they are taking other prescribed medicines.

Famotidine

Famotidine does not affect the cytochrome P450 system and therefore does not cause the same range of interactions as cimetidine. The drug is licensed for over the counter use at a maximum dose of 10 mg and a maximum daily dose of 20 mg. Famotidine is available as a tablet in combination with the antacids magnesium hydroxide and calcium carbonate. The idea behind this is to provide rapid symptom relief from the antacid and longer action from famotidine. The maximum continuous treatment period is six days.

Ranitidine

Ranitidine is licensed for over the counter use in a dose of 75 mg with a maximum daily dose of 300 mg. Ranitidine does not affect the cytochrome P450 system. It can be used for up to two weeks.

Proton pump inhibitors

Omeprazole can be used for the relief of heartburn symptoms associated with reflux in adults. PPIs, including omeprazole, are generally accepted as being amongst the most effective medicines for the relief of heartburn. It may take a day or so for them to start being fully effective. During this period a patient with ongoing symptoms may need to take a concomitant antacid. Omeprazole works by suppressing gastric acid secretion in the stomach. It inhibits the final stage of gastric hydrochloric acid production by blocking the hydrogen-potassium ATPase enzyme in the parietal cells of the stomach wall (also known as the proton pump).

Two 10-mg tablets once daily is the initial starting dose. Subsequently, symptomatic relief from heartburn can be achieved in some subjects by taking 10 mg once daily, increasing to 20 mg if symptoms return. The lowest effective dose should always be used and the maximum daily dose is two tablets. Patients taking omeprazole should be advised not to take H2 antagonists at the same time. The tablets should be swallowed whole with plenty of liquid prior to a meal. It is important that the tablets are not crushed or chewed. Alcohol and food do not affect the absorption of omeprazole.

If no relief is obtained within 2 weeks, the patient should be referred to the doctor. Omeprazole should not be taken during pregnancy or whilst breastfeeding. Drowsiness has been reported but rarely. Treatment with over the counter omeprazole may cause a false-negative result in the ‘breath test’ for helicobacter.

Practical points

Obesity

If the patient is overweight, weight reduction should be advised. There is some evidence that weight loss reduces symptoms of heartburn.

Food

Small meals, eaten frequently, are better than large meals, as reducing the amount of food in the stomach reduces gastric distension, which helps to prevent reflux. Gastric emptying is slowed when there is a large volume of food in the stomach; this can also aggravate symptoms. High-fat meals delay gastric emptying. The evening meal is best taken several hours before going to bed.

Posture

Bending, stooping and even slumping in an armchair can provoke symptoms and should be avoided where possible. It is better to squat rather than bend down. Since the symptoms are often worse when the patient lies down, there is evidence that raising the head of the bed can reduce both acid clearance and the number of reflux episodes. Using extra pillows is often recommended but this is not as effective as raising the head of the bed. The reason for this is that using extra pillows raises only the upper part of the body, with bending at the waist, which can result in increased pressure on the stomach contents.

Clothing

Tight, constricting clothing, especially waistbands and belts, can be an aggravating factor and should be avoided.

Other aggravating factors

Smoking, alcohol, caffeine and chocolate have a direct effect by making the oesophageal sphincter less competent by reducing its pressure and therefore contribute to symptoms. The pharmacist is in a good position to offer advice about how to stop smoking, offering a smoking cessation product where appropriate. The knowledge that the discomfort of heartburn will be reduced can be a motivating factor in giving up cigarettes.

Heartburn in practice

Patient perspectives

I’ve been having trouble with heartburn. In fact, it is one of the reasons I wanted to lose weight. I used to get it every once in a while, but then it started to get more frequent. It used to be only in the evening, but then it started happening in the middle of the day. A burning feeling in my chest and coming up into my throat. Leaving a horrible taste in the back of my throat. Because I started getting it during the day, I had to start carrying antacid tablets around in my handbag. I haven’t been to a doctor. I found that getting my weight down to a certain level (out of the overweight range) got rid of my heartburn. It seems it doesn’t take much excess weight to push on the contents of your stomach and cause them to go up in the wrong direction.

Case 1

Mrs Amy Beston is a woman aged about 50 years who wants some advice about a stomach problem. On questioning, you find out that sometimes she gets a burning sensation just above the breastbone and feels the burning in her throat, often with a bitter taste, as if some food has been brought back up. The discomfort is worse when in bed at night and when bending over whilst gardening. She has been having the problem for 1 or 2 weeks and has not yet tried to treat it. Mrs Beston is not taking any medicines from the doctor. To your experienced eye this lady is at least a stone overweight. You ask Mrs Beston if the symptoms are worse at any particular time and she says they are worst shortly after going to bed at night.

The pharmacist’s view

This woman has many of the classic symptoms of heartburn: pain in the retrosternal region and reflux. The problem is worse at night after going to bed, as is common in heartburn. Mrs Beston has been experiencing the symptoms for about 2 weeks and is not taking any medicines from the doctor.

It would be reasonable to advise the use of an alginate antacid product about 1 h after meals and before going to bed or an H2 antagonist. Practical advice could include the tactful suggestion that Mrs Beston’s symptoms would be improved if she lost weight. If your pharmacy provides a weight management service you could ask if Mrs Beston is interested in participating. Alternatively advice on healthy eating and contact with a local weight watchers group could be given. Mrs Beston could also try cutting down on tea, coffee and, if she smokes, stopping. This is a long list of potential lifestyle changes. It might be a good idea to explain the contributory factors to Mrs Beston and negotiate with her as to which one she will begin with. Success is more likely to be achieved and sustained if changes are introduced one at a time.

Menopausal women are more prone to heartburn, and weight gain at the time of the menopause will exacerbate the problem.

The doctor’s view

The advice given by the pharmacist is sensible. Acid reflux is the most likely explanation for her symptoms. It is not clear from the presentation whether she was seeking medication or simply asking for an opinion about the cause of her symptoms, or both. It is always helpful to explore a patient’s expectations in order to produce an effective outcome to a consultation. In this instance the interchange between the pharmacist and Mrs Beston is complex as a large amount of information needs to be given, both explaining the cause of the symptoms (providing an understandable description of esophagus, stomach, acid reflux and oesophagitis) and advising about treatment and lifestyle. It is often sensible to offer a follow-up discussion to check on progress and reinforce advice. If her heartburn was not improving, it would provide an opportunity to recommend referral to her doctor.

The doctor’s next step would be very much dependent on this information. If a clear story of heartburn caused by acid reflux were obtained, then reinforcement of the pharmacist’s advice concerning posture, weight, diet, smoking and alcohol would be appropriate. If medication was requested, antacids or alginates could be tried. If the symptoms were severe, an H2 antagonist or omeprazole would be treatment options. In the case of persistent symptoms or diagnostic uncertainty, referral for endoscopy would be necessary. Helicobacter pylori eradication is not thought to play a role in the management of heartburn.

Case 2

You have been asked to recommend a strong mixture for heartburn for Harry Groves, a local man in his late fifties who works in a nearby warehouse. Mr Groves tells you that he has been getting terrible heartburn for which his doctor prescribed some mixture about 1 week ago. You remember dispensing a prescription for a liquid alginate preparation. The bottle is now empty and the problem is no better. When asked if he can point to where the pain is, Mr Groves gestures across his chest and clenches his fist when describing the pain, which he says feels heavy. You ask whether the pain ever moves and Mr Groves tells you that sometimes it goes to his neck and jaw. Mr Groves is a smoker and is not taking any other medicines. When asked if the pain worsens when bending or lying down, Mr Groves says it does not, but he tells you he usually gets the pain when he is at work, especially on busy days.

The pharmacist’s view

This man should see his doctor immediately. The symptoms he has described are not those that would be typical of heartburn. In addition, he has been taking an alginate preparation, which has been ineffective. Mr Groves’ symptoms give cause for concern; the heartburn is associated with effort at work and its location and radiation suggest a more serious cause.

The doctor’s view

Mr Groves’ story is suggestive of angina. He should be advised to contact his doctor immediately. The doctor would require more details about the pain, such as duration and whether or not the pain can come on without any exertion. If the periods of pain were frequent, prolonged and unrelieved by rest, it would be usual to arrange immediate hospital admission as the picture sounds like unstable or crescendo angina.

If an urgent inpatient referral is not required, the doctor would carry out a fuller assessment that would usually include an examination, electrocardiogram (ECG), urine analysis and blood test. This in turn could lead to medication, e.g. aspirin and glyceryl trinitrate (GTN), possibly a beta-blocker, a long acting nitrate or a rate-limiting calcium channel blocker being prescribed and an urgent outpatient referral to a cardiologist. Mr Groves would be strongly advised to stop smoking.

More detailed tests are likely to be arranged in hospital. These would probably include an exercise cardiogram and an angiogram. This latter test allows visualisation of the blood vessels supplying the heart muscle and assessment of whether surgery would be advisable.

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