Emmanuel Ojo
In this interview, a professor of medicine and consultant gastroenterologist at the Obafemi Awolowo University, Ile-Ife, Dennis Ndububa, tells EMMANUEL OJO the causes and predisposing factors of heartburn and how it can be managed
What does it mean to have a heartburn?
Basically, heartburn means a burning feeling that is felt behind the chest or breast bone, as they call it. It’s a burning sensation a person feels behind the breastbone, which is usually due to the acid contents of the stomach going up toward the throat. That is the definition of heartburn.
Is there any relationship between heartburn and heart disease?
Heartburn is not in any form a heart disease or a symptom of heart disease. It’s just that because of the location where the sensation is felt, at the chest region, close to the heart, that is why it is called heartburn.
Actually, it’s felt in the digestive system, in the gastrointestinal tract. It’s different from heart disease and heart conditions.
What’s the feeling like? Can you describe it?
The feeling is just like I defined it. It feels like a burning sensation, like there is fire behind the breast bone and sometimes, one may feel like something is moving up from the stomach to the throat. It usually occurs after a meal.
What’s the usual duration of this burning sensation?
It can last for two minutes and then goes away. Most people will have that symptom once in a while but when it becomes frequent, up to twice a week or more, then it’s something that we look into. The patient will need to see a doctor.
How common is this condition?
Heartburn as a symptom affects a large number of people. In fact, at one time or the other, there are things that provoke it like spicy meals, onions, fatty foods, alcohol, or heavy meals taken at night. Also, if one lies down immediately after eating a meal, he may have that sensation. So, a lot of people have that symptom but it occurs once in a while. People who experience it frequently, have more complaints.
The prevalence varies from country to country. In western society, perhaps up to 15 to 25 per cent of people because they have more of the risk factors. One such factor is obesity. Obesity is one major problem that is associated with this complaint, then it can progress to a condition called gastroesophageal reflux disease, a condition in which reflux or return of food to the gullet gives rise to some troublesome symptoms on a more regular basis or even complications.
In this part of the world, Africa, it varies because we are gradually adopting the lifestyle of western people. Obesity is also gradually becoming a phenomenon among us and then we are adopting their lifestyle. We are taking a lot of meals that have fat and all that, so we are beginning to see this as a major complaint among our people. We have about 10 per cent of our people or more who experience it.
Some people who have experienced it have also attributed it to not taking sufficient fluid after a meal. How true is that?
Well, that has not been found to be associated with it. What has been found is that when one consumes a heavy meal and the person lies down immediately, or bends over, symptoms of heartburn can come up. That’s why we advise people to avoid eating a heavy meal late at night. When one eats heavily and goes to bed, this symptom can come about. It’s better to eat earlier in the evening and not heavy.
You described heartburn as a symptom. What underlying condition gives rise to it?
Yes, like I said, most people once in a while have this symptom but if one has it more than twice a week, it is possibly evidence of a condition. In fact, there is a chart that the doctor will use to ask the person some questions. It depends on what the person scores from the chart, then the person can be said to have a significant problem that there will be a need to look into it. The person may have what is called GERD, Gastroesophageal Reflux Disease, which is a condition in which the valve at the lower end of the gullet/esophagus, which functions to disallow the content of the stomach from returning up the gastrointestinal tract (food passageway), becomes incompetent, hence, the stomach content can return upwards, towards the mouth. With the way the food tract is made, it’s not able to handle acidic contents like the stomach, so, that’s where the burning sensation comes from.
The lining of the gullet or oesophagus is not well suited to handle the acidic content of the stomach, so, that’s what gives the sensation of burning in the chest. Some people may have it but if this symptom occurs more than twice a week, the patient may have a precondition called Gastroesophageal Reflux Disease and the person will have to see a doctor for the diagnosis and treatment.
Also, pregnancy can be a predisposing factor. When the uterus becomes big because of the baby inside, it may push the stomach up and then the content of the stomach may be returned to the mouth. So, pregnant women in their last trimester may have this symptom.
Also, people that use a tight belt or wear tight clothes that tighten the abdomen so much, may have the problem because such clothes won’t allow the stomach to accommodate what is inside and there will a tendency for food to go back to the mouth.
Alcohol, smoking, and some drugs can also predispose to it. Drugs like aspirin and some hypertensive drugs can cause the valve at the end of the food pipe to become incompetent so that food returns to the mouth.
Are there complications that can result from heartburn?
Yes. If the GERD continues for a long without attention or treatment, it can produce ulcers in the lower end of the esophagus. It can also cause a narrowing towards the end of the oesophagus; food might remain in the food tract without going into the stomach.
Like I said before, the lining of the oesophagus is different from the lining of the stomach. The stomach is able to accommodate acidic contents, it is meant to do so but once acid continues to come over the lining of the oesophagus, it damages it and that can lead to cancer. It can cause oesophageal cancer in the long run. When the changes in the esophagus become like that of the stomach because of constant invasion by acids, then it becomes what is called ‘varices esophagus’ and that can lead to cancer.
How is heartburn diagnosed?
Diagnosis is made mainly by what is called endoscopy, upper-gear endoscopy. That is a procedure whereby a tube with a torch in front of it is passed through the mouth of the patient so that the doctor can look through the food tract and stomach. If it is there, there will be aberrations or ulcerations towards the end of the oesophagus and it will be red, showing peeling of the surface, then that will make a diagnosis.
There are other ways of diagnosing it but this is the most direct and common way of diagnosing it. You can do special X-rays to look at it but it’s not as specific as this endoscopy that I have described to you. You can also do some acid tests in which case the individual is made to take a particular substance. The acid coming out of the stomach is measured and after some time, we are allowed to find out if there are acids in the oesophagus or not because there are not supposed to be acids there.
So, these are the ways of testing for it but the main one, like I said, is endoscopy, which looks through the oesophagus and stomach and checks for the peeling of the surface or ulceration and we may even take some tissues, send them for laboratory test.
After diagnosis, how is heartburn managed?
First of all, for some people, they may get symptomatic delay if they take antacids. Antacids are substances that neutralise the acids or the acidic contents that are coming towards the throat. Some people may have symptomatic relief after taking antacids.
There are also drugs that can be used to suppress acid secretion. They prevent stomach acid secretion. These can give some form of long-term relief for those who have this symptom.
If the drugs do not work, the patient might have to go for surgery but that’s the last resort. That’s for patients who do not respond to the drugs but most people respond to the drugs.
I want to say here that one way of treatment is lifestyle modification. If someone is obese, they need to cut down on their size a bit. Also, learning to eat early, not late-night meals and not heavy ones and when one lies down, one should raise his head with very good pillows, not just one pillow so that he won’t lie flat. If they take such precautions, they will help with healing.
Are there side effects that come with the treatment and use of antacids?
Well, just like many other drugs, antacids also have their own side effects but they are usually not severe. Some of the antacids can give diarrhoea. Some can even give the opposite effect, constipation, that is, reducing the frequency of stooling. Most antacids nowadays have a combination of both. Combined substances bring about frequent stooling and constipation at the same time, so, they are combined so that the effects of one can nullify the other.
The other problem is that antacids can interfere with other drugs. So, one has to make sure not to take them with other drugs to avoid interference.
You said surgery is the last resort. What is it that is done in surgery?
Like I said earlier, there could be narrowing or constriction, or long-standing damage of the lower part of the food tract by acidic stomach content. In some people, it may lead to narrowing, so what surgery does is distend the food tract and make it wider. The other one is to do a constructive surgery just to repair that end surgically so that acid content cannot come into the oesophagus again but remain in the stomach. So, those are the surgical manoeuvres that can be done.
Of course, if the person has developed cancer already, they can remove part of the oesophagus that contains the cancerous growth but these are very rare procedures and most times, patients don’t get to that stage.
Are there preventive measures?
The preventive measures are to avoid eating late-night meals and avoid lying down immediately after eating, maybe within two hours of eating. If within two hours of eating you lie down, you are likely to have heartburn because a lot of the meals are still in the stomach. It takes about two to three hours before the meal in the stomach is evacuated completely. So, within two to three hours of eating, if one lies down, they may have heartburn. So, avoid such. If one is obese, they should reduce their weight and the symptoms might improve.
Also, if smoking can be avoided, that will be great. Then also cut down on fatty meals; chocolate and the like. These are the ways one can cut it down.
Stress can also aggravate this condition. If someone is going through stress, somehow, it has a way of affecting the valve at the end of the esophagus that prevents acid content in the stomach from coming up. If we can find a way of reducing stress in this case, it might also help.
Also, avoid wearing tight clothes and belts. If it’s too tight, it might predispose to heartburn. These are part of the measures one can take to prevent it.
How about pregnant women, since they are already predisposed to it, how best could it be managed in them knowing that some of the drugs used have few side effects?
Before I answer that, there is something I missed out. In the treatment, there is a group of drugs called reflux suppressants. They are liquid drugs just like antacids but they are not antacids. They suppress the return of food to the oesophagus. That’s another category of drug which can be used and it’s very useful for pregnant women. Women who are pregnant, and have this symptom have relief from antacids and these reflux suppressants. Most of the drugs used for pregnant women are those that will remain in the digestive system without entering into the blood, so it doesn’t affect the baby. These drugs give them relief during the period of pregnancy.
What’s usually the first line of action or first aid when there is an attack?
The first line of action is to take an antacid or reflux suppressant. It will bring relief and if there is a return of symptoms, the person is to receive treatment.
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