Heartburn and acid reflux
The burning behind the breastbone that climbs towards the throat and leaves a sour taste in the mouth is familiar to almost everyone: a heavy supper, you lie…
On this page
Medicines commonly prescribed for Heartburn and acid reflux
For informational purposes only. Always consult a doctor before using any medicine.
Dosage form: TABLET, 40 mg pantoprazoleActive substance: pantoprazoleManufacturer: Tecnimede España Industria Farmaceutica S.A.Prescription requiredDosage form: TABLET, 20 mg pantoprazoleActive substance: pantoprazoleManufacturer: Farmalider S.A.Prescription requiredDosage form: TABLET, 40 mgActive substance: pantoprazoleManufacturer: Mabo Farma S.A.Prescription required
The burning behind the breastbone that climbs towards the throat and leaves a sour taste in the mouth is familiar to almost everyone: a heavy supper, you lie down, and there it is. One such evening means nothing. The conversation starts when it repeats week after week, because then the thing has a name — gastro-oesophageal reflux disease. What follows explains why the gate between stomach and oesophagus stops holding, what medicines can and cannot do, and when burning in the chest has nothing to do with the stomach at all.
What it feels like
The classic picture is easy to recognise: burning in the pit of the stomach and behind the breastbone, the sensation creeping up towards the throat, a sour or bitter taste, and sometimes stomach contents rising into the throat on their own. It lasts from a few minutes to a couple of hours and gets worse lying down, bending forwards and after a large meal.
But reflux has a second half of complaints, and it is almost never recognised from those:
- a dry cough that starts at night or in the early hours and drags on for months;
- morning hoarseness, a tickly throat, a constant need to clear it;
- a lump-in-the-throat feeling that does not interfere with swallowing but never quite goes;
- bad breath, and darkened, thinned enamel on the back teeth;
- night-time choking episodes and asthma that flares more often;
- belching, bloating, nausea and feeling full very quickly.
Heartburn once a month after a feast is not a disease. Reflux disease is the word for burning that comes a couple of times a week or more, lasts for months and gets in the way of ordinary life.
And here is the part that surprises people: how badly it burns says nothing about the state of the oesophagus. There is agonising heartburn with a perfectly intact lining, and there are deep erosions with barely any symptoms. That is why the decision to look inside is not based on the severity of the burning but on the warning signs listed further down.
Why the acid comes up
Between the oesophagus and the stomach sits a muscular ring that relaxes for a swallow and keeps the passage shut the rest of the time. Reflux happens when that ring relaxes of its own accord, or when pressure inside the abdomen forces it open from below. That is where the whole list of aggravating factors comes from:
- extra weight, especially around the middle — the pressure on the stomach never lets up;
- large portions and a late supper: a full stomach plus lying flat is the worst combination there is;
- smoking, which relaxes that same ring and cuts down the saliva that normally washes acid back down;
- alcohol, coffee, chocolate, mint, fizzy drinks, fatty and spicy food, tomatoes and citrus — with the caveat below;
- a hiatus hernia, where part of the stomach slides up into the chest and the valve stops working mechanically;
- pregnancy: hormones relax the muscle and the growing womb raises pressure in the abdomen. By the end of pregnancy most women have heartburn, and it settles on its own after the birth;
- medicines — anti-inflammatory painkillers, some blood pressure and angina drugs, asthma treatments, osteoporosis tablets, certain antidepressants and hormone preparations.
The caveat about food is this: there is no universal blacklist. The tomatoes that keep your neighbour awake half the night may do nothing to you, while coffee is what catches you out. Instead of banning everything, it is more useful to keep a note for a fortnight of what you ate and when it struck, then drop the real culprits rather than the theoretical ones.
Stress does not manufacture acid, but it does raise the sensitivity of the oesophagus: the same amount of acid feels worse in a hard patch of life. That is why heartburn often settles on holiday without any tablets.
When burning in the chest is not heartburn
The heart and the oesophagus produce similar pain because they share nerves, and people spend years damping down with antacids something that needs treating quite differently. Call an ambulance (in Europe, the single number 112) if crushing or burning chest pain:
- comes on with exertion — uphill, in cold weather, walking briskly — and eases when you stop;
- spreads to the left arm, both arms, the neck, the jaw or between the shoulder blades;
- comes with cold sweat, faintness or sudden weakness;
- arrives together with breathlessness or an irregular heartbeat;
- lasts more than fifteen or twenty minutes and will not let go.
Some heart attacks announce themselves precisely as burning with a sour taste, particularly in people with diabetes and in older people, so "it feels like indigestion" is not a reason to wait. If burning in the chest has appeared for the first time later in life, the sensible order is to rule out the heart first.
What you can change without medicines
These measures sound dull, but in mild cases they work as well as tablets, and above all they do not end when a course of treatment does.
- Finish eating three to four hours before bed. That one habit clears night-time heartburn for a great many people.
- Eat less at a sitting and more often: an overfilled stomach pushes on the valve from below.
- Raise the head of the bed by ten to twenty centimetres with blocks under the legs. The bed, not your head: a stack of pillows folds the body in half and only makes things worse.
- Losing weight helps markedly, and no dramatic figures are needed: five to ten per cent off already changes the picture.
- Stop smoking — one of the few measures that acts on the heartburn and on everything else at once.
- Do not pull your belt tight, and give up clothing that grips at the waist.
- After eating, do not lie down or bend over, and leave heavy exertion until later; a walk, on the other hand, is a good idea.
- Never stop a prescribed medicine by yourself, even if you suspect it is causing the heartburn. The substitute is the doctor's decision.
What the pharmacy offers and what the doctor prescribes
First-line remedies are sold over the counter. Antacids neutralise acid that has already been produced: they work within minutes but not for long, so they are taken when needed rather than to a timetable. Alginates work differently, forming a thick raft over the stomach contents that physically stops them rising; they suit being taken after meals and at bedtime. Both interfere with the absorption of many medicines, so leave a couple of hours between them. They relieve the symptom without removing the cause, and if you need a tablet every day, that is a reason to see a doctor rather than to buy another packet.
The mainstay of prescribed treatment is the proton pump inhibitor: it reduces acid production, and under its cover a damaged lining has time to heal. The usual course runs from four to eight weeks. Two practical points that rarely get mentioned: take them on an empty stomach, roughly half an hour before the first meal, or the effect is noticeably weaker; and come off them by tapering rather than stopping dead, because after an abrupt halt acid production rebounds above its old level for a while and people conclude the illness is back. If symptoms return, the conversation is about the lowest dose that works or taking it only when needed. When the drug does nothing at all, pushing the dose up is pointless: more often it means acid was never the problem. As an alternative, H2 receptor blockers are prescribed.
Helicobacter pylori deserves a paragraph of its own. This bacterium lives in the stomachs of a large proportion of adults and does not usually cause heartburn as such, but it is behind ulcers and chronic inflammation of the stomach, so persistent symptoms are a reason to look for it with a breath test or a stool or blood sample. If it is found, a course of several antibiotics together with a proton pump inhibitor is given, and the result is checked afterwards.
Surgery on the valve gives good results in carefully selected patients; it is discussed when reflux has been confirmed by investigation and tablets either fail or would be needed for life. And one domestic warning: bicarbonate of soda kills the burning for five minutes, but it fills the stomach with gas and brings on a fresh wave of acid.
Signs that cannot wait
See a doctor the same day — and if you vomit blood or pass black stools, call an ambulance:
- food sticks on the way down and has to be washed or pushed through — the single most important sign of all;
- swallowing has become painful;
- vomiting blood, or dark material resembling coffee grounds;
- black, tarry stools;
- weight falling away on its own, with no diet and no extra exercise;
- vomiting that repeats day after day;
- new weakness, breathlessness on exertion and pallor — how anaemia from unnoticed blood loss shows itself;
- heartburn that has appeared for the first time later in life and does not settle;
- hoarseness lasting more than three weeks.
In these situations a gastroscopy is arranged: an examination of the oesophagus and stomach with a thin flexible instrument carrying a camera. It is a short test, done under local anaesthetic or sedation, and it is the only way to see the lining directly and take a tissue sample if one is needed.
Where years of reflux lead
For most people heartburn stays a nuisance that leads nowhere serious. But in some of those who put up with it for years, acid does change the oesophagus. Inflammation and erosions come first; if they heal over and over, scar tissue forms in their place, the passage narrows, and dry meat and bread stop going down, followed by the rest of solid food. Such a narrowing is stretched endoscopically, but it is far better not to get there.
The second change is called Barrett's oesophagus: the ordinary lining is replaced by another kind, tougher against acid but more inclined to turn abnormal. It is found in roughly one person in ten with long-standing reflux. In itself it is not cancer and rarely becomes one, yet these are exactly the people worth following up endoscopically. If your heartburn has gone on for years and you have never had a gastroscopy, that is a good reason to raise it.
Online consultation
Heartburn is one of those problems a remote appointment handles well. The doctor goes through when exactly it burns, what precedes it and what medicines you take, separates ordinary reflux from complaints that need examining in person, and explains whether a gastroscopy and a Helicobacter pylori test are called for. It is also the place to sort out the common situation where over-the-counter remedies have stopped helping, or where a drug has been taken for years without review, and to talk about heartburn in pregnancy. What cannot be handled on a screen is acute chest pain or signs of bleeding: that is an ambulance.
This material is for information only and does not replace medical advice.
Consult with a doctor about Heartburn and acid reflux
Discuss your symptoms and possible next steps with a doctor online.
Online doctors for Heartburn and acid reflux
Discuss your symptoms and possible next steps for Heartburn and acid reflux with a doctor online.
