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The commonest cause of indigestion is gastro-oesophageal reflux, which results from a leaking valve between the gullet (oesophagus) and stomach. This condition is sometimes loosely referred to as "hiatus hernia". The "valve" has two main functions: to protect the lining of the oesophagus from stomach-acid burns, and to protect the lungs from stomach-acid inhalation. People of all ages may be affected, even new-born babies.
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People who suffer with reflux oesophagitis often believe they are producing too much stomach acid, but this is not the case. The stomach has a special protective lining, which is acid-resistant. The lining of the oesophagus is not designed to withstand acid. In cases of reflux oesophagitis, some of the stomach acid refluxes upward and burns the oesophageal lining. The problem is leakage of acid into the wrong place, rather than excessive acid production.
Two factors appear to be responsible for reflux oesophagitis - the effectiveness of the "anti-reflux valve" (its correct name is the lower oesophageal sphincter) and eating and drinking habits. Some of us are born with a grossly defective sphincter, which will result in reflux problems which may surface in infancy, childhood or early adult life, apparently unrelated to lifestyle. More often, people born with a reasonably well functioning sphincter may develop significant reflux problems resulting from excessive intake of calories, particularly the high-fat, high-sugar, low-fibre foods which pass for a "normal diet" in our culture. Alcohol and caffeine also excerbate the problem. If an overweight adult with reflux oesophagitis manages to reduce weight significantly, by voluntary dietary restriction, the reflux problem is usually (but not always) significantly improved. Minor reflux problems are often adequately controlled with over-the-counter antacids. More troublesome reflux usually requires either long term drug therapy or surgery (see below). Fortunately, in recent years, there has been a revolution in anti-reflux surgery (see below). Gastro-oesophageal reflux disease, sometimes referred to as "hiatus hernia", typically causes some or all of the following:
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Heartburn - is an old word referring to burning pain in the upper abdomen, chest or throat. It results from acid burning the oesophageal lining. It has nothing to do with the heart, but can occasionally be confused with pain from true heart disease, and when real doubt exists, special cardiac investigations may be required.
A Sour Taste - the result of bringing up small amounts of acid and bile from the stomach. In severe cases, regurgitation after meals may occur.
Excessive Burping - or a persistent feeling of wanting to burp
A Feeling Of "Something There" in the throat, chest or upper abdomen.
Waking With Fits Of Coughing - or a choking sensation. Aspiration of tiny amounts of stomach acid may occur unnoticed during sleep, and is an easily overlooked cause of "asthma", recurrent chest infections or a persistent cough. If you suspect you may have this problem, discuss it further with your General Practitioner.
Painful Swallowing - or food sticking in the gullet.
Throat Problems - such as recurring sore throat, a chronic cough, hoarseness or a sensation of a constriction in the throat. If such problems are continual or progressive, rather than intermittent, immediately report them to your doctor to make sure there is no more serious disease present.
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Barrett's Oesophagus - with long-standing reflux, occasionally the lining of the lower oesophagus can change, and this change is easily recognisable at gastroscopy. It cannot be detected by barium meal x-ray. This abnormal lining poses an increased risk of cancer, and for this reason patients with Barrett's oesophagus may require gastroscopy with biopsy every 1-2 years, to see if any cancerous change is likely. If so, the pre-cancerous cells (dysplasia) can be destroyed without surgery (photo-dynamic therapy and endoscopic mucosal resection). If cancer has already developed, it can be detected early and surgical resection or radiotherapy would then have a much higher chance of a permanent cure. Cancer in Barrett's oesophagus occurs in approximately 5% of cases.
Smaller Meals - which means learning to stop when you have had enough, not just when you are uncomfortable from overeating. Reflux is much less of a problem in countries where food is scarce. In many cases it can be controlled by simply eating less. It is often said that "the last 10% of the meal causes 90% of the reflux".
Low-Fat, low-sugar, high-fibre Diet - High calorie foods, particularly fatty or oily foods, slow down stomach emptying which makes reflux worse. In addition, obesity itself increases gastric reflux by increasing the abdominal pressure.
Drink Before Eating instead of the other way round. Liquid will reflux more easily than solids and taking your liquids before a meal, rather than after, seems to reduce reflux in some people.
Before Going To Bed do not have a late meal; avoid coffee and alcohol. Take an antacid if necessary.
Raise The Bed Head 5-10 cm. by placing blocks under the head posts, or foam-rubber under the top end of the mattress, or a "boomerang" cushion (especially useful for water beds). This is not necessary in every case, but is most useful if heartburn, coughing fits or "asthma" disturb your sleep.
Avoid Tight Fitting Clothes - Corsets, etc. increase abdominal pressure and promote more reflux.
Avoid Certain Drugs - Minimise or abolish your intake of alcohol, tobacco and coffee (caffeine). If you are taking anti-inflammatory tablets for arthritis, it may make reflux worse, and you should discuss it further with your doctor.
Antacids like Mylanta, Gelusil, Gaviscon, Quick-Eze, can be taken whenever heartburn is bothersome. If you are using such antacids regularly more than once a day, it is an indication that you may require more effective treatment, and you should discuss it with your doctor.
Stronger Drugs (such as Tagamet, Zantac, Pepcidine, Amfamox , Rani 2 and Tazac) greatly reduce the amount of acid produced In the stomach. Much more powerful and expensive drugs (Losec, Zoton or Somac) almost totally block the production of acid in the stomach, and must be taken indefinitely unless the problem is corrected with surgery.
Other Drugs like Motilium, Maxolon and Prepulsid help the stomach to empty quickly after food. A small, low-fat meal may achieve a similar result. None of these drugs attacks the source of the problem, ie, the incompetent lower oesophageal sphincter (valve). They mainly work by reducing the strength and volume of stomach acid to well below normal levels. This does not appear to have any detrimental effect on digestion. Drug therapy for reflux oesophagitis is nearly always a life-long requirement, unless the problem is cured with surgery.
