Dr Stephen John Middleton MA MD FRCP FAHE

Consultant Gastroenterologist

Heartburn (gastro- oesophageal reflux disorder, GORD)

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Treatment of this condition can be divided into simple measures such as lifestyle changes, medicines that provide a protective barrier between the oesophagus (gullet) and the acid and other irritants which reflux up from the stomach, and acid blockers which reduce the production of acid by the stomach so that less acid is available to reflux.

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Medical Treatment
There are two main types of acid blockers; the H2 antagonists that block the histamine receptors on the acid producing cells of the stomach such as Ranitidine (Zantac) and Cimetidine (Tagamet).  These reduce the amount of acid to a moderate degree, but often these are not powerful enough to resolve the symptoms of reflux. 

The strongest acid blockers are called proton pump inhibitors, these block the pump that makes the acid, acting directly on the acid producing mechanism and are very effective.  They have a very powerful acid blocking effect.  Examples of these drugs are Omeprazole or Lansoprazole.  A small number of patients (less than 10%) are quite resistant to these drugs and require large doses to control symptoms.  Specialists may use doses above those licensed in certain cases. 

Another type of drug used in some cases has an effect on the movement of food down the oesophagus and stomach.  These are known as prokinetic agents and they speed the transit of food and liquid through the oesophagus and stomach, so that there is less food and acid residue to reflux up.  These can be useful in certain cases, but do not tend to be the first treatment of choice.

There are two general ways to use drug therapy, either starting with the weakest treatment and building up to the strongest treatments if required, or starting with the strongest treatment to control symptoms rapidly and then reduced in potency until the minimum effective strength of treatment is found. 
 
Lifestyle changes can be extremely useful in helping to control symptoms and thereby reducing the amount of medication needed. 

Raising the head of the bed by at least 15cm, usually by placing blocks underneath the legs of the bed head. 

Retiring to bed with an empty stomach.  The stomach usually takes 2-3 hours to empty and one should therefore eat and drink early and refrain from having the last minute drink before retiring.

Surgical Treatment
Where medical treatment and lifestyle changes fail, surgical treatment can be considered.  This is often quite useful for people who have volume reflux of liquids into the mouth which can be very disturbing and difficult to treat.   Surgical treatment is usually offered to those whose symptoms can not be controlled by drug therapy, or who want to either avoid drugs for personal reasons or are unable to tolerate them.  Some prefer the surgical option.  There are two types of surgery the traditional operation and the new keyhole type surgery.  Surgeons quote success rates of between  80 – 90 % but it should be remembered that even in the best hands there can be serious complications of surgery and some of these complications can lead to permanent damage of the stomach which causes symptoms that can not be corrected very easily and are sometimes permanent.  In most cases however the surgery is very successful.  
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