Reflux and heartburn: when it is time to see a gastroenterologist

Almost everyone feels heartburn from time to time, perhaps after a large meal or a late night. For most people it passes quickly and causes no lasting trouble. When reflux becomes frequent, keeps returning or starts to affect sleep, eating or everyday comfort, it is worth understanding what is going on and when a specialist opinion can help. This guide explains what reflux is, what tends to trigger it, which self-help steps are worth trying and which signs mean it is time to see a gastroenterologist.

What reflux and heartburn are

At the lower end of the oesophagus (the food pipe) there is a ring of muscle that normally opens to let food into the stomach and then closes again. Reflux happens when this muscle weakens or relaxes at the wrong moment, allowing stomach contents, including acid, to flow back up into the oesophagus.

Heartburn is the burning feeling in the middle of the chest that this backflow can cause. Doctors use the term gastro-oesophageal reflux disease (often shortened to GORD, or GERD in American English) when reflux is frequent or troublesome enough to need attention.

Common symptoms

Reflux does not look the same in everyone. Typical symptoms include:

• a burning feeling in the middle of the chest (heartburn)
• a sour or unpleasant taste in the mouth, or stomach contents coming back up into the throat or mouth (regurgitation)
• a persistent cough or hiccups
• a hoarse voice
• bad breath
• bloating or feeling sick

Symptoms are often worse after eating, when lying down or when bending over. It is also worth knowing that not everyone with reflux disease has heartburn: some people mainly notice a cough, a hoarse voice or regurgitation. Chest pain is listed among the symptoms that should always be assessed by a doctor rather than managed at home, because it can have several causes.

What can trigger or worsen reflux

Heartburn often has no single obvious cause, but a number of factors are known to make it more likely or more intense:

• certain foods and drinks, which differ from person to person
• being overweight
• smoking, including breathing in other people's smoke
• pregnancy
• stress and anxiety
• some medicines, such as anti-inflammatory painkillers and several other groups of medicines
• a hiatus hernia, a stomach ulcer or a bacterial infection of the stomach

If you suspect a medicine is contributing, do not stop it on your own. Speak to the doctor who prescribed it; there may be a suitable alternative.

Where a hiatus hernia fits in

A hiatus hernia is when part of the stomach moves up into the chest. It is common, particularly in people over 50, during pregnancy and in people who are overweight, and the exact cause is not clear. Many people with a hiatus hernia have no symptoms at all. When symptoms do occur, they are the same as those of reflux disease: heartburn, regurgitation, bloating, nausea and sometimes difficulty or pain when swallowing. A hiatus hernia can raise the chance of reflux or make existing symptoms worse.

Self-help steps worth trying

For many people, a few practical changes make a noticeable difference:

• Eat smaller, more frequent meals rather than a few large ones.
• Leave a gap before bed. Try not to eat in the three to four hours before you lie down.
• Raise the head of the bed itself, rather than simply adding extra pillows.
• Work towards a healthy weight if you are carrying extra weight.
• Stop smoking and avoid heavy drinking.
• Avoid tight waistbands and belts, which press on the stomach.
• Notice your own triggers. A short food and symptom diary can help you see which foods or drinks affect you.
• Find ways to relax, as stress can make symptoms more noticeable.

A pharmacist can suggest antacids or alginates, which are usually taken with or soon after food. They can ease symptoms for a short time but do not deal with the underlying cause and are not intended for regular use over long periods. If you find yourself relying on them, that is a good reason to see a doctor.

When it is time to see a doctor or a gastroenterologist

Book an appointment with a doctor if:

• you have heartburn on most days
• lifestyle changes and pharmacy remedies are not helping
• symptoms have lasted more than about three weeks, are severe or are getting worse

Some symptoms need prompt medical assessment, because they can point to a complication of reflux or to a different problem. Seek medical advice quickly if you have heartburn or reflux together with any of the following:

• difficulty or pain when swallowing, or a feeling that food is sticking in your throat
• frequent or persistent vomiting
• vomit that contains blood or looks like coffee grounds
• black, tarry stools or blood in your stools
• weight loss you cannot explain, or loss of appetite
• pain in the upper abdomen or chest pain

If you are vomiting blood, feel faint or have severe pain, seek urgent care or contact emergency services.

A gastroenterologist is a doctor who specialises in the digestive system. Referral to a gastroenterologist is usually considered when symptoms do not improve with treatment, when tests are needed to look for a complication, or when another condition needs to be ruled out.

Tests a gastroenterologist may recommend

Many people are diagnosed from their symptoms and medical history alone, and treatment may begin without any tests. When tests are needed, the most common are:

Upper GI endoscopy (gastroscopy)

A thin, flexible tube with a camera is passed through the mouth to look at the lining of the oesophagus, stomach and the first part of the small intestine. Small tissue samples (biopsies) can be taken during the same procedure. Endoscopy helps doctors check for complications of reflux and look for other causes of symptoms.

Oesophageal pH monitoring

This test measures how much acid reaches the oesophagus over a period of time. It uses either a thin tube passed through the nose or a small wireless capsule attached to the lining of the oesophagus during an endoscopy. You wear a small recorder and note when you eat, sleep and feel symptoms. It is used to confirm reflux disease or to check whether treatment is working.

Tests for stomach bacteria

Your doctor may also test for a bacterial infection of the stomach, which can be treated if it is found.

Before any appointment, it helps to bring a list of your medicines, a note of how long you have had symptoms and what makes them better or worse, and any questions you want to ask.

Treatment options

Treatment is tailored to how often symptoms occur, how severe they are and whether there are any complications.

Lifestyle changes

The self-help steps above remain the foundation of care, even when medicines are added.

Medicines

Several groups of medicines are used for reflux, and your doctor will choose what suits you:

• Antacids relieve mild symptoms but are not intended for daily use without medical advice.
• H2 blockers reduce the amount of acid the stomach makes.
• Proton pump inhibitors (PPIs) reduce stomach acid more strongly and can help the lining of the oesophagus heal. Side effects are usually mild, and your doctor will review whether longer-term treatment is needed.

Surgery and endoscopic procedures

Surgery is considered when symptoms continue despite lifestyle changes and medicines, or when someone does not wish to take medicine long term. The most common operation, called fundoplication, wraps the upper part of the stomach around the lower end of the oesophagus to strengthen the barrier against reflux. It is usually done as keyhole (laparoscopic) surgery. For people who have both reflux disease and obesity, weight-loss surgery may sometimes be recommended instead.

Surgery for a hiatus hernia is considered only when other treatments have not worked and symptoms remain severe. Recovery takes time: returning to normal eating can take several weeks, and bloating, wind or swallowing difficulties may take some months to settle. Your surgical team will guide you through each stage. Endoscopic procedures for reflux exist but are used only rarely.

Living with reflux over the long term

For many people reflux is a long-running condition that can be kept well under control. A few habits help: keep up the changes that work for you, review your medicines with your doctor from time to time rather than stopping or starting them on your own, and report any new or changing symptoms, particularly the warning signs listed above. If you are travelling for care, bring copies of previous endoscopy reports and test results so your new team can build on what is already known.

Next steps

If reflux or heartburn is affecting your daily life, or you have any of the warning signs described here, a specialist review can clarify the cause and the options available to you.

• Learn more about our gastroenterology services.
• Answer a few short questions to be matched with a suitable specialist: Find my physician.