Symptoms in the Pharmacy :Gastrointestinal Tract Problems(4)

Heartburn

Symptoms of heartburn are caused when there is reflux of gastric
contents, particularly acid, into the oesophagus, which irritate the
sensitive mucosal surface (oesophagitis). Patients will often describe
the symptoms of heartburn; typically a burning discomfort/pain felt in
the stomach passing upwards behind the breastbone (retrosternally).
By careful questioning, the pharmacist can distinguish conditions that
are potentially more serious.

What you need to know

• Age
• Adult, child
• Symptoms
• Heartburn
• Difficulty in swallowing
• Flatulence
• Associated factors
• Pregnancy
• Precipitating factors
• Relieving factors
• Weight
• Smoking habit
• Eating
• Medication
• Medicines tried already
• Other medicines being taken

 Significance of questions and answers

Age
The symptoms of reflux and oesophagitis occur more commonly in
patients aged over 55. Heartburn is not a condition normally experienced
in childhood, although symptoms can occur in young adults and
particularly in pregnant women. Children with symptoms of heartburn
should therefore be referred to their doctor.

Symptoms/associated factors
A burning discomfort is experienced in the upper part of the stomach
in the midline (epigastrium) and the burning feeling tends to move
upwards behind the breastbone (retrosternally). The pain may be felt
only in the lower retrosternal area or on occasion right up to the
throat, causing an acid taste in the mouth.

Deciding whether or not someone is suffering from heartburn can
be greatly helped by enquiring about precipitating or aggravating
factors. Heartburn is often brought on by bending or lying down. It
is more likely to occur in those who are overweight and can be
aggravated by a recent increase in weight. It is also more likely to
occur after a large meal. It can be aggravated and even caused by
belching. 

Many people develop a nervous habit of swallowing to clear
the throat. Each time this occurs, air is taken down into the stomach,
which becomes distended. This causes discomfort which is relieved by
belching but which in turn can be associated with acid reflux.

Severe pain
Sometimes the pain can come on suddenly and severely and even
radiate to the back and arms. In this situation differentiation of
symptoms is difficult as the pain can mimic a heart attack and urgent
medical referral is essential. Sometimes patients who have been admitted
to hospital apparently suffering a heart attack are found to have
oesophagitis instead.

Difficulty in swallowing (dysphagia)
Difficulty in swallowing must always be regarded as a serious symptom.
The difficulty may either be discomfort as food or drink is
swallowed or a sensation of food or liquids sticking in the gullet.
Both require referral . 

It is possible that discomfort may be secondary to oesophagitis from acid reflux
(gastro-oesophageal reflux disease (GORD) ), especially when it
occurs whilst swallowing hot drinks or irritant fluids (e.g. alcohol or
fruit juice). A history of a sensation that food sticks as it is swallowed
or that it does not seem to pass directly into the stomach (dysphagia) is
an indication for immediate referral. It may be due to obstruction of
the oesophagus, e.g. by a tumour.

Regurgitation
Regurgitation can be associated with difficulty in swallowing.
It occurs when recently eaten food sticks in the oesophagus and
is regurgitated without passing into the stomach. This is due to a

mechanical blockage in the oesophagus. This can be caused by a
cancer or, more fortunately, by less serious conditions such as a peptic
stricture. 

A peptic stricture is caused by long-standing acid reflux with
oesophagitis. The continual inflammation of the oesophagus causes
scarring. Scars contract and can therefore cause narrowing of the
oesophagus. This can be treated by dilatation using a fibre-optic
endoscope. However, medical examination and further investigations
are necessary to determine the cause of regurgitation.

Pregnancy
It has been estimated that as many as half of all pregnant women
suffer from heartburn. Pregnant women aged over 30 are more likely
to suffer from the problem. The symptoms are caused by an increase in
intra-abdominal pressure and incompetence of the lower oesophageal
sphincter. It is thought that hormonal influences, particularly progesterone,
are important in the lowering of sphincter pressure. Heartburn
often begins in mid to late pregnancy, but may occur at any stage. The
problem may sometimes be associated with stress.

Medication
The pharmacist should establish the identity of any medication that
has been tried to treat the symptoms. Any other medication being
taken by the patient should also be identified; some drugs can cause
the symptoms of heartburn, 

e.g.

• anticholinergic agents such as hyoscine,
•  drugs with anticholinergic actions such as tricyclic antidepressants and phenothiazines. Calcium channel blockers, nitrates (especially nifedipine), 
• theophylline and aminophylline 
• caffeine in compound analgesics

Failure to respond to antacids and pain radiating to the arms could
mean that the pain is not caused by acid reflux. Although it is still a
possibility, other causes such as ischaemic heart disease (IHD) and gall
bladder disease have to be considered.

When to refer

• Failure to respond to antacids
• Pain radiating to arms
• Difficulty in swallowing
• Regurgitation
• Long duration
• Increasing severity
• Children