Chronic heartburn: When over-the-counter remedies aren’t enough.

Heartburn is a common issue for many people, often relieved by over-the-counter remedies like antacids. However, when heartburn becomes chronic and persists despite over-the-counter treatment, it may indicate a more serious condition requiring medical intervention.

Mr Francesco Di Maggio, renowned consultant general and upper GI surgeon, provides an expert insight into chronic heartburn, why over-the-counter remedies may not work, and the other treatments available when they don’t.

What is chronic heartburn?

Chronic heartburn is a condition where acid reflux occurs frequently, usually more than twice a week over a prolonged period.

Symptoms include:

• a burning sensation in the chest or throat
• a sour or bitter taste in the mouth
• difficulty swallowing or feeling food stuck in the throat
• chronic coughing
• hoarseness or voice changes

While occasional heartburn is common, frequent episodes may suggest gastroesophageal reflux disease (GERD), a condition where stomach acid regularly flows back into the oesophagus, causing discomfort and damage to the oesophageal lining.

Why might over-the-counter remedies not be working anymore?

Over-the-counter remedies, such as antacids, are effective for mild or occasional heartburn to neutralise or reduce stomach acid. However, these medications aren’t designed for life-long management of chronic heartburn. Over time, they can cause side effects, patients may develop a tolerance to these medications, and chronic heartburn might become more severe.

Additionally, chronic heartburn is often a sign of an underlying medical condition like GERD or a hiatal hernia, where part of the stomach pushes up through the diaphragm into the chest. In such cases, addressing the root cause requires more than just neutralising stomach acid. Instead, structural or physiological issues in the digestive system will need medical treatment or lifestyle changes to prevent the symptoms from recurring.

What treatments are available for chronic heartburn if over-the-counter remedies don’t work?

A specialist, such as a consultant general and upper GI surgeon, can offer a variety of treatments, depending on the severity and cause of the heartburn. These include:

• Prescription medications

The specialist may prescribe stronger versions of over-the-counter drugs or entirely different medications to manage chronic heartburn. Examples include H2 blockers like Cimetidine, proton pump inhibitors (PPIs) such as Omeprazole, and prokinetics like Metoclopramide.

• Lifestyle changes

In many cases, chronic heartburn can be managed with significant lifestyle and dietary adjustments, including avoiding trigger foods such as spicy, fatty, or acidic items. Other modifications that might also be recommended include quitting smoking, elevating the head during sleep, and eating smaller and frequent meals.

• Medical procedures

In certain cases, prescription medications and lifestyle adjustments might not be sufficient. In such cases, keyhole surgical procedures may be recommended.

Is surgery ever required for chronic heartburn?

When other treatments have proven ineffective, surgery may be required to manage chronic heartburn or GERD.

The most common surgical procedure for chronic heartburn is fundoplication. This involves wrapping the top of the stomach around the lower oesophagus to reinforce the lower oesophageal sphincter and prevent acid from refluxing into the oesophagus. This operation can be done laparoscopically in many cases, allowing for quicker recovery.

Another surgical option is LINX® surgery, where a ring of magnetic beads is placed around the lower oesophageal sphincter to strengthen it. The beads allow the patient to swallow normally but prevent acid from backing up.

If a hiatal hernia is contributing to the chronic heartburn, surgery may be required to repair the hernia and reposition the stomach below the diaphragm.