Conquer Your Heartburn

In 2019, after enduring three years of headaches and frequent bouts of heartburn, Murali Bharadwaj of London learnt what sparked his discomfort: gastroesophageal reflux disease (GERD), a chronic condition caused by stomach acid repeatedly rising into his esophagus. Whenever Bharadwaj drank beer or ate late in the evening, he experienced symptoms.

“The acid reflux meant I couldn’t focus on the present moment, in meetings, playing sports or having social drinks with my friends,” says the now 41-year-old. “My thoughts always went to the burning sensation in my throat.”

He began taking medication called proton pump inhibitors (PPIs) to lower the acidity in his stomach. It helped, but only a little. In 2021, his doctor suggested a procedure to strengthen his lower oesophageal sphincter, the valve between the stomach and esophagus. Bharadwaj was skeptical, but when he learnt that transoral incisionless fundoplication (TIF) didn’t involve invasive surgery—it’s performed endoscopically through the mouth and oesophagus—he decided to try it.

In TIF, a small portion of the upper stomach is folded over the bottom of the oesophagus and stapled in place. After the procedure, Bharadwaj says his quality of life improved, and he no longer needed to take PPIs as often.

“I used to take them once per day, minimum, sometimes twice,” he says. “Since the procedure, it’s been just three times per week. I get acid reflux sometimes, but it’s way more manageable—less frequent and less intense.”

Gastroesophageal reflux disease (also known as chronic acid reflux) affects up to 25 per cent of Europeans, around 12 per cent of Australians and 23 per cent of people in South America, according to a 2018 American study. A 2011 population-based study reported an 18.5 per cent GERD prevalence in certain regions of India. When stomach acid repeatedly enters the oesophagus, it can change the delicate tissue, which over time can lead to bleeding or ulcers. Complications may include narrowing of the passage due to repeated healing and scar formation, which can make swallowing difficult, or Barrett’s oesophagus—permanent changes in the lower oesophagus lining that, in very rare cases, can lead to cancer.

Many people experience occasional acid reflux, perhaps after overindulging in alcohol or certain foods. The vast majority of people will never see a doctor about it, says Dr Arjan Bredenoord, gastroenterologist at University Medical Centers Amsterdam. And that’s okay, because “bothersome symptoms can be managed with lifestyle adjustments or over-the-counter antacids,” he says.

But GERD is different. It happens when people experience heartburn, regurgitation, chronic cough, hoarseness or chest pain three or more times a week. People with GERD often also have a hiatal hernia—when part of the upper stomach pokes through the diaphragm muscle in the chest, making it easier for stomach contents to enter the oesophagus.

“The symptoms of GERD are typically heartburn and regurgitation,” says Dr Edoardo Savarino, assistant professor of gastroenterology at the University of Padua in Italy. “So when you have these two symptoms, it’s likely that you have reflux disease.”

Doctors may diagnose GERD after performing an upper endoscopy to examine the oesophagus. If it looks normal, other tests may be offered, including catheter-based pH-impedance monitoring or a wireless pH test. Proper diagnosis is necessary because if it isn’t GERD, treatments for GERD won’t help (for example, if the problem is actually dyspepsia, commonly known as indigestion; an ulcer; or gastroparesis, when the stomach empties into the small intestine too slowly).

Ten per cent of GERD sufferers will develop Barrett’s oesophagus. “With Barrett’s, you need to get an endoscopy every two or three years to see if there are any changes, because you can treat it early,” says Dr Rami Sweis, a gastroenterologist with University College Hospital in London who advises the non-profit Guts UK. If any pre-cancer or cancer is detected, he says, treatment can be provided through the endoscope.

When doctors diagnose GERD, they usually prescribe PPIs, medication that suppresses acid production within the stomach. H2 blockers, another type of acid suppressor, are prescribed less often because they are less effective.

“In reflux, gastric acid comes up into the oesophagus and causes symptoms or lesions,” says Dr. Jan Tack, gastrointestinal (GI) disorders researcher at KU Leuven in Belgium. “So controlling acid makes a big difference for the majority of patients, and apparently does not have a negative effect on the digestive process.”

Doctors also recommend lifestyle changes to discourage stomach acid from entering the oesophagus. They include refraining from eating between two and four hours before bedtime, sleeping with your head elevated (wedge pillows are specially designed to relieve GERD; they go underneath your regular pillow), avoiding tight-fitting clothing and losing weight.

“In perhaps 75 per cent of patients with reflux, treatment with lifestyle changes plus medication are absolutely successful,” says Dr Sebastian Schoppmann, head of the upper GI department at Medical University of Vienna.

Some GERD patients seek other kinds of treatment because medication doesn’t improve their symptoms well enough, as with Bharadwaj, or it has unwanted side effects.

The good news is that the number of GERD treatments has grown in recent years. “The reason there are more and more treatment choices is that no one thing is perfect for everyone,” says Dr Paul Goldsmith, an upper GI surgeon at Manchester University NHS Foundation Trust in the UK. Here are some of those options.

FundoplicationFundoplication is the most common treatment to strengthen the valve between the esophagus and stomach. It is performed laparoscopically, meaning that open surgery (when one large incision is made) can usually be avoided. The surgeon makes several small incisions in the abdomen and inserts the tools and a camera. The hiatal hernia is corrected by returning the upper stomach to its place below the diaphragm. Next, the uppermost portion of the stomach is wrapped around the valve, which strengthens the its ability to stay closed—reducing the risk of stomach acid rising into the esophagus.

In the past, surgeons mostly performed a 360-degree stomach wrap, but that was often too tight; as a result food didn’t move down the esophagus as easily, and some patients had difficulty belching or vomiting. Some also had trouble swallowing food. Today, surgeons can perform one of several partial wraps, such as a 270 or 180 degrees, which improve GERD symptoms without causing more discomfort.

Dr Radu Tutuian, chief of gastroenterology at Civic Hospital Solothurn in Switzerland, recalls treating a Swiss man in his 60s with heartburn, regurgitation and a chronic cough. After he underwent fundoplication, most of his GERD symptoms faded, although he had trouble swallowing and was not able to eat full meals during recovery.“For a couple of weeks he was very uncomfortable,” Tutuian says. “But he said, ‘I don’t want to go back to how I was before, to my reflux and the cough.’ He felt better and no longer needed to take PPIs. So his goals were met.”

Transoral incisionless fundoplication (TIF)Appropriate for people with small hiatal hernias, this is a version of fundoplication that surgeons perform endoscopically, placing a camera and tools through the mouth and esophagus to the upper stomach. A barrier is created at the lower esophageal sphincter by folding a portion of the upper stomach over itself and stapling it in place.

Tack was involved in a study of the treatment that was published in 2015 in the journal Alimentary Pharmacology and Therapeutics. He says 59 per cent of the patients who had TIF did not experience GERD symptoms for six months afterwards (the end point of the study) and were able to stop taking PPI medication.

StrettaFor this endoscopic procedure, surgeons insert a camera and catheter via the mouth and oesophagus to deliver radiofrequency energy to the oesophageal wall near the stomach opening. “The idea is that, over time, it strengthens the sphincter muscle,” Tack says. “There is evidence, based on measurements of pressure in the sphincter, that it has an anti-reflux effect. However, it is not a huge effect and does not match the efficacy of fundoplication.”

LINX DeviceA band of magnetic titanium beads is placed around the lower oesophageal sphincter during this laparoscopic procedure. The magnetic force among the beads helps to tighten the valve, discouraging stomach acid from entering the oesophagus. When you eat, the force of swallowing moves the beads apart, and food passes easily from esophagus to stomach.

Whereas most other GERD procedures are irreversible, the LINX device can later be removed if needed. And a hiatal hernia can be repaired during the procedure. Years ago, there were problems with the device, as the beads migrated from where they were implanted. But newer versions of the device fit better and are lighter, so that risk is substantially reduced.

RefluxStopDuring this laparoscopic procedure, which is done under general anaesthetic, surgeons repair a hiatal hernia, then place a spherical device the size of a ping-pong ball into the upper stomach—the area that may contribute to the reflux—to bulk it up. The procedure is reversible.

“It restores our anatomy to the way it was before we were suffering from reflux,” Goldsmith says.

RefluxStop is the newest GERD treatment, and researchers have only two to three years’ worth of safety data. It may appeal to people who worry that tightening the lower oesophageal sphincter could cause swallowing difficulties.

Photo Credit: MariusFM77/Getty Images (lemons), Rosemary Calvert/Getty Images (chocolate), Barcin/Getty Images (peppers), nantonov/Getty Images (pizza), Chris Clor/Getty Images (drink)

The benefits of GERD therapies don’t necessarily last forever. “This is soft tissue that moves,” Sweis says—for example, when you swallow. So, the new structure might change over time.

After five or 10 years, some patients need to go back to PPIs if their symptoms return. “Therapy for your GERD does not necessarily guarantee that you’re going to have 30 years of proton-pump-inhibitor-free life,” says Dr Ian Gralnek, chief of gastroenterology at Emek Medical Center in Afula, Israel, and president of the European Society of Gastrointestinal Endoscopy.

Within a few years, European doctors may be able to prescribe potassium-competitive acid blockers (P-CABs) to treat GERD. The medi-cation, which has been approved in Japan and Korea, is more effective than PPIs at neutralizing stomach acid. “The suppression of the gastric acidity is longer,” Savarino says. “With PPIs, you have to take them one hour before a meal. But with P-CABs, you can take them even if you have just eaten.”

Another possible therapy may alleviate symptoms in a novel way. “Some researchers are looking at strengthening oesophageal lining, which would make it less sensitive,” Tack says. “This is an avenue of further research.”