Heartburn/indigestion

• Heartburn

  Burning discomfort/pain from the stomach and oesophagus (behind the breastbone), acidic taste in mouth. Nausea/vomiting, fullness, belching/flatulence
• Indigestion (Dyspepsia)


  Discomfort in the upper abdomen, belching, nausea, feeling of fullness, occurs when stomach acid comes into contact with the upper digestive tract
• Causes of indigestion/GORD

  • Gastritis
  • Gastric/Duodenal ulcer
  • Spicy foods
  • Pregnancy
  • Smoking
  • Alcohol
  • NSAIDs
• Symptoms requiring referral (ALARMD)

  • Anaemia
  • Loss of weight
  • Anorexia
  • Recent onset of progressive symptoms
  • Malaena ( blood in stools)
  • Dysphagia ( difficulty swallowing )
• 1st Line Treatment: Antacids (Rennies)

  1. Neutralise excess acid in the stomach

  2. Taken during or immediately prior to symptoms developing

  3. Provide immediate symptom relief in 15-30 minutes

  4. Can last for about 3 hours
• Antacids

  Contain aluminium(constipating) magnesium(diarrhoea), calcium carbonate, or sodium bicarbonate
• 2nd Line Treatment: Alginates (gaviscon, peptac)

  1. Form a raft that sits on the surface of the stomach contents and prevents reflux

  2. Best taken after each main meal and bedtime

  3. can be taken when required
• Gaviscon is safe to use in pregnancy
• 3rd Line Treatment: H2-receptor antagonists ( Ranitidine, famotidine)

  1. Inhibit the production of acid in the stomach lining

  2. Provide relief within one hour

  3. Lasts up to 9-12 hours
• H2-receptor antagonists are very rarely used nowadays
• Zantac (Ranitidine) is only for over 16 years old, not in pregnancy/breastfeeding, and maximum 14 days OTC
• New Line Treatment: Proton Pump Inhibitors (PPIs)

  1. Inhibit the production of stomach acid

  2. Do not provide rapid relief

  3. Suppress acid within one or two hours of taking the first dose

  4. Can take 1-3 days for full effect
• PPIs are OTC licensed for over 18 years old only, not in pregnancy/breastfeeding
• Long-term use of PPIs can cause osteoporosis and hypomagnesemia
• Common side effects of PPIs

  • Headache
  • Abdominal pain
  • Constipation/diarrhoea
  • Flatulence
  • Nausea/vomiting
• PPIs can interact with other drugs due to change in gastric pH


  Reduces absorption of itraconazole/ketoconazole, increases plasma concentration of digoxin
• PPIs can inhibit CYP450

  Omeprazole can delay elimination of warfarin, phenytoin and diazepam
• Lifestyle advice for heartburn/indigestion?

  • Raise the head of the bed ( extra pillows)
  • Avoid bending over, lying down, slumping in a chair
  • Have frequent small meals, avoid large evening meal close to bedtime
  • Avoid fatty foods, smoking, alcohol, caffeine, chocolate
  • Avoid pressure on the waist, weight reduction
• Pregnant women (3rd trimester), elderly, and hypertensive patients with heartburn should use a sodium-free/low-sodium antacid preparation containing alginate
• Patient presents with new or recently changed symptoms of heartburn/indigestion and they’re >55yrs. What is the course of action and reason?

  REFER ( increased risk of carcinomas )
• Course of action ? Pain radiating to the arms/jaw or precipitated by exercise, antacid failure

  REFER ( suspect angina/heart attack)
• Course of action? Patient has been taking symptomatic treatment of indigestion or heartburn for 4 or more weeks

  REFER
• RED FLAG SYMPTOMS for heartburn/indigestion

  GAUD

  GI bleed

  AGE 55 years+ new onset of symptoms

  UNEXPLAINED weight loss

  DYSPHAGIA