Today ' s Treatment Diseases of the alimentary system Pain LAURENCE

Heartburn is a retrosternal burning sensation, often worse on lying down or bending over and commonly associated with a sour or acid taste in the mouth. The symptom is caused by gastric acid reflux into the oesophagus through an incompetent cardiac sphincter. The diagnosis may be confirmed by a barium meal examination provided the cardiac sphincter mechanism is challenged by various manoeuvres. If the history is suggestive of reflux it is important not to be deterred by a normal barium meal result since the examination may have been inadequate and, in addition, incompetence of the cardiac sphincter may be intermittent. Treatment consists of important common-sense measures such as removal of tight abdominal garments and appreciable weight reduction when necessary, together with small regular meals and, for nocturnal heartburn, raising the head of the bed. In addition, regular antacid treatment is usually needed, such as 10-15 ml or tablets of alternating magnesium trisilicate and aluminium hydroxide every two hours. More resistant cases may need metaclopramide, 10 mg three to four times a day by mouth. This drug probably increases cardiac sphincter pressure and gastric emptying and is virtually free of side effects. Medication may often be gradually reduced over two to three months. If the symptoms persist or need maximum medication, surgery may be considered, particularly in the presence of a hiatal hernia.