Persistent
heartburn, chest burning and regurgitation are often treated with increasingly
prolonged courses of acid-suppressing medicinesa. According to GI motility and
neurogastroenterology specialist Dr Zubin Sharma, patients who do not improve
may need the diagnosis itself to be reconsidered.
For
many patients with “acidity”, the treatment journey is remarkably predictable.
An
antacid is started.
Symptoms
continue.
A
proton pump inhibitor, commonly called a PPI, is prescribed.
The
dose is increased. The timing is changed. Another medicine is added.
Months
later, the patient is still experiencing burning behind the chest,
regurgitation, throat discomfort or an unpleasant sensation rising from the
stomach.
According
to Dr Zubin
Sharma, a gastroenterologist specialising in GI motility,
neurogastroenterology and advanced endoscopy, persistent symptoms despite
appropriate acid suppression raise an important question.
Is
acid actually causing the symptoms?
“PPIs
are extremely effective medicines when acid-mediated disease is the problem,”
says Dr Zubin Sharma. “But if a patient remains symptomatic despite properly
administered treatment, simply increasing acid suppression indefinitely may not
answer the clinical question.”
Not Every
Burning Sensation Is Acid Reflux
Gastro-oesophageal
reflux disease, or GERD, is a genuine and common disorder.
Acid
and other stomach contents can move into the oesophagus and produce troublesome
symptoms or complications.
But
symptoms alone do not always reveal the mechanism.
Heartburn
can occur in patients with pathological acid exposure.
It
can also occur when the oesophagus is unusually sensitive to reflux events that
would not trouble most people.
And
in some patients, burning symptoms may have little or no temporal relationship
with reflux.
Dr
Zubin Sharma believes this distinction is particularly important in patients
labelled as having “refractory GERD”.
“The
word refractory implies that we know what disease we are treating and that the
disease is resistant to treatment,” he explains. “Sometimes the real issue is
that the mechanism behind the symptom has not yet been established.”
A Normal
Endoscopy Does Not Exclude Every Reflux Disorder
Endoscopy
plays an important role in evaluating selected patients with reflux symptoms.
It
can identify erosive oesophagitis, strictures, Barrett's oesophagus and other
abnormalities.
However,
many patients with reflux symptoms have a normal-appearing oesophagus during
endoscopy.
This
is where the clinical picture becomes more complex.
According
to Dr Zubin Sharma, a normal endoscopy should not automatically lead to either
of two extremes.
The
patient should not simply be told that nothing is wrong.
But
neither should every symptom automatically be assumed to represent severe acid
reflux.
“We
need objective physiology when the diagnosis remains uncertain,” says Dr Zubin
Sharma.
What Does
24-Hour Reflux Monitoring Actually Measure?
Ambulatory
reflux monitoring allows doctors to study reflux over a prolonged period while
a patient continues normal daily activities.
Depending
on the clinical situation, testing may involve pH monitoring or combined pH-impedance
monitoring.
These
investigations can help assess oesophageal acid exposure.
Impedance
technology can also detect movement of liquid or gas within the oesophagus and
provide information about reflux events that are not strongly acidic.
Perhaps
equally important is symptom association.
If a
patient presses the symptom button when chest burning occurs, the test can help
examine whether the symptom repeatedly follows a reflux event.
“This
allows us to move from assumption towards measurement,” says Dr Zubin Sharma.
Acid
Exposure, Reflux Hypersensitivity and Functional Heartburn Are Different
Modern
oesophageal physiology recognises that patients with apparently similar
heartburn can fall into very different categories.
One
patient may have excessive oesophageal acid exposure consistent with GERD.
Another
may have normal acid exposure but symptoms that are closely associated with
physiological reflux events. This pattern may be consistent with reflux
hypersensitivity.
A
third patient may have normal reflux exposure and no convincing relationship
between symptoms and reflux events. In an appropriate clinical setting,
functional heartburn may be considered.
The
symptoms can feel remarkably similar.
The
treatment logic is not.
“If
you put all three patients into one basket called acidity, you will inevitably
overtreat some and undertreat others,” says Dr Zubin Sharma.
This
is one reason his work in neurogastroenterology and gastrointestinal motility
increasingly focuses on understanding symptom mechanisms rather than relying on
symptom labels alone.
Why the
Oesophagus Can Become Hypersensitive
The
oesophagus is not merely a passive pipe.
It
contains sensory pathways that continuously communicate with the nervous
system.
In
some patients, the processing of oesophageal sensations may become altered.
A
physiological reflux event that another person barely notices may produce
intense burning or discomfort.
This
concept is known as visceral hypersensitivity.
According
to Dr Zubin Sharma, explaining hypersensitivity requires careful language.
“Hypersensitivity
does not mean the patient is imagining the symptom,” he says. “The symptom is
real. The biological question is why the nervous system is generating a
disproportionately intense experience from that stimulus.”
This
is where the gut-brain axis becomes relevant to reflux medicine.
Sometimes
the Problem Is Oesophageal Movement
Persistent
chest symptoms or regurgitation may occasionally raise another question: is the
oesophagus moving normally?
High-resolution
oesophageal manometry measures pressure and coordination within the oesophagus.
It
plays an important role in diagnosing disorders such as achalasia and other
major oesophageal motor abnormalities.
Manometry
may also be required before selected anti-reflux interventions.
Dr
Zubin Sharma cautions that manometry is not a universal test for every person
with heartburn.
“Physiology
testing should be driven by the clinical question,” he says. “The objective is
not to perform every available test. It is to choose the test that can change
management.”
Dr Zubin
Sharma Advocates Testing Before Endless Treatment Escalation
For
patients with persistent reflux-like symptoms, Dr Zubin Sharma believes the
first step is to review the basics.
Was
the PPI taken correctly?
Was
the dose appropriate?
Are
the dominant symptoms truly typical of reflux?
Are
alarm symptoms present?
Has
relevant structural disease been evaluated?
Only
then should specialised oesophageal physiology be considered in selected
patients.
The
result may confirm pathological reflux.
But
sometimes it points towards reflux hypersensitivity, functional heartburn or an
alternative oesophageal disorder.
Each
answer opens a different treatment pathway.
“Good
medicine is not about proving that every patient has acid reflux,” says Dr
Zubin Sharma. “It is about identifying which mechanism best explains the
patient's symptoms.”
Before
Taking Another Acidity Tablet, Ask a Better Question
Acid-suppressing
medicines have transformed the treatment of acid-related digestive disease.
The
problem is not the medicine.
The
problem begins when the diagnosis of “acidity” becomes permanent without being
questioned.
For
patients who continue to experience symptoms despite months or years of
treatment, Dr Zubin Sharma believes modern oesophageal physiology can offer a
more precise framework.
Because
persistent burning does not always mean more acid.
Sometimes
the oesophagus is hypersensitive.
Sometimes
reflux is not the dominant event.
And
occasionally, the original diagnosis needs to be reconsidered.
As
Dr Zubin Sharma puts it:
“Before
suppressing more acid, we should sometimes prove that acid is actually the
problem.”