Apart from a notable profit margin for the milk companies, there was no big difference for the patients. This is because after a temporary suppression of acid, milk actually causes a rebound increase in acidity. With the advent of antacids , came relief by the quarts. Ingestion of antacids decreases the acidity in the stomach and brings about a fairly quick relief from symptoms. Two new generations of drugs, which have arrived after antacids have revolutionized the management of this disease. The first among them involves blocking receptors in the stomach namely H2 receptors (Histamine receptors). The second drug involves blocking a proton pump which is situated within the cell wall of the acid secreting cells of the stomach.

Suffice it to say, to underline the commonness of this condition, that two drugs, Ranitidine (Commonly sold as Zinetac) and Omeprazole have been sold in the last 10-15 years, to the tune of billions of dollars! These tablets are available over the counter in most countries of the world. It is important to take these pills for a period of 6 weeks continuously. Also, it is essential that the patient should eat a meal within 1/2 to 1 hour after consumption of the pills, for maximum effect.

Yet another group of drugs, “the prokinetics”, attempts to set right the deranged and loose valve which is the backbone of this disease. These release a chemical that promotes tightening of the junction between the gullet and the stomach. Foremost in the group is Cisapride, which due to its cardiac side effects has been withdrawn from use in most countries.

However, hope, as Pope said, springs eternal in the human breast, and there is always a good chunk of patients that seeks a permanent solution to this problem, which they often perceive as a millstone around their necks. As I mentioned earlier these drugs are mostly temporary and some patients become quite disturbed at the prospect of a life time stretching ahead of them, wedded to the pillbox!

This is where physics and medicine have truly come together (perhaps a good time to say Salaam to Kalaam!). Several new exciting modes of intervention have now evolved. One is injection. In order to tighten the sphincter at the lower end of the oesophagus, a special type of cement is injected into its wall. Like cement, it congeals, the hardened material strengthening the sphincter. There are two pieces of good news 1) if the effect is not enough further injections may be done, and this is an easy outpatient procedure. 2) Unlike the cement that we struggle to obtain for our homes, this costs the same in every state!

Next, the Endocinch : this is a special sewing machine which is attached to the endoscope. It permits us to take 2 or 3 stitches at the junction of the gullet and the stomach. These stitches will ‘pleat’ the valve and so prevent reflux. Although it is a little expensive, the major advantage of the endo-stitch is that is can be performed as an OP or day-case procedure, even without anaesthesia. Although only available at a few centres in our country so far, it will eventually find its place, with increasing technological, sophistication and dissipation of endoscopic techniques.

In terms of permanence, time-testedness, and true correction of the mechanical problem, the procedure of choice in patients with acid heart burn is an operation known as the Laparoscopic Fundoplication., which is certainly not as a complex as its spelling! Hippocrates said “the art of medicine consists of of using the patients, allowing nature to heal the disease!” With the advent of Laparoscopic Surgery this statement has been surely disproved with regard to reflux disease. In this procedure, using 3 or 4 tiny keyholes, the upper portion of the balloon like stomach is freed from its attachments, and wrapped around the lower end of the oesophageal tube. This acts as a strut to the natural valve, and the increased pressure created by wrapping the stomach, acts as an efficient sphincter to prevent acid reflux. Although there was a definite learning curve in the performance of this procedure, it has now been established as the idea treatment. Indeed, recently 600 consecutive day case Laparoscopic Fundoplications were reported from Australia. The good access of Laparoscopic approach and its magnification, make it a viable option for us surgeons, and the lack of bloodloss and pain makes it particularly attractive for the patient!

The last option, is of course, the 90yr old open fundoplication, where the procedure described above is performed, but with a huge incision on the patient’s abdomen. This makes the procedure a little easier for the surgeon, but the poor patient is quite likely to remember the surgery angrily for several unpleasant weeks after the operation is performed! It was the postoperative pain that earned it a bad name operation is performed! It was the postoperative pain that earned it a bad name among the public and the physicians. These problems having been overcome by the deployment of the Laparoscopic approach, this procedure is enjoying a huge rebirth in the minds of doctors and patients.

I have laid open all the available options in the treatment of this condition. For each patient, the family physician, patient and the surgeon should plan together and adopt a tailor made approach so that according to his lifestyle, mindset, and his physical fitness, every patient gets the optimal treatment.

As the “Deep Purple” sang 25 years ago, with heartburn, there will continue to be “Smoke on the water and fire in the sky” for many decades to come.

Mrs. Smith: Help me, doctor! My son, John, swallowed the can opener!
Doctor: Don't panic. He'll be alright.
Mrs. Smith: But how do I open the can of beans?! The toast is getting cold!