Heartburn

Heartburn Overview

Heartburn is an uncomfortable but common feeling of burning or warmth in the chest. Although the pain of heartburn is felt in the chest, heartburn has nothing to do with your heart. Instead, heartburn is caused by stomach acid (see Media file 1).

Continual bouts of heartburn can be a symptom of a more serious condition called gastroesophageal reflux disease or GERD. Frequent or severe heartburn may limit daily activities and lead to further complications such as ulcers in the esophagus. With proper understanding of heartburn and treatment, relief can be obtained from this condition.

About 30% of adults experience occasional heartburn, while 10% experience heartburn every day. About 25% of pregnant women have heartburn or related symptoms.


Heartburn Causes

The food that is swallowed travels from the mouth to the stomach through a hollow tube called the esophagus (or food pipe). Before entering the stomach, food must pass through a tight muscle at the lower part of the esophagus called the lower esophageal sphincter (LES). The lower esophageal sphincter prevents food from traveling backward into the esophagus.

Once in the stomach, stomach acid digests the food. This acid is very strong and can damage most parts of the body. Fortunately, the stomach is protected from its own acid by a special mucous layer. The esophagus, however, does not have any such special protection. If the lower esophageal sphincter does not close completely, the lower part of the esophagus can be damaged by stomach acid. When this happens, heartburn may be experienced.

The lower esophageal sphincter may not close completely thus allowing stomach acid into the esophagus for these reasons:
Certain foods and drinks are known to loosen the lower esophageal sphincter. These include chocolate, peppermint, caffeine-containing beverages (such as coffee, tea, and soft drinks), fatty foods, and alcohol.
Heartburn often depends on the body's position. It is easier for stomach acid to flow back into the esophagus if you are lying down or bending over.
Anything that increases the pressure on the stomach and forces stomach acid backward into the esophagus can also cause heartburn. This is why lifting, straining, coughing, tight clothing, obesity, and pregnancy can worsen heartburn.
People who suffer from certain medical conditions may have an increased chance of heartburn. These conditions include hiatal hernia, diabetes, and many autoimmune diseases (CREST syndrome, Raynaud phenomenon, and scleroderma).
Many prescription medications can loosen the lower esophageal sphincter, including certain blood pressure and heart medications, and the asthma drug theophylline.
Many substances directly irritate the lining of the esophagus and can contribute to heartburn. These include spicy foods, citrus fruits and juices, tomatoes and tomato sauces, cigarette smoke, aspirin, ibuprofen (with brand names such as Motrin and Advil), and medicines for osteoporosis.


Heartburn Symptoms

The pain of heartburn is described as a burning feeling in the chest. Often, the sensation may spread up into the throat, jaw, arms, or back. That's why heartburn is often mistaken for chest pain due to a heart attack. However, do not second guess yourself. If you are having chest pain for any reason, seek medical attention immediately, if only to rule out a heart attack.

Heartburn (often called acid indigestion) typically occurs 30-60 minutes after meals. The pain is worse when lying down, bending forward, and straining to pass stools. The pain is relieved by standing upright, swallowing saliva or water, or by taking antacids.
If small amounts of stomach acid or food travel beyond the esophagus and up into the mouth, you may experience bitter or sour taste. This is known as regurgitation. It is common after meals, especially if you are lying down, bending over, or straining.
Stomach acid can also affect the respiratory tract, causing asthma, hoarseness, chronic cough, sore throat, or tooth damage (acid eats the enamel on teeth). You may feel as if you have a lump in your throat.

If the acid exposure continues for long periods of time, the esophagus becomes damaged. You may then have difficulty swallowing. In more serious cases, you may lose weight and become dehydrated. Very rarely, the esophagus may bleed or tear completely because it is so damaged. In severe cases, you may vomit blood or have small amounts of blood in your bowel movements. However, all these are uncommon.


When to Seek Medical Care

Call your health care provider if your heartburn continues to bother you despite lifestyle modifications and use of antacids or low doses of acid blockers. Call if you have heartburn more than 3 times a week for over 2 weeks. Your provider will prescribe medications or make other recommendations to help your pain.

Seek emergency medical care. Chronic heartburn can sometimes lead to serious complications that require immediate medical attention. Go to a hospital's emergency department if you have any of the following symptoms:

Throwing up blood or passing blood in your stools

Severe pain, dizziness, or lightheadedness

Difficulty swallowing

Dehydration

Unintentional weight loss

NOTE: The pain of heartburn can often be confused with pain that is actually due to more serious heart problems, such as a heart attack. If you or a family member has a history of heart disease, you need to be particularly aware of this possibility. If your pain is accompanied by sweating, nausea, vomiting, difficulty breathing, or is worse with activity, you may need to have your heart evaluated immediately.


Exams and Tests

Heartburn may be obvious from your symptoms, so your health care provider may not need to perform any tests or do an extensive exam. You may be advised about lifestyle modifications, diet, or medications to begin immediately.

Your provider may order certain procedures if the diagnosis is unclear or if prescribed medications are not relieving your heartburn.
The most common procedure is called an upper GI (gastrointestinal) endoscopy, also called esophagogastroduodenoscopy or EGD. You are lightly sedated. A special camera is placed through your mouth and into the esophagus and stomach. The doctor can then see how much damage has been done to the esophagus from stomach acid. The doctor will also be able to determine and possibly treat the complications of heartburn, such as problems swallowing or bleeding. In addition, an upper endoscopy will let your doctor see if there are other explanations for the pain, such as an infection.

You may undergo an upper GI series. In this test, you drink a liquid that coats your esophagus and stomach and shows up on x-rays that are taken.

If an upper endoscopy shows that everything is normal but you continue to have pain, the doctor may do further testing to clarify the diagnosis. This includes procedures to measure the weakness of the LES muscle. This procedure is called an esophageal manometry.

Another procedure is the 24-hour pH monitoring to measure the strength of your stomach acid. A very thin tube is passed through your nose into your esophagus. For the next 24 hours, the test measures the amount of acid reflux that occurs while you go about your regular activities, including eating. A new test uses a tiny capsule to measure acid reflux levels. The doctor uses an endoscope to attach the bean-sized capsule to your esophagus. It measures pH levels and delivers readings by radio wave to a receiver you wear on your belt. After about 48 hours, the capsule detaches and passes through your digestive system and is not recovered.

If your health care provider feels you are at risk for heart problems, additional tests may be performed to make sure your heart is healthy.


Heartburn Treatment

Antacids, acid blockers, and perhaps surgery may provide relief from heartburn and prevent it from turning into more serious disease.


Self-Care at Home

For mild or occasional symptoms, simple lifestyle modifications can be helpful.

Avoid large meals.

Avoid caffeine (coffee, teas, some soft drinks).

Avoid foods or drinks that reduce pressure on the lower esophageal sphincter such as chocolate, peppermint, caffeine-containing beverages, and fatty or fried foods.

Avoid foods that damage the esophagus such as spicy foods, citrus fruits and juices, tomatoes and tomato sauces.

After eating, beware of activities that force acid back into your esophagus. Such activities include lifting, straining, coughing, and wearing tight clothing.

Use gravity to your advantage. Avoid lying down within 3 hours of meals. If you suffer from nighttime heartburn, elevate the head of your bed when sleeping. Place 6-inch blocks underneath the head of the bed, or place a wedge under the mattress. Simply using more pillows under your head will not help. In fact, it may worsen the heartburn by increasing the pressure on your stomach.

Lose weight if you are overweight.

Stop smoking.

Limit alcohol intake.

Antacids such as Maalox, Mylanta, Tums, or Rolaids can also be helpful. Antacids work by neutralizing acid. They should be taken 1 hour after meals or when heartburn symptoms occur.

Low doses of drugs that block the production of stomach acid are available over-the-counter. Some examples include cimetidine (Tagamet), ranitidine (Zantac), and famotidine (Pepcid).


Medical Treatment

Your health care provider will recommend treating heartburn in a stepwise fashion.

Over-the-counter antacids are the oldest effective self-treatments for heartburn. Through the centuries, people have chewed on chalk (the active ingredient is calcium carbonate) to ease heartburn. Antacid tablets are slow to act. Tablets are less powerful in neutralizing stomach acid than liquid antacids.

Antacids are useful because they provide rapid relief of heartburn, especially if it is caused by foods or certain activity. But relief is only temporary. Over-the-counter antacids do not prevent heartburn from returning or allow an injured esophagus to heal. If you need antacids for more than 2 weeks, talk with your health care provider to get a better diagnosis of your condition and appropriate treatment.

Most varieties of antacids you can buy in drug stores are combinations of aluminum and magnesium hydroxide. Antacids containing these ingredients may produce unwanted diarrhea or constipation.

Antacids containing calcium carbonate are the most potent in neutralizing stomach acid. Popular brands are Tums and Titralac.

Follow label instructions and do not take more than the recommended daily dose. Most commonly, users take antacids after meals and at bedtime—or when you have symptoms.

Always tell your health care provider about your antacid use.


Medications

If you still have heartburn symptoms after lifestyle modifications and use of antacids, your health care provider may prescribe drugs.

The next group of drugs to be tried is called histamine-2 blockers. Examples include ranitidine (Zantac), cimetidine (Tagamet), famotidine (Pepcid), and nizatidine (Axid). These tablets decrease the amount of acid your stomach produces. Many of these drugs can be bought over-the-counter at low doses but need a doctor's prescription for higher doses. They provide relief of symptoms within 30 minutes and are taken twice a day.

If you continue to have heartburn, the doctor may recommend adding a drug such as metoclopramide (Reglan). This type of drug empties food and acid quickly from the stomach so less can travel back into the esophagus. Reglan also helps tighten the LES muscle.

If you still have symptoms, the doctor will then recommend drugs called proton pump inhibitors. Examples of these drugs include omeprazole (Prilosec), lansoprazole (Prevacid), esomeprazole (Nexium), and pantoprazole (Protonix). These compounds prevent the stomach from secreting acid. They are very effective and are typically taken only once a day. These drugs are usually only prescribed if other drugs have not helped.


Surgery

If prescription drugs are not relieving heartburn, or if you have serious complications of heartburn, surgery may be required. The surgery is relatively simple and is called fundoplication. Its purpose is to tighten the lower esophageal sphincter muscle. The stomach is tied in such a way as to prevent acid from flowing backward into the esophagus. This surgery is successful for more than 85% of people.


Next Steps

Prevention

Many cases of heartburn can be prevented by simple lifestyle modifications in diet, activity, and habits. Watching what kinds of foods you eat and how much you eat can influence your symptoms. Also, pay attention to your body position after eating. Don't lie down. Limit alcohol intake, quit smoking, and lose weight to improve not only your heartburn symptoms but also your overall health.