Heartburn

Definition

The symptoms of heartburn are hard to ignore. You've just eaten a big meal and leaned back in your favorite chair. As you begin to relax, your chest starts to hurt so much it feels like it's on fire.

Heartburn is common, and an occasional episode is generally nothing to worry about. However, many people battle heartburn — a burning sensation in the food pipe (esophagus), just below or behind the breastbone — regularly, even daily. Frequent heartburn can be a serious problem, and it deserves medical attention. Frequent or constant heartburn is the most common symptom of gastroesophageal reflux disease (GERD) — a disease in which stomach acid or, occasionally, bile flows back (refluxes) into your esophagus.

Most people can manage the discomfort of heartburn with lifestyle modifications and over-the-counter medications. But if heartburn is severe, these remedies may offer only temporary or partial relief.

Symptoms

The primary symptom of heartburn is a burning pain in your chest, under your breastbone. This pain may worsen when you bend over, lie down or eat. It may also be more frequent or worse at night.

Causes

When you swallow, your lower esophageal sphincter — a circular band of muscle around the bottom part of your esophagus — relaxes to allow food and liquid to flow down into your stomach. Then it closes again.

However, if this valve relaxes abnormally or weakens, stomach acid can flow back up into your esophagus, causing heartburn. The acid backup is worse when you're bent over or lying down.

Frequent heartburn is usually a symptom of GERD, although other conditions such as hiatal hernia also are related to heartburn. In this condition, also called diaphragmatic hernia, part of your stomach protrudes into your lower chest. If the protrusion is large, a hiatal hernia can worsen heartburn by further weakening the lower esophageal sphincter muscle.

Some other factors that can make heartburn worse include:

• Certain foods, such as fatty foods, spicy foods, chocolate, caffeine, onions, tomato sauce, carbonated beverages and mint
• Alcohol
• Large meals
• Lying down too soon after eating
• Certain medications, including sedatives, antidepressants and calcium channel blockers for high blood pressure
• Cigarette smoking

In heartburn, the sphincter at the lower end of your esophagus relaxes at the wrong time, allowing stomach acid to back up into your esophagus.

Risk factors

Conditions that cause difficulty with digestion can increase the risk of heartburn. These include:

• Obesity. Excess weight puts extra pressure on your stomach and diaphragm — the large muscle that separates your chest and abdomen — forcing open the lower esophageal sphincter and allowing stomach acids to back up into your esophagus. Eating very large meals or meals high in fat may cause similar effects.
• Hiatal hernia. If this protrusion of part of your stomach into your lower chest is large, it can worsen heartburn by further weakening the lower esophageal sphincter muscle.
• Pregnancy. Pregnancy results in greater pressure on the stomach and a higher production of the hormone progesterone. This hormone relaxes many of your muscles, including the lower esophageal sphincter.
• Asthma. Doctors aren't certain of the exact relationship between asthma and heartburn. It may be that coughing and difficulty exhaling lead to pressure changes in your chest and abdomen, triggering regurgitation of stomach acid into your esophagus. Some asthma medications that widen (dilate) airways may also relax the lower esophageal sphincter and allow reflux. Or it's possible that the acid reflux that causes heartburn may worsen asthma symptoms. For example, you may inhale small amounts of the digestive juices from your esophagus and pharynx, damaging lung airways.
• Diabetes. One of the many complications of diabetes is gastroparesis, a disorder in which your stomach takes too long to empty. If left in your stomach too long, stomach contents can regurgitate into your esophagus and cause heartburn.
• Gastric outlet obstruction. This is a partial blockage caused by scarring, an ulcer or a growth near the valve (pylorus) in the stomach that controls the flow of food into the small intestine. It can keep this valve from working properly or can obstruct the release of food from the stomach. Food doesn't empty from your stomach as fast as it should, causing stomach acid to build up and back up into your esophagus. This usually causes more signs and symptoms than just heartburn, such as abdominal pain, difficulty eating, weight loss, nausea and vomiting. If you experience any of these signs and symptoms, consult your doctor.
• Delayed stomach emptying. In addition to diabetes or an ulcer, abnormal nerve or muscle functions can delay emptying of your stomach, causing acid backup into the esophagus. Medications may also lead to delayed stomach emptying. These include narcotics, some antidepressants and antihistamines.
• Connective tissue disorders. Diseases such as scleroderma that cause muscular tissue to thicken and swell can keep digestive muscles from relaxing and contracting as they should, allowing acid reflux.
• Zollinger-Ellison syndrome. One of the complications of this rare disorder is that your stomach produces extremely high amounts of acid, increasing the risk of acid reflux.

When to seek medical advice

Most problems with heartburn are fleeting and mild. But if you have severe or frequent discomfort, you may be developing complications that need more intensive medical treatment and prescription medications. Talk to your doctor if you have:

• Heartburn several times a week
• Heartburn that returns soon after your antacid wears off
• Heartburn that wakes you up at night

You may need further medical care, possibly even surgery, if you experience any of these:

• Symptoms that persist even though you're taking prescription heartburn medications
• Difficulty swallowing
• Regurgitated blood or black material
• Stool that's black
• Weight loss

Tests and diagnosis

Usually a description of your symptoms will be all your doctor needs to establish the diagnosis of heartburn. However, if your symptoms are particularly severe, don't respond to treatment, or your doctor suspects GERD or another condition, you may need to undergo other tests.

• Barium X-ray. This procedure requires you to drink a chalky liquid that coats and fills the hollows of your digestive tract. The coating allows your doctor to see a silhouette of the shape and condition of your esophagus, stomach and upper intestine (duodenum). X-rays can then reveal whether a hiatal hernia may be contributing to your heartburn. They can also reveal an esophageal narrowing or stricture, or a growth, which may cause difficulty swallowing.
• Endoscopy. A more direct test for diagnosing the cause of heartburn is esophagogastroduodenoscopy (EGD). In this test your doctor inserts a thin, flexible tube equipped with a light and camera (endoscope) down your throat. The endoscope allows your doctor to see if you have an ulcerated or inflamed esophagus (esophagitis) or stomach (gastritis). It can also reveal a peptic ulcer. During an EGD, your doctor can take tissue samples to test for Barrett's esophagus — a condition in which precancerous changes occur in cells in your esophagus — or esophageal cancer, two potential complications of severe heartburn. Analysis of these samples may also reveal the presence of the Helicobacter pylori (H. pylori) bacterium that may cause peptic ulcers.
• Ambulatory acid (pH) probe tests. These tests use an acid-measuring (pH) probe to identify when, and for how long, stomach acid regurgitates into your esophagus. This information can help your doctor determine how best to treat your condition. In the standard tube test, a nurse or technician sprays your throat with a numbing medication while you're seated. Then a thin, flexible tube (catheter) is threaded through your nose into your esophagus to insert the probe. The probe is positioned just above the lower esophageal sphincter. A second probe may be placed in your upper esophagus. Attached to the other end of the catheter is a small computer that you wear around your waist or with a strap over your shoulder during the test. It records acid measurements. After the probe is in place, you go about your business and then come back one or two days later to have the device removed. A test called a Bravo pH probe may be more comfortable than the standard test, because it eliminates the need for a tube in your nose. In the Bravo test, the probe is attached to the lower portion of your esophagus during endoscopy. The probe transmits a signal to a small computer that you wear around your waist for about two days, and then the probe falls off to be passed in your stool. Another benefit of the Bravo test is that you can shower and sleep more comfortably than with the standard test.
• Esophageal impedance. Rather than measuring acid, this test can measure whether gas or liquids reflux back into your esophagus. It's helpful for people who have regurgitation or reflux of materials in the esophagus that aren't acidic and wouldn't be detected by a pH probe. The test works by placing a catheter through your nose and into your esophagus, similar to a standard pH probe tube test. However, because the test is new, its role in helping people with GERD hasn't been clearly defined.

Complications

Most heartburn is only occasional. If your heartburn is severe or chronic, it may suggest you have GERD. Complications of GERD include irritation and inflammation of your esophagus (esophagitis), narrowing of your esophagus (stricture) and a slightly increased risk of esophageal cancer.

Treatments and drugs

If you experience only occasional, mild heartburn, you may get relief from an over-the-counter (OTC) medication and self-care measures. OTC remedies include:

• Antacids. Antacids, such as Maalox, Mylanta, Gelusil, Rolaids and Tums, neutralize stomach acid and can provide quick relief. But antacids alone won't heal an inflamed esophagus damaged by stomach acid. Overuse of some antacids can cause side effects such as diarrhea or constipation.
• H-2-receptor blockers. Over-the-counter H-2-receptor blockers, such as cimetidine (Tagamet HB), famotidine (Pepcid AC), nizatidine (Axid AR) or ranitidine (Zantac 75), are available at half the strength of their prescription versions. Instead of neutralizing the acid, these medications reduce the production of acid. They don't act as quickly as antacids, but they provide longer relief. Take these medications before a meal that you think may cause heartburn because it takes them about 30 minutes to work. They're also effective in reducing reflux at night if taken at bedtime. Some H-2-receptor blockers can cause infrequent side effects, including dizziness, diarrhea, headache, kidney problems and temporary breast enlargement in men. In rare instances they can also react dangerously with other medications.
• Proton pump inhibitors. These medications block acid production and allow time for damaged esophageal tissue to heal. Omeprazole (Prilosec) was previously available only by prescription, but now is available in an over-the-counter form for the short-term treatment of heartburn.

If you have frequent and persistent heartburn, you may have GERD, leading to an inflamed esophagus. GERD usually requires prescription-strength medication or medical treatment and sometimes surgery.

Lifestyle and home remedies

You may eliminate or reduce the frequency of heartburn by making the following lifestyle changes:

• Control your weight. Being overweight is one of the strongest risk factors for heartburn. Excess pounds put pressure on your abdomen, pushing up your stomach and causing acid to back up into your esophagus.
• Eat smaller meals. This reduces pressure on the lower esophageal sphincter, helping to prevent the valve from opening and acid from washing back into your esophagus.
• Loosen your belt. Clothes that fit tightly around your waist put pressure on your abdomen and the lower esophageal sphincter.
• Eliminate heartburn triggers. Everyone has specific triggers. Common triggers such as fatty or fried foods, alcohol, chocolate, peppermint, garlic, onion, tomatoes, caffeine and nicotine may make heartburn worse.
• Avoid stooping or bending. Tying your shoes is OK. Bending over for longer periods to weed your garden isn't, especially soon after eating.
• Don't lie down soon after a meal. Wait at least two to three hours after eating before going to bed, and don't lie down right after eating.
• Raise the head of your bed. An elevation of about six to nine inches puts gravity to work for you. You can do this by placing wooden or cement blocks under the feet of your bed at the head end. If it's not possible to elevate your bed, you can insert a foam wedge between your mattress and box spring to elevate your body from the waist up. Wedges are available at drugstores and medical supply stores. Raising your head only by using pillows is not a good alternative. If you need to raise the head of your bed most nights, talk to your doctor because it may indicate GERD and require stronger medication and evaluation.
• Don't smoke. Smoking may increase stomach acid. The swallowing of air during smoking may also aggravate belching and acid reflux. In addition, smoking and alcohol increase your risk of esophageal cancer.

Alternative medicine

Several home remedies exist for treating heartburn, but they provide only temporary relief. They include drinking baking soda (sodium bicarbonate) added to water or drinking other fluids such as baking soda mixed with cream of tartar and water.

Although these liquids create temporary relief by neutralizing, washing away or buffering acids, eventually they aggravate the situation by adding gas and fluid to your stomach, increasing pressure and causing more acid reflux. Further, adding more sodium to your diet may increase your blood pressure and add stress to your heart, and excessive bicarbonate ingestion can alter the acid-base balance in your body.