Your Health - Heartburn

Heartburn—Overview

(Gastroesophageal Reflux Disease; Gastro-oesophageal Reflux Disease [GORD]; GERD; Reflux, Heartburn)

Definition

Heartburn is a burning sensation in the lower chest. It is the main symptom of gastroesophageal reflux disease (GERD).

Heartburn

Causes

When you eat, food travels down the esophagus to the stomach. The muscle between the esophagus and stomach lets food enter the stomach. When this muscle weakens, stomach acid flows into the esophagus. This causes a burning sensation, called heartburn.

Other causes of GERD include:

Conditions that:
- Interfere with food passing through the esophagus
- Cause excess acid production
Possible genetic factor

Risk Factors

These factors increase your chance of developing GERD. Tell your doctor if you have any of these risk factors:

Being obese
Being pregnant
Having a hiatal hernia —a weakening in the diaphragm (large muscle separating the thorax and the abdomen) causing the stomach to partially slip into the chest cavity
Exercising immediately after eating (especially jogging or running)
Smoking
Using alcohol
Eating chocolate (can worsen symptoms)
Drinking caffeinated beverages
Eating a high-fat diet
Taking certain medications, including:
- Anticholinergics
- Calcium channel blocking agents
- Theophylline
- Nonsteroidal anti-inflammatory drugs (NSAIDs)
- Quinidine
- Tetracycline
- Potassium and iron supplements
- Anti- osteoporosis agent alendronate
- Hormone replacement therapy
Having prior surgery for heartburn, including gastric reflux surgery and vagotomy
Having asthma and using asthma medications
Having and treating a peptic ulcer
Having certain diseases, including diabetes , cancer , scoliosis , cystic fibrosis , and nervous system diseases
Having defects in the respiratory system or gastrointestinal system
Having food allergies

Symptoms

Heartburn symptoms usually occur after overeating or lying down after a big meal. The symptoms may last for a few minutes or a few hours.

The severity of symptoms depends on the:

Reason the muscle is weakened
Amount of acid entering the esophagus
Amount of saliva to neutralize the acid

Symptoms include:

Burning feeling that starts in the lower chest and moves up the throat
Feeling that food is coming back up
Sour or bitter taste in the throat
Pain that increases when bending over, lying down, exercising, or lifting heavy objects

Other symptoms and complications of reflux include:

Sore throat
Hoarseness
Chronic cough
Feeling of a lump in the throat
Asthma
Hoarse voice ( laryngitis )
Waking up with a sensation of choking

If reflux persists, the acid can damage the esophagus. Symptoms of esophageal damage include:

Bleeding and ulcers in the esophagus
Difficulty swallowing
Vomiting blood
Black or tarry stools
Inflammation and scarring of the esophagus
Barrett's esophagus —This is a precancerous condition of the esophagus that has no unique symptoms, but can be diagnosed by endoscopic exams.
Dental problems (due to the effect of the stomach acid on the tooth's enamel)

Diagnosis

Heartburn can feel like heart attack pain. If you feel this pain, call 911 right away.

The doctor will ask about your symptoms and medical history, and perform a physical exam. Tests may include:

Upper GI series —a series of x-rays of the upper digestive system taken after drinking a barium solution
24-hour pH monitoring—a probe placed in the esophagus tracks of the level of acidity in the lower esophagus
Manometry—a test that measures muscle pressure in the lower esophagus
Endoscopy —a thin, lighted tube is passed down the throat to look at the esophagus and stomach, a tissue sample may be taken
Biopsy —a small sample of esophageal tissue is removed to measure the amount of acid or pressure in the esophagus

Treatment

Treatment aims to decrease the number of episodes of heartburn and its complications. This focuses on:

Stopping the flow of acid back into the esophagus
Decreasing production of stomach acid

Treatment may include:

Lifestyle Changes

Lifestyle changes may include:

Keep a food diary of what you eat and what the reaction is. Make gradual changes to your diet and record the results.
Avoid foods that may cause symptoms, such as:
- High-fat foods
- Fried foods
- Spicy foods
- Onions and garlic
- Chocolate
- Peppermint
- Citrus fruits
- Tomatoes
- Peppers
- Alcohol
- Coffee
- Carbonated drinks
Eat smaller portions.
Allow at least 2-3 hours between meals and lying down.
Lose weight .
If you smoke, quit .
Avoid belts and clothing that are too tight. This may increase pressure on the abdomen.
Elevate head of bed 6-8 inches.

Medication

Medications may include:

Over-the-counter antacids —to neutralize stomach acid; works quickly, but can cause problems with long-term use (eg, Maalox, Tums, Rolaids, Mylanta
Over-the-counter H2-blocker drugs—to stop the stomach from producing as much acid (eg, Tagamet , Pepcid , Zantac )
Proton-pump inhibitors—to suppress acid production or reduce the chance of acid entering the esophagus (eg, omeprazole , lansoprazole )
Medications that coat and protect the lining of the stomach (eg, sucralfate )
Medications that improve muscle tone in the lower esophageal sphincter (eg, metoclopramide )

Procedures

If symptoms are severe and you can't tolerate the medications, surgery may be an option.

The most common surgery for heartburn is fundoplication . The doctor wraps the stomach around the esophagus. This creates pressure on the muscle at the opening to the stomach. If you have a hiatal hernia, it can also be repaired at this time.

In some cases, the surgery can be done with smaller incisions, called laparascopy .

Endoscopic Antireflux Procedures

An advantage of endoscopic techniques is that they do not involve incisions in the skin. Instead, the doctor inserts a lighted device called an endoscope through the mouth and down the esophagus to reach the first part of the stomach. Through the endoscope, the doctor can perform one of a variety of procedures that decreases the backward flow of stomach acid into the esophagus, including transoral incisionless fundoplication.

If surgery or endoscopy is successful, you may not need to take heartburn medications anymore. Talk to your doctor about the best treatment for you.

Prevention

Lifestyle changes can help prevent heartburn, including:

Avoid overeating.
Sit up for 2-3 hours after eating.
Avoid wearing tight clothing.
Elevate the head of the bed.
Do not smoke.
Avoid drinking beverages that contain alcohol or caffeine.
Change your diet to avoid certain foods.
Chew sugarless gum for about 30 minutes after a meal. This will increase saliva flow, which can neutralize stomach acids in the esophagus.
Maintain a healthy weight.
Manage stress .

RESOURCES:

American College of Gastroenterology
http://www.acg.gi.org/

American Gastroenterological Association
http://www.gastro.org/

National Institute of Diabetes and Digestive and Kidney Diseases
http://www.niddk.nih.gov/

CANADIAN RESOURCES

Canadian Institute for Health Information
http://www.cihi.ca/

Health Canada
http://www.hc-sc.gc.ca/

References:

Alan R. Causes of gastroesophageal reflux disease (GERD)/heartburn. EBSCO Health Library website. Available at: http://www.ebscohost.com/thisTopic.php?marketID=15topicID=81 . Updated February 2007. Accessed July 1, 2008.

Alan R. Gastroesophageal reflux disease (GERD)/heartburn. EBSCO Health Library website. Available at: http://www.ebscohost.com/thisTopic.php?marketID=15topicID=81 . Updated February 2007. Accessed July 1, 2008.

American Gastroenterological Association website. Available at: http://www.gastro.org .

Conn HF, Rakel RE. Conn's Current Therapy 2001 . 53rd ed. Philadelphia, PA: WB Saunders Company; 2001.

EsophyX receives FDA clearance for performing transoral incisionless fundoplication surgery. Medical News Today website. Available at: http://www.medicalnewstoday.com/articles/83410.php . Published September 24, 2007. Accessed August 19, 2009.

Gastroesophageal reflux disease (GERD). EBSCO DynaMed website. Available at: http://www.ebscohost.com/dynamed/what.php . Updated May 2008. Accessed July 1, 2008.

Heartburn: hints on dealing with the discomfort. American Academy of Family Physicians website. Available at: http://www.familydoctor.org . Updated April 2008. Accessed July 1, 2008.

Heartburn, gastroesophageal reflux (GER), and gastroesophageal reflux disease (GERD). National Institute of Diabetes and Digestive and Kidney Diseases website. Available at: http://digestive.niddk.nih.gov/ddiseases/pubs/gerd/ . Updated May 2007. Accessed July 1, 2008.

Transoral incisionless fundoplication with EsophyX. Endogastric Solutions website. Available at: http://www.endogastricsolutions.com/esophyx_for-pt.htm . Accessed August 19, 2009.

Treating GERD. Ohio State University Medical Center website. Available at: http://medicalcenter.osu.edu/patientcare/healthcare_services/digestive_disorders/gerd_heartburn/diagnosing_treating_gerd/treating_gerd/Pages/index.aspx . Accessed August 19, 2009.

Understanding GERD. American College of Gastroenterology website. Available at: http://www.acg.gi.org/patients/gerd/word.asp . Published 2006. Accessed July 1, 2008.

¹9/30/2008 DynaMed's Systematic Literature Surveillance http://www.ebscohost.com/dynamed/what.php : Jacobson BC, Moy B, Colditz GA, Fuchs CS. Postmenopausal hormone use and symptoms of gastroesophageal reflux. Arch Intern Med. 2008;168:1798-1804.

Last reviewed September 2009 by Daus Mahnke, MD

Please be aware that this information is provided to supplement the care provided by your physician. It is neither intended nor implied to be a substitute for professional medical advice. CALL YOUR HEALTHCARE PROVIDER IMMEDIATELY IF YOU THINK YOU MAY HAVE A MEDICAL EMERGENCY. Always seek the advice of your physician or other qualified health provider prior to starting any new treatment or with any questions you may have regarding a medical condition.