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 the heart. Instead, heartburn is caused by stomach acid.

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 its treatment, relief can be obtained from this condition.

Heartburn is a common symptom in most people. About one-third of adults experience heartburn. Anywhere from 17%-45% 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 end 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 the stomach is protected from its own acid by a special mucous layer. The esophagus does not have this special protection. If the lower esophageal sphincter does not close completely, the lower part of the esophagus can be damaged by refluxing stomach acid. When this occurs, heartburn may be experienced.

The lower esophageal sphincter may not close completely allowing stomach acid into the esophagus for these reasons:

• Certain foods and drinks the lower esophageal sphincter. These include chocolate, peppermint, caffeinated 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 a person is lying on the back, on the right side, or bending over.
• Anything that increases the pressure in the abdomen, forcing stomach acid backward into the esophagus, can cause heartburn. Lifting, straining, coughing, tight clothing, obesity, and pregnancy can worsen heartburn.
• People with certain medical conditions have an increased risk of heartburn. These conditions include: hiatal hernia, diabetes, gastroparesis, and many autoimmune diseases (CREST syndrome, Raynaud's phenomenon, and scleroderma).
• Many prescription medications can loosen the lower esophageal sphincter, including blood pressure and heart medications, and the asthma drugtheophylline.
• Many substances directly irritate the lining of the esophagus and contribute to heartburn. These include spicy foods, citrus fruits and juices, tomatoes and tomato sauces, cigarette smoke, aspirin, ibuprofen (Motrin, Advil etc.), and medicine prescribed to treat osteoporosis.

Heartburn Symptoms

Heartburn is a burning feeling in the chest. 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, if a person is having chest pain for any reason, seek medical attention immediately.

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, the person may experience bitter a or sour taste (regurgitation). Regurgitation is common after meals, especially if the person is 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). The person may feel as if he or she has a lump in the throat.
• If the acid reflux continues for long periods of time, the esophagus becomes damaged. The person may have difficulty swallowing. In more serious cases, weight loss and dehydration occur. Very rarely, the esophagus may bleed or tear completely because it is so damaged. In severe cases, the person may vomit blood or have small amounts of blood in bowel movements.

When to Seek Medical Care

Call your health care professional if heartburn continues despite lifestyle modifications and use of antacids or low doses of acid blockers. Call a health care professional if a person has heartburn more than three times a week for over 2 weeks. The health care professional will prescribe medications or make other recommendations to help the 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 the stools
• Chest pain
• Severe pain, dizziness, or lightheadedness
• Difficulty swallowing
• Shortness of breath
• 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, be aware of this possibility. If pain is accompanied by sweating, nausea, vomiting, difficulty breathing, or worsens with activity, you may need your heart evaluated immediately.

Heartburn Diagnosis

Heartburn may be obvious from the symptoms, so the health care professional may not need to perform any tests or do an extensive exam. The patient may be counseled to make lifestyle modifications and dietary changes to begin immediately.

The doctor may order certain procedures if the diagnosis is unclear or if the prescribed medications are not relieving the patient's heartburn.

Exams and Tests

• The most common procedure is called as gastrointestinal endoscopy(esophagogastroduodenoscopy or EGD). During this procedure the patient is lightly sedated. A special camera is placed through the mouth and into the esophagus and stomach. The doctor can see how much damage has been done to the esophagus from stomach acid. The doctor will be able to determine and possibly treat the complications of heartburn, such as problems swallowing or bleeding. An upper endoscopy assist the doctor in diagnosing other explanations for the pain, such as an infection.
• The patient may undergo an upper GI series. In this test, the patient drinks a liquid that coats the esophagus and stomach and shows up on X-rays that are taken subsequently.
• If an upper endoscopy shows everything is normal but the patient continues to have pain, the doctor may do further testing to clarify the diagnosis. This includes a procedure to measure the weakness of the LES muscle, called as esophageal manometry.
• The 24-hour pH monitoring test measures the strength of stomach acid. A very thin tube is passed through nose into the patient's esophagus. For the next 24 hours, the test measures the amount of acid reflux that occurs while the patient goes about his or her regular activities, including eating.
• Another test uses a tiny capsule to measure acid reflux levels. The doctor uses an endoscope to attach the bean-sized capsule to the patient's esophagus. It measures pH levels and delivers readings by radio wave to a receiver the patient wears on the belt. After about 48 hours, the capsule detaches and passes through the digestive system and is not recovered.

If the patient's health care professional feels the patient is at risk for heart problems, additional tests may be performed to make sure the patient's 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.

Heartburn Foods and Remedies

For mild or occasional symptoms, simple lifestyle modifications can help provide relief of symptoms.

• Avoid large meals.
• Avoid caffeine (coffee, teas, soft drinks).
• Avoid foods or drinks that reduce pressure on the lower esophageal sphincter such as chocolate, peppermint, caffeine-containing beverages, alcohol, 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 the 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 and may worsen heartburn by increasing pressure on the stomach.
• Lose weight if you are overweight.
• Stop smoking.
• Limit alcohol intake.
• Antacids such as Maalox, Mylanta, Tums, or Rolaids can also provide relief. 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 including cimetidine (Tagamet), ranitidine (Zintac), and famotidine (Topcid).

Heartburn Medical Treatment

The health care professional will recommend treating heartburn in a gradual progression.

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. Tablets are less powerful in neutralizing stomach acid than liquid antacids.

• Antacids are useful because they provide rapid, but temporary relief of heartburn, especially if it is caused by foods or certain activity. Over-the-counter (OTC) antacids do not prevent heartburn from returning or allow a patient's injured esophagus to heal. If the patient need antacids for more than two weeks, talk to a your health care professional to have your condition reviewed and receive appropriate treatment.
• Most varieties of antacids you can buy in drug stores are combinations of aluminumand magnesium hydroxide. Antacids containing these ingredients may produce unwanted diarrhea or constipation. Discuss these medications with your doctor before use if you have any history of kidney (renal) disease.
• Antacids containing calcium carbonate are the most potent in neutralizing stomach acid. Popular brands includes Digene Gel, Gelusil Gel etc

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

Always tell a health care professional about your antacid use.

Heartburn Medications

If the patient still has heartburn symptoms after lifestyle modifications and use of antacids, the health care professional may prescribe drugs.

• Histamine-2 blockers decrease the amount of acid the stomach produces. Examples include ranitidine (Zintac), cimetidine(Tagamet), famotidine (Topcid), and nizatidine (Axid). Many of these drugs can be purchased over-the-counter at lower doses, but patients will need a doctor's prescription for higher doses. They provide relief of symptoms within 30 minutes and are taken twice a day.
• If heartburn persists, the doctor may recommend adding a drug such as metoclopramide (Perinorm). Thisf drug empties food and acid quickly from the stomach so less acid can reflux back into the esophagus. Reglan/Perinorm also helps tighten the LES muscle.
• If the patient still has symptoms, the doctor will then recommend drugs called proton pump inhibitors. Examples of these drugs include omeprazole (Ocid), lansoprazole(Lanzol),Rabeprazole (Razo) esomeprazole (Nexium), and pantoprazole (Pantop). These compounds prevent the stomach from secreting acid. They are very effective and are typically taken once a day. These drugs are usually only prescribed if other drugs have not helped the symptoms. Many of these drugs can be bought OTC at lower doses, however, a doctor's prescription is required for higher doses.

Heartburn Surgery

If prescription drugs are not relieving heartburn, or if the patient has serious complications of heartburn, surgery may be required. The surgery is called fundoplication. Its purpose is to tighten the lower esophageal sphincter muscle. The stomach is repositioned in such a way as to prevent acid from flowing backward into the esophagus. This surgery is successful in 70%-95% of people, depending on the severity of the disease. Laparoscopic fundoplication tends to yield better results than invasive surgery.

Heartburn 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 symptoms. Pay attention to body position after eating. Don't lie down soon after a meal. Limit alcohol intake, quit smoking, and lose weight to improve not only heartburn symptoms but also your overall health.

Heartburn Prognosis

Most cases of heartburn are treated effectively with lifestyle modifications, antacids, or prescription drugs. Relapse is common when treatment is stopped. Other possible problems caused by acid reflux include inflammation of the throat, voice box, and airways. Serious complications, such as bleeding or difficulty swallowing, are rare. A complication of chronic heartburn and inflammation of the esophagus is called Barrett's esophagus. If left untreated for years, chronic heartburn can in rare cases lead to cancer of the esophagus.