Overview of Heartburn
The esophagus is a tube that connects the mouth to the stomach. It is made of muscles that work to push food toward the stomach in rhythmic waves. Once in the stomach, food is prevented from refluxing (moving back into the esophagus), by a special area of circular muscle located at the junction of the esophagus and stomach, called the lower esophageal sphincter (LES). A pressure difference across the diaphragm, the flat muscle that separates the chest from the abdomen, also tends to keep stomach contents in the stomach.
The stomach combines food, acids, and enzymes together to begin digestion. There are special protective cells that line the stomach to prevent the acid from causing inflammation. The esophagus does not have this same protection, and if stomach acid and digestive juices reflux back into the esophagus, they can cause inflammation and damage to its unprotected lining.
Heartburn is actually a symptom of GERD (gastroesophageal reflux disease), and is caused by acid refluxing back into the esophagus. Risk factors include those that increase the production of acid in the stomach, as well as structural problems that allow acid reflux into the esophagus.
- Some common foods that we eat and drink, stimulate increased stomach acid secretion setting the stage for
heartburn. Over-the-counter medications also may precipitate heartburn. Examples of these irritants include:
- aspirin (Bayer, etc.),
- ibuprofen (Motrin, Advil, Nuprin, etc.)
- Naproxen (Naprosyn, Aleve)
- carbonated beverages,
- acidic juices (grapefruit, orange, pineapple)
- acidic foods (tomatoes, grapefruit, and oranges), and
- Smoking and the consumption of high-fat content foods tend to affect function of the lower esophageal sphincter (LES), causing it to relax from the stomach and allow acid to reflux into the esophagus.
- A hiatal hernia where a portion of the stomach lies within the chest instead of the in abdomen, can affect the way the LES works and is a risk factor for reflux. Hiatal hernias by themselves cause no symptoms. It is only when the LES fails that heartburn occurs.
- Pregnancy can cause increased pressure within theabdominal cavity and affect LES function and predispose it to reflux.
- Obesity may also cause increased pressure in the abdomen, and thus reflux in the same way.
- Primary diseases of the esophagus can also present with heartburn as a symptom. These include, among others, scleroderma and sarcoidosis.
Gastroesophageal reflux disease (GERD), is a condition in which heartburn is a symptom. Stomach acid refluxes up into esophagus and causes pain. This pain can be felt as a burning sensation behind the sternum or breastbone, either as a spasm or a sharp pain. Many times the pain of acid reflux can be mistaken for the pain of a heart attack.
The pain of acid reflux (heartburn) can remain in the lower chest or it can radiate to the back of the throat and be associated with waterbrash, a sour taste in the back of the throat. If there is acid reflux near the larynx (voicebox) in the throat, it may cause coughing episodes or hoarseness. Reflux over prolonged periods of time can be severe enough that acid wears away the enamel on teeth and causes decay.
Symptoms are often worsened after heavy meals, leaning forward, or lying flat. Those affected may often awaken from sleep with heartburn.
Heartburn is not without complications. If ignored, recurrent irritation and inflammation of the esophagus can lead to ulcers, which are small areas of tissue breakdown. These can cause serious bleeding.
As well, scarring and stricture are other significant complications of GERD. Changes in the type of cells lining the esophagus may result from acid reflux, causing a condition known as Barrett's esophagus, which is associated with an increased risk of esophageal cancer.
Heartburn is a common complaint, though it can be confused with other chest-related illnesses, including:
The diagnosis begins with a complete history and physical examination. In many cases that provides enough information for the health care professional to make the diagnosis and begin a treatment plan. In some instances, further testing may be required:
X-ray: The patient may be asked to swallow barium or Gastrografin (two types of contrast materials) while a radiologist, using an X-ray or fluoroscopy machine, watches the contrast material travel down the esophagus and enter into the stomach. Aside from looking for irregularities or inflammation within the esophagus and of the esophageal walls, this test can determine if the esophagus muscles are working properly in a rhythmic fashion to push the contrast material into the stomach.
Endoscopy: In this test a gastroenterologist uses a flexible scope and with a fiberoptic camera to look at the lining of the esophagus and stomach. Inflammation and ulcers can be identified. Biopsies and small bits of tissue can be obtained to look for cancerous or pre-cancerous cells.
Manometry and pH testing: Less commonly, when conventional therapy has failed to confirm the diagnosis, or when symptoms are atypical, use of pressure monitors and acid measurements from within the esophagus may be helpful in making the diagnosis.
- Eat smaller, more frequent meals
- Avoid eating before bedtime
- Avoid alcohol, aspirin, ibuprofen, and caffeine
- Stop smoking
- Elevate the head of the bed (or use two or three pillows) to allow gravity to keep acid in the stomach and avoid acid reflux.
Antacids may be taken after meals, at bedtime, or when needed, to bind excess acid in the stomach and to coat the esophagus.
Histamine H2 antagonists are medications that block the action of histamine (a chemical that stimulates stomach cells to produce acid) on the acid-producing cells of the stomach. This decreases acid production to hopefully decrease symptoms. Examples include:
- cimetidine (Tagamet),
- ranitidine (Zantac), and
- famotidine (Pepcid).
Some H2 blockers and proton pump inhibitors are available OTC without a prescription. However, there may be potential interactions with some prescription medications. Check with your health care professional or pharmacist for advice about their safe use.
Proton pump inhibitors (PPIs) are another class of drugs that block the production of acid by the stomach. PPIs include:
- omeprazole (Prilosec, Rapinex),
- rabeprazole (Aciphex)
- pantoprazole (Protonix)
- lansoprazole (Prevacid), and
- esomeprazole (Nexium).
Surgery is an option for those patients:
- for whom intensive medical therapy does not provide adequate relief,
- with Barrett's esophagus,
- with reflux so severe that it causes hoarseness, pneumonia, or wheezing.
Different surgical approaches to esophageal reflux are available. In fundoplication, the stomach is wrapped around the lower esophagus, in effect creating a new physiologic valve to take the place of the lower esophageal sphincter. New devices have been recently approved that can be wrapped around the lower esophagus that act link the LES. The specific procedure will be recommended based upon the patient's situation.
- Heartburn is a symptom of a common medical condition (GERD) that affects up to 20% of the population.
- Initial therapies to limit the amount of stomach acid production include lifestyle changes including avoiding certain foods, alcohol, anti-inflammatory medications, and quitting smoking.
- Medications can be helpful in controlling symptoms of heartburn.
- Weight loss may help decrease heartburn symptoms by decreasing intra-abdominal pressure.
- Heartburn is not a benign condition. If neglected over long periods of time it may lead to other more serious conditions such as Barrett's esophagus or esophageal cancer.
Tova Alladice, M.D.
American Board of Physical Medicine & Rehabilitation