(Gastroesophageal Reflux Disease; GERD)
Heartburn is a burning sensation in the lower chest. It is the main symptom of gastroesophageal reflux disease.
Heartburn occurs when gastric juices from the stomach flow up into the esophagus (tube connecting the mouth to the stomach).
Food travels down the esophagus to the stomach. The opening between the esophagus and stomach opens to let food enter the stomach. Normally it closes as soon as the food enters the stomach. With heartburn, the opening does not close tightly. Stomach acid flows into the esophagus (called acid reflux), causing the burning sensation. Other causes include diseases that interfere with food passing through the esophagus or cause excess acid production.
A risk factor is something that increases your chance of getting a disease or condition.
Risk factors include:
- Hiatal hernia
- Exercise immediately after eating (especially jogging or running)
- Alcohol use
- Carbonated beverages, caffeinated beverages, and decaffeinated coffee
- High-fat or high-carbohydrate foods and spicy foods
- Certain medications, including anticholinergics, calcium channel blocking agents, theophylline, NSAIDs, quinidine, tetracycline, potassium and iron supplements, anti-osteoporosis agent alendronate
- Prior surgery for heartburn, including gastric reflux surgery and vagotomy
- Asthma and the use of asthma medications
- Peptic ulcer and its treatment
- Certain diseases, including diabetes, cancer, scoliosis, cystic fibrosis, and nervous system diseases
- Defects in the respiratory system or gastrointestinal system
- Food allergies
Heartburn symptoms usually occur after overeating or lying down after a big meal. They may last for a few minutes or a few hours. The severity of symptoms depends on the reason the opening does not close, the amount of acid entering the esophagus, and how much the saliva is available to neutralize it.
- Burning feeling that starts in the lower chest and may move 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
- Feeling of a lump in the throat
- Hoarse voice (laryngitis)
- Sleep apnea (stopping breathing repeatedly throughout the night)
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 (precancerous condition of the esophagus that has no unique symptoms but can be diagnosed by periodic medical surveillance examinations involving endoscopy)
- Dental problems (due to the effect of the stomach acid on the tooth's enamel)
Heartburn can feel like the pain associated with a heart attack. Never assume that chest pain is heartburn or ingestion. Seek medical care if you're not sure.
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 to keep track of the level of acidity in the lower esophagus. This is done over a 24-hour period.
Manometry–a test that measures muscle pressures in the lower esophagus
Endoscopy–looking at the esophagus and stomach through a thin, lighted tube that is passed down the throat
Biopsy–removing a small sample of esophageal tissue to measure the amount of acid or pressure in the esophagus
Treatment aims to decrease the number of episodes of heartburn and its complications. Therapies focus on stopping the flow of acid back into the esophagus and neutralizing or decreasing production of stomach acid.
Treatment may include:
Medications may include:
- Over-the-counter antacids, which neutralize stomach acid. They work quickly but can cause problems with long-term use. Examples include Maalox, Tums, Rolaids, and Mylanta.
- Over-the-counter H2-blocker drugs, which stop the stomach from producing as much acid. These include Tagamet, Pepcid, and Zantac.
- Prescription drugs that suppress acid production or reduce the chance of acid entering the esophagus. These are called proton-pump inhibitors and include omeprazole and lansoprazole.
- Medications that coat and protect the lining of the stomach (sucralfate)
- Medications that improve muscle tone in the lower esophageal sphincter (reglan)
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 provoke symptoms, such as:
- High-fat foods
- Spicy foods
- Citrus fruits
- Carbonated drinks
- Try eating smaller portions, since large meals increase the chance of heartburn.
- Allow at least two or three hours between meals and bed or naptime. This allows the stomach to partially empty before you lie down.
- Losing weight may help decrease symptoms.
- Don't smoke cigarettes. Cigarette smoking relaxes the muscle, allowing stomach acid into the esophagus.
- Avoid belts and clothing that are too tight.
- Elevate head of bed 6-8 inches.
If symptoms are severe enough and you can't tolerate the medications, surgery may be an option:
Fundoplication–the doctor wraps the stomach around the esophagus to create pressure on the muscle at the opening to the stomach. In some patients esophageal reflux surgery can now be performed by laparoscopy. This means that the actual incisions made are quite small, and recovery may be more rapid than with traditional procedures.
Both surgery and long-term medical treatment are effective, and studies have shown no significant advantage for one over the other. Successful surgery can greatly reduce or permanently eliminate the need to take medication. Despite surgical costs, discomforts, and risks, for many patients surgery leads to both an improvement in quality of life and to a significant reduction in expensive medication costs. Whether surgery or medical management is more effective in reducing the risk of Barrett’s esophagus (precancer or cancer) remains to be seen.
Several lifestyle changes can help prevent heartburn. Suggestions include:
- Avoid overeating.
- Sit up for 2-3 hours after eating.
- Avoid wearing clothing or belts that are too tight.
- Do not smoke.
- Avoid drinking beverages that contain alcohol or caffeine.
- Modify diet to avoid foods that increase heartburn.
- Chew sugarless gum for about 30 minutes after a meal. This will increase saliva flow, which can neutralize stomach acids in the esophagus.
- Obtain and maintain a healthy weight.
- Learn and practice stress-management techniques.