Heartburn

Definition
The symptoms of heartburn are hard to ignore. The patient has just eaten a big meal
and leaned back in his favorite chair. As he begin to relax, his 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

How heartburn occurs

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

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.