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Heartburn

Definition

Heartburn is a painful burning sensation in the esophagus, just below or behind the breastbone. The pain often rises in your chest and may radiate to your neck or throat.

Alternative Names

Pyrosis; Non-cardiac chest pain

Causes

Almost everyone has occasional heartburn. If you have frequent, ongoing heartburn, you may have gastroesophageal reflux disease (GERD).

Normally, when food or liquid enters your stomach, a band of muscle at the end of your esophagus (called the lower esophageal sphincter or LES) closes off the esophagus. If this muscle fails to close tightly enough, stomach contents can back up (reflux) into the esophagus. This partially digested material is usually acidic and can irritate the esophagus, causing heartburn and other symptoms.

Heartburn is more likely to occur if you have a hiatal hernia, which is when the top part of the stomach protrudes upward into the chest cavity. This weakens the LES and makes it easier for acid to reflux from the stomach into the esophagus.

Heartburn can be brought on or worsened by pregnancy and by many different medications.

Such drugs include:

• Anticholinergics (e.g., for sea sickness)
• Beta blockers for high blood pressure or heart disease
• Calcium channel blockers for high blood pressure
• Certain bronchodilators for asthma
• Dopamine for Parkinson's disease
• Progestin for abnormal menstrual bleeding or birth control
• Sedatives for insomnia or anxiety
• Tricyclic antidepressants

If you suspect that one of your medications may be causing heartburn, talk to your doctor. NEVER change or stop medication you take regularly without talking to your doctor.

Home Care

Pay attention to heartburn and treat it, especially if you feel symptoms often. Over time, ongoing reflux can damage the lining of your esophagus and cause serious problems. The good news is that making changes to certain habits can go a long way to preventing heartburn and other symptoms of GERD.

The following tips will help you avoid heartburn and other GERD symptoms. If these measures are not working, talk to your doctor.

First, avoid foods and beverages that can trigger reflux, such as:

• Alcohol
• Caffeine, carbonated beverages
• Chocolate
• Citrus fruits and juices
• Peppermint and spearmint
• Spicy or fatty foods, full-fat dairy products
• Tomatoes and tomato sauces

Next, try changing your eating habits:

• Avoid bending over or exercising just after eating.
• Avoid eating or lying down within 2-3 hours of bedtime. Lying down with a full stomach results in stomach contents pressing harder against the lower esophageal sphincter (LES).
• Eat smaller meals. A full stomach puts extra pressure on the LES, increasing the chance that food will reflux.

Make other lifestyle changes as needed:

• Avoid tight-fitting belts or garments around the waist. They squeeze the stomach, and may force food to reflux.
• Lose weight if you are overweight. Obesity increases abdominal pressure, which can push stomach contents up into the esophagus. In some cases, GERD symptoms disappear completely after an overweight person loses 10-15 pounds.
• Sleep with your head raised about 6 inches. Sleeping with the head higher than the stomach reduces the likelihood that partially digested food will reflux into the esophagus. Place books, bricks, or blocks securely under the legs at the head of your bed. Or use a wedge-shaped pillow under your mattress. Sleeping on extra pillows does NOT work well for relieving heartburn.
• Stop smoking. Chemicals in cigarette smoke weaken the LES.
• Reduce stress. Try yoga, tai chi, or meditation.

If you still do not have full relief, try over-the-counter medications:

• Antacids, like Maalox or Mylanta, work by neutralizing stomach acid.
• H2 blockers, like Pepcid AC, Tagamet, and Zantac, reduce stomach acid production.
• Proton pump inhibitors, like Prilosec OTC, stop nearly all stomach acid production.

When to Contact a Medical Professional

Call 911 if:

• You vomit material that is bloody or black like coffee grounds.
• Your stools are black (like tar) or maroon.
• The burning sensation is accompanied by chest squeezing, crushing, or pressure. Sometimes a heart attack is mistaken for heartburn.

Call your doctor if:

• The problem becomes frequent or doesn't go away with a few weeks of self-care.
• You start losing weight unintentionally.
• You have difficulty swallowing (food feels stuck as it goes down).
• You have a persistent, unexplained cough or wheezing.
• Your symptoms get worse with antacids or H2 blockers.
• You think that one of your medications may be causing heartburn. DO NOT change or stop your medication on your own, without discussing with your doctor.

What to Expect at Your Office Visit

Heartburn is usually easy to diagnose from the symptoms you describe to your doctor. Sometimes, heartburn can be confused with another stomach problem called dyspepsia. If the diagnosis is unclear, then you may be sent to a gastroenterologist for further testing.

First, your doctor will perform a physical examination and ask questions about your heartburn, such as:

• When did it begin?
• How long does each episode last?
• Is this the first time you have had heartburn?
• What do you usually eat at each meal? Before you feel heartburn, have you eaten a spicy or fatty meal?
• Do you drink a lot of coffee, other caffeinated beverages, or alcohol? Do you smoke?
• Do you wear clothing that is tight in the chest or abdomen?
• Does the pain also appear in the chest, jaw, arm, or elsewhere?
• What medications are you taking?
• Are you vomiting blood or black material?
• Do you have blood in your stools?
• Do you have black, tarry stools?
• Are there other symptoms accompanying your heartburn?

The following tests may be performed:

• Esophageal motility to measure the pressure of your LES
• Upper endoscopy to look at the inside lining of your esophagus and stomach
• Upper GI series

If self care has not been successful, your doctor may consider prescribing you medications to reduce acid secretion. These are stronger than the medications available over the counter. Any sign of bleeding will require a more complicated treatment plan.

References

Kahrillas PJ, Shaheen NJ, Vaezi MF, Hiltz SW, Black E, Modlin IM. American Gastrointestinal Association Medical Position Statement on the management of gastroesophageal reflux disease. Gastroenterology. 2008;135:1383-1391.

Wilson JF. In the clinic: gastroesophageal reflux disease. Ann Intern Med. 2008;149:ITC2-1-15.

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