Heartburn is a burning sensation in the chest that can extend to the neck, throat, and face. It usually occurs after eating and is worsened by bending, lifting, or lying down.
Heartburn, sometimes called acid indigestion or gastroesophageal reflux, is very common. More than one third of the population suffers from occasional heartburn, as do about one half of pregnant women. Some 50 million adult Americans complain of frequent heartburn. The occurrence of heartburn generally increases with age; however, it is common—and often overlooked—in infants and children.
Heartburn occurs when digestive juices from the stomach move back up into the esophagus, the tube connecting the throat to the stomach. The upper third of the esophagus consists of skeletal muscle that propels the food downward. The lower two-thirds of the esophagus is smooth muscle. The lower esophageal sphincter (LES) is a thick band of muscle that encircles the esophagus just above the uppermost part of the stomach. This sphincter is usually tightly closed—opening only when food passes from the esophagus into the stomach—and prevents the contents of the stomach from moving back into the delicate esophageal tissue. The stomach has a thick mucous coating that protects it from the strong hydrochloric acid it secretes to digest food. However the much-thinner esophageal mucous coating does not protect against stomach acid. Thus, if the LES opens inappropriately or fails to close completely, stomach acids can back up and burn the esophagus, causing heartburn.
Occasional heartburn is usually harmless. However, frequent or chronic heartburn (recurring more than twice per week) is called gastroesophageal reflux disease (GERD) and requires early management. Repeated episodes of GERD can lead to esophageal inflammation (esophagitis). If the esophagus is repeatedly subjected to
stomach acid and digestive enzymes, ulcerations, scarring, and thickening of the esophageal walls can result. This causes a narrowing of the interior of the esophagus that can affect swallowing and the peristaltic movements that send food downward. Repeated esophageal irritation also can result in Barrett's syndrome—changes in the types of cells lining the esophagus. Barrett's esophagus can develop into esophageal cancer.
Gastroesophageal reflux may occur in children under age one, particularly pre-term babies or those with cerebral palsy. It also may be a cause of some migraine headaches. In addition, chronic heartburn can be a symptom of a gastric ulcer or coronary artery disease.
Heartburn is caused by:
- a relaxed LES that does not close properly
- over-production of stomach acid
- increased stomach pressure
- a damaged esophagus with increased acid sensitivity
Many factors can contribute to LES malfunction:
- irregular eating, skipping meals
- some medications, including diazepam (Valium), meperidine (Demerol), theophylline, morphine, prostaglandins, calcium channel blockers, nitrate heart medications, progesterone, and anticholinergic and adrenergic drugs (drugs that limit nerve reactions)
- paralysis and scleroderma (an autoimmune disease that hardens body organs)
- large meals that distend the stomach and prevent the LES from closing
- alcohol, which lowers the pressure on the LES, allowing it to relax and open. Alcohol also may irritate the esophageal lining
- weakening LES and loss of LES muscle tone with increasing age
Hiatal hernias are common among pregnant women, smokers, the obese, and those over age 50. The hiatus is an opening in the diaphragm (the large muscle that separates the chest cavity and the abdomen) through which the esophagus connects to the stomach. If the hiatus loses its tautness and shape, the stomach may protrude through, forming a pocket just below the LES where stomach acid can be trapped. These hiatal hernias can cause the LES to relax and open. Hiatal hernias may result in frequent and severe heartburn and GERD.
Various factors can increase stomach pressure, causing gastroesophageal reflux:
- lying down within one or two hours of eating
- tight clothing
- Pregnancy, which causes the enlarged uterus to displace the stomach, delaying the removal of stomach contents
Eating too fast, chewing insufficiently, and smoking all increase stomach acid production. Smoking also dries up saliva that protects the esophagus from acid.
Many foods are known to contribute to heartburn:
- greasy, fried, or fatty foods
- spicy foods
- black pepper
- such acidic foods as tomatoes, pickles, and vinegar
- coffee with or without caffeine
- Peppermint or other mints
Heartburn itself is a symptom of gastroesophageal reflux and GERD. Heartburn sufferers may salivate excessively or regurgitate stomach contents into their mouths, leaving a sour or bitter taste.
Other symptoms of GERD include:
Heartburn usually is diagnosed by patient histories, symptoms, and clinical assessments. Additional procedures may be used to confirm the diagnosis, assess damage to the esophagus, and monitor the healing progress. The following diagnostic procedures are appropriate for anyone with frequent, chronic, or difficult-to-treat heartburn, or complicating GERD symptoms as listed above.
Esophageal manometry uses a thin flexible catheter placed down the esophagus. Small openings in the catheter sense pressure at various points on the esophagus while the muscle is at rest and during swallowing. The pressures are transmitted to a computer that analyzes the wave patterns.
An upper gastrointestinal (GI) series, or "barium swallow," can reveal esophageal narrowing, ulcerations, tumors, hiatal hernia, or reflux episodes as they occur. X rays are taken after a patient swallows a barium (a chemical element) suspension. This procedure takes about 15 minutes. However, it cannot detect structural changes associated with different degrees of esophagitis.
Upper GI endoscopy uses a thin flexible tube to view the inside of the esophagus directly. It is performed by a gastroenterologist, a physician specializing in diagnosis and treatment of disorders of the gastrointestinal tract, or by a gastrointestinal endoscopist. Upper GI endoscopy enables the physician to distinguish the degree of esophagitis and provides an accurate profile of esophageal damage. This procedure may include a biopsy—the removal of a small piece of tissue—to examine for Barrett's syndrome or malignancies. Patients with Barrett's esophagus may have frequent examinations of the esophageal lining for early detection of precancerous cells.
Other diagnostic tests include measurements of esophageal acidity (pH), usually over a 24-hour period, using an ambulatory acid probe. The patient is given a large capsule containing an acid-sensing probe, a battery, and a transmitter. Acid in the esophagus is measured by
Note: A burning sensation in the chest is usually heartburn and is not associated with the heart itself. About 15 percent of the annual six million U. S. emergency room visits for chest pain are due to heartburn. However, angina (one type of temporary chest pain, pressure, or discomfort) sometimes is mistaken for severe heartburn. Chest pain that radiates into the arms and is not accompanied by regurgitation is a warning sign of a possible serious heart problem. Persistent chest pain should always be evaluated by a physician.
These herbal remedies may be used to treat heartburn:
- ginger (Zingiber officinalis) as a tea or candied. (Ginger may cause heartburn in some people.)
- chamomile (Matricaria chamomilla) tea
- slippery elm (Ulmus fulva) tea
- cinnamon tea
- anise (Pimpinella anisum), caraway, dill, and/or fennel seed tea
- cardamom (Elettaria cardamomum) on buttered raisin toast
- turmeric (Curcuma domestica) added to warm water
- marsh mallow root (Althaea officinalis)
- licorice (Glycyrrhiza glabra), especially deglycyrrhizinated licorice (DGL) (The capsules or tablets may be dissolved in the mouth or in tea or two to four chewable 380-mg. wafers are taken about 20 minutes before eating. DGL should not be used more than three times per week, as repeated use can be toxic.)
- peppermint tea (Peppermint also can cause heartburn by relaxing the LES.)
- Ayurvedic (traditional East Indian) herbs
Homeopathic remedies for heartburn include:
- Calcarea carbonica
- Nux vomica after eating spicy foods
- Carbo vegetalis after eating rich foods
- Arsenicum album (for burning pain)
- Natrum muriaticum (for nervousness, tension, and pain)
- Zinc metallicum after eating too fast
A variety of other remedies and therapies may be used to treat heartburn:
- Sodium bicarbonate (baking soda) reduces esophageal acidity immediately. However, its effect is short-lived and it should not be used by people on sodium-restricted diets.
- Nutritional remedies include carrots, celery, angelica, fennel, and/or parsley. These can be combined in a juice taken before meals.
- Acupressure points Stomach 36, Spleen 6, Pericardium 6, and Conception Vessel 12. CV 12 should not be pressed just after eating or during pregnancy.
- In Chinese medicine, foods and herbs that balance and cool the qi (Chinese term for universal life energy), including radishes, radish seed, citrus fruit peels, and cardamom.
- Walking after a meal.
- Chewing gum after eating to help produce saliva for soothing the esophagus and washing acid back into the stomach.
- Relaxation therapy, visualization, and deep breathing.
Occasional heartburn is commonly treated with nonprescription antacids that neutralize the pH of stomach acid. The neutralized acid does not burn the esophagus. Antacids usually work within 15 minutes and their effects last one to two hours. Liquid or dissolving antacids usually act faster than tablets. However, antacids, if taken for too long, can cause side effects, including diarrhea or constipation.
Some antacids interfere with medications for kidney or heart disease. Heartburn sufferers with two or more episodes per week, or with an episode lasting more three weeks, should not rely on antacids as the sole treatment, since they may be at risk of kidney damage or other metabolic changes.
Common antacids include Maalox, Mylanta, Alka-Seltzer, Pepto-Bismol, Riopan, and Rolaids. The active ingredient in antacids such as Tums is calcium carbonate. Alginate (Gaviscon) is a foaming agent that coats the esophagus and the stomach to help prevent reflux. Other antacids are made from aluminum hydroxide, magaldrate, or magnesium hydroxide. Some antacids contain baking soda (sodium bicarbonate), which may interfere with vitamin and mineral absorption during pregnancy.
Histamine receptor (H2) blockers, such as famotidine (Pepcid), ranitidine (Zantac), nizatidine (Axid), and cimetidine (Tagamet), decrease stomach acid secretion. They relieve heartburn in about 75% of users. However, they take 30 to 45 minutes to act and usually are taken two to four times daily for several weeks. H2 blockers are both over-the-counter (OTC) and prescription medicines. They may have side effects or interactions with other medications.
Proton pump inhibitors (PPI) are for severe heartburn. They are the most effective drugs for inhibiting acid production and allowing the esophagus to heal in GERD. It may take up to five days for PPIs to take effect. They cannot be used by people with kidney or liver problems. Although it appears safe to take PPIs for at least 10 years, the lowest effective dosage reduces the risk of side effects that may include headache, diarrhea, stomach pain, and interactions with other medications. Common PPIs include lansoprazole (Prevacid), omeprazole (Prilosec), rabeprazole (Aciphex), pantoprazole (Protonix), and esomeprazole (Nexium). Prilosec OTC is available in 20-milligram doses to be taken once a day for 14 days to treat frequent heartburn.
Prokinetics are drugs that strengthen the LES (lower esophageal sphincter) and increase the rate of stomach emptying. These include metoclopramide (Reglan) and bethanechol (Urecholine). These drugs frequently have side effects.
Laparoscopic Nissen fundoplication is a surgical procedure to increase pressure on the LES by stretching and wrapping the upper part of the stomach around it. It is performed under general anesthetic and takes one to two hours. The complete recovery period is less than two weeks.
GERD (gastroesophageal reflux disease) may be treated successfully by endoscopic suturing of the weakened LES to stop acid reflux. Studies have shown that symptoms usually improve with this procedure and the use of medications declines. Another procedure involves using electrodes to make tiny cuts in the LES tissues. The resulting scarring tightens the LES. These outpatient procedures take less than an hour. They are not used in cases of hiatal hernia or Barrett's esophagus.
If the esophagus has become narrowed and badly scarred from stomach acid, a procedure that stretches and widens the esophageal tissue may be used along with acid-suppressing medication. Enteryx is a liquid that can be injected into the LES where it forms a spongy muscle implant that strengthens the LES.
Occasional heartburn without esophageal damage has an excellent prognosis. Esophageal damage that is treated with a program that promotes healing also has an excellent prognosis. Infants usually outgrow gastroesophageal reflux by age one.
Untreated heartburn and GERD may lead to bleeding, esophageal ulcers, and infections. With treatment, the damaged tissue that forms ulcers can heal. About ten percent of patients with GERD experience esophageal narrowing from acid damage that leads to the formation of scar tissue in the lower esophagus. GERD also can cause laryngitis, bronchitis, and aspiration pneumonia. After five years of heartburn, the risk of developing Barrett's esophagus increases. About five percent of GERD patients have Barrett's syndrome. This condition is incurable and may lead to cancer. The prognosis for esophageal cancer is very poor. There is a strong likelihood of painful illness and a less than five percent chance of survival for more than five years.
Dietary adjustments to eliminate many causes of heartburn include:
- eating smaller, more frequent meals to reduce pressure on the LES
- eating slowly, chew thoroughly, and take deep breaths between bites
- avoiding caffeine, chocolate, onions, spicy foods, and mint, all of which tend to increase stomach acid and relax the LES
- avoiding fatty, fried, and greasy foods. Fatty foods relax the LES and slow stomach emptying, and fat consumption has been linked to GERD
- avoiding milk, garlic, peppers, and carbonated beverages
- avoiding nicotine
- avoiding citrus fruits and juices and tomato-based foods, which are acidic and can irritate an inflamed esophagus
- replacing meat at dinner with carbohydrates and easier-to-digest proteins such as rice, beans, and pastas
- avoiding alcohol
- adding the spice annato (Bix orellana) or bouquet garni to foods
- drinking tea made with crushed caraway seeds with meals
- controling body weight
Lifestyle changes that can alleviate heartburn include:
- avoiding drugs known to contribute to heartburn, including aspirin or other nonsteroidal anti-inflammatories
- avoiding clothing that fits tightly around the abdomen
- not lying down until the stomach is empty—within about three hours of eating
- elevating the head of the bed six to nine inches to prevent nighttime heartburn
- avoiding strenuous exercise for two to three hours after a meal
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American Gastroenterological Association (AGA). 4930 Del Ray Avenue, Bethesda, MD 20814. (310 654-2055. <http://www.gastro.org/>.
National Digestive Diseases Information Clearinghouse. 2 Information Way, Bethesda, MD 20892–3570. (800) 891-5389. (301) 654-3810. firstname.lastname@example.org. <http://digestive.niddk.nih.gov/>.
The National Heartburn Alliance. 303 East Wacker Drive, Suite 440, Chicago, IL 60601. (877) 471-2081. email@example.com. <http://www.heartburnalliance.org/>.
Margaret Alic, PhD