Heartburn (GERD)

Heartburn is caused by stomach acid moving up into the esophagus.

NOTE: The pain of heartburn can be confused with pain due to more serious heart problems, such as a heart attack. Individuals need to be especially aware of this possibility if you or a family member has a history of heart disease. If a person has chest pain accompanied by sweating, nausea, vomiting, difficulty breathing, or pain that worsens with activity, should seek medical attention immediately.

Heartburn is an uncomfortable feeling of burning or warmth in the chest.

• Heartburn has nothing to do with the heart. Instead, heartburn is caused by the upward movement of stomach acid into the esophagus. Heartburn is sometimes called acid indigestion.
• Stomach acid is strong acid produced by the stomach to help digest the foods people eat. Normally the acid stays in the stomach. When the acid backs up into the esophagus, it burns and causes the uncomfortable sensation known as heartburn (the cause of heartburn is gastroesophageal reflux disease).
• The esophagus is the muscular tube that stretches between the mouth and the stomach. The foods we eat and the liquids we drink travel down the esophagus into the stomach.
• The stomach has a special lining to protect it from the acid. The esophagus doesn't have this protection.

A muscle called the lower esophageal sphincter (LES) at the bottom of the esophagus normally prevents foods and acid from backing up. This muscle acts like a tight drawstring to close off the opening between the esophagus and stomach when a person is  not eating.

Heartburn occurs when the lower esophageal sphincter does not close all the way.

Why doesn't the lower esophageal sphincter close all the way?

Many different things loosen the lower esophageal sphincter.

• Certain foods and drinks loosen the lower esophageal sphincter. These include chocolate, peppermint, caffeine-containing beverages (such as coffee, tea, and soft drinks), fatty foods, and alcohol.
• The body's position affects the lower esophageal sphincter. It is easier for stomach acid to flow back into the esophagus if a person is lying down or bending over.
• Anything that increases the pressure on the stomach can force stomach acid backward and cause heartburn. Lifting, straining, coughing, tight clothing, obesity, and pregnancy can worsen heartburn.
• Certain medical conditions increase a person's chance of suffering from heartburn. A hiatal hernia, diabetes, and many autoimmune diseases (CREST syndrome, Raynaud's phenomenon, and scleroderma) are linked to heartburn.
• Many prescription medications can loosen the lower esophageal sphincter, including certain blood pressure and heart medications and the asthma drug theophylline.

• Excess stomach acid in the esophagus can cause ulcers, damage to the inner layers of the esophageal wall, and narrowing (stricture and swallowing difficulty).
• Very rarely, the esophagus may bleed or tear completely because it is so damaged. In severe cases, a person may vomit blood or have small amounts of blood in bowel movements, found only on testing the stool.
• Regurgitated stomach acid can damage the respiratory tract, causing asthma, hoarseness, chronic cough, sore throat, or tooth damage (acid destroys the enamel on teeth). A person may feel as if he or she has a lump in the throat.
• If the acid exposure continues for long periods of time, the esophagus becomes thick and damaged. A person may then have difficulty swallowing and food becomes stuck.

Many substances directly irritate the lining of the esophagus and can contribute to heartburn. These include spicy foods, citrus fruits and juices, tomatoes and tomato sauces, cigarette smoke, aspirin, and ibuprofen (with brand names such as Motrin and Advil). Some of these foods can also increase the production of stomach acid and decrease the LES pressure, leading to heartburn.

• Heartburn usually starts about 30-60 minutes after a meal.
• It can occur at any time of day or night, but the pain is usually worse when lying down, so a person will notice it more when he or she is lying on the sofa, in a recliner, or in bed.
• Bending over or straining to go to the bathroom also may make heartburn worse.
• At night, saliva is not produced and the movement of the esophagus (peristalsis) decreases.

That is another symptom of reflux. If the acid backs up all the way to the mouth, the person notices a sour or bitter taste. This is called regurgitation.

Occasional heartburn is common in adults. Daily heartburn is less common and about a quarter of pregnant women have heartburn or related symptoms.

Generally speaking, heartburn is not serious. An occasional bout of heartburn usually means that the foods the person ate produced too much acid in the stomach. If a persons suffers from heartburn often, or every day, it can be a symptom of a more serious condition called gastroesophageal reflux disease or GERD. Frequent or severe heartburn may limit a person's daily activities and lead to further complications.

That depends. If a person has heartburn more than three times a week for at least two weeks, he or she should see a health care professional. On the other hand, if a person only has occasional bouts of heartburn, he or she may find that taking nonprescription antacids and making some simple changes in lifestyle can resolve the heartburn. If these measures do not help, then a visit to a health care professional is warranted.

If a person has any of these symptoms, with or without heartburn, call a doctor or go to a hospital emergency department right away:

• Throwing up blood or passing blood in bowel movements
• Severe pain, dizziness, or lightheadedness
• Difficulty swallowing
• Dehydration
• Unintentional weight loss

With proper understanding of the condition and treatment, relief can be attained.

When I have chest pain, how can I tell whether it is my heart or just heartburn?

Sometimes a person can't tell the difference. Just like chest pain from the heart, heartburn sometimes spreads from the chest to the jaw, shoulders, arms, or back. If a person has chest pain for any reason, seek medical care immediately.

If it is obvious from the symptoms that a person has heartburn, no tests or exams may be necessary. Advice in regard to lifestyle modifications, diet, or medications may begin immediately.

If your health care professional is not sure about the diagnosis, or if he or she is concerned about damage done by chronic heartburn, tests may be ordered. This is true especially if the patient has already been prescribed medications that are not relieving the heartburn.

There is no simple blood test for heartburn. The tests used to diagnose heartburn include the following:

• Upper GI (gastrointestinal) endoscopy: While the patient is lightly sedated, a thin tube is passed down the esophagus. The tube has a light and a tiny camera on the end. The camera sends pictures of the esophagus to a video monitor. The doctor can then see how much damage has been done to the esophagus from stomach acid. The endoscopy also shows other causes of heartburn, such as infection, and whether the patient has any complications of heartburn, such as bleeding. Some problems can actually be treated with the endoscope.
• Upper GI series: An upper GI series is a series of X-rays of the patient's chest and abdomen taken after a liquid that coats the inside of the esophagus and stomach is swallowed. This liquid provides contrast so that any problems are easier to see.
• Esophageal manometry: An esophageal manometry test measures the strength of the LES and the contraction movement of the esophagus after a swallow. This test usually is done if an upper GI endoscopy shows nothing abnormal but the patient continues to have pain.
• 24-hour pH monitoring: This test measures the strength of the patient's stomach acid. A very thin tube is passed through the nose into the esophagus and left in place for the next 24 hours. During this period, the test measures the amount of acid back-up that occurs while the patient goes about his or her regular activities, including eating. Another version of this test uses a tiny capsule to measure acid back-up. The doctor uses an endoscope to attach the bean-sized capsule to the esophagus. The capsule measures pH levels and delivers readings by radio wave to a receiver you wear on your belt. After about 48 hours, the capsule detaches and passes harmlessly through your digestive system.

The health care professional will recommend treating heartburn in a stepwise fashion. For mild or occasional symptoms, simple lifestyle modifications may be enough. The next step is nonprescription antacids such as Maalox, Mylanta, Tums, or Rolaids. Other treatments include acid blockers and even surgery. In most cases, one or more of these treatments provide relief from heartburn and prevent it from turning into a more serious disease.

I take nonprescription antacids for heartburn, but they don't seem to help.

Nonprescription antacids are only part of the treatment for heartburn. They can work very well, but these antacids alone usually can't stop heartburn. A health care professional will probably recommend that the patient make lifestyle changes in addition to other treatments.

What kind of lifestyle changes and remedies can I make to reduce heartburn?

Try any or all of the following:

• Avoid large meals, especially at night.
• Avoid caffeine (coffee, teas, some soft drinks).
• Avoid foods or drinks that relax the lower esophageal sphincter such as chocolate, peppermint, caffeine-containing beverages, and fatty or fried foods.
• Avoid foods that may damage the esophagus such as spicy foods, citrus fruits and juices, tomatoes and tomato sauces, or any food that causes symptoms.
• After eating, avoid activities that force acid back into the esophagus. Such activities include lifting, straining, coughing, and wearing tight clothing.
• Use gravity as an advantage. Avoid lying down for three hours after a meal. If a person suffers from nighttime heartburn, elevate the head of the bed when sleeping. Place 6-inch blocks underneath the head of the bed, or place a wedge under the mattress. Simply using more pillows under the head will not help. In fact, it may increase heartburn because it increases pressure on your stomach.
• Lose weight if you are overweight.
• Stop smoking.
• Limit alcohol intake.

Will these changes stop the heartburn?

They may. If they don't, adding a nonprescription antacid can be helpful.

How do antacids work?

• Antacids work by neutralizing acid. They should be taken 1 hour after meals or when heartburn symptoms occur. Liquid antacids usually work faster than tablets or chewables.
• Antacids are useful because they relieve heartburn rapidly, especially if it is caused by foods or certain activity. But relief is only temporary. Over-the-counter antacids do not prevent heartburn from returning or allow an injured esophagus to heal. If a person needs antacids for more than 2 weeks, talk with a health care professional to get a better diagnosis of the condition and appropriate treatment.
• Most varieties of antacids can be bought in drugstores and are combinations of aluminum hydroxide and magnesium hydroxide. Antacids containing these ingredients may produce unwanted diarrhea or constipation. Antacids containing calcium carbonate are the most potent in neutralizing stomach acid, but can cause a rebound of increased acid production. Popular brands are Tums and Titralac.
• When taking antacids, follow label instructions and do not take more than the recommended daily dose. Take antacids after meals and at bedtime-or when symptoms occur.
• Always tell a health care professionl about any antacid use.

What if lifestyle changes and antacids don't work?

If a person still has symptoms after lifestyle modifications and antacids, a health care professional probably will prescribe a stronger drug. The usual choice is one of the histamine-2 (H2) blockers, or acid blockers. These drugs block the biochemical process that creates acid in the stomach.

What are acid blockers?

The name says it all. Acid blockers reduce production of acid by the stomach. Less acid in the stomach means less acid back-up into the esophagus. Some examples are cimetidine (Tagamet), ranitidine (Zantac), and famotidine (Pepcid). Low doses of these drugs are available without a prescription. More potent doses require a prescription. These drugs relieve symptoms within 30 minutes and are usually taken twice a day.

If a person continues to have heartburn, a health care professional may recommend adding a drug such as metoclopramide (Reglan). This drug empties food and acid quickly from the stomach so less can back up into the esophagus. Reglan also helps tighten the lower esophageal sphincter.

If a person still have symptoms, a health care professional will then recommend one of the drugs called proton pump inhibitors. Examples of these drugs are omeprazole (Prilosec), lansoprazole (Prevacid), esomeprazole (Nexium), rabeprazole (Aciphex), and pantoprazole (Protonix). These tablets prevent the stomach from secreting acid. They are very effective and are typically taken only once a day. These drugs usually are prescribed if other drugs have not helped. They may have to be used indefinitely.

If prescription drugs are not relieving heartburn, or if a person has serious complications of heartburn, surgery may be necessary.

• The operation is relatively simple and is called fundoplication.
• Its purpose is to tighten the lower esophageal sphincter muscle.
• The stomach is tied in such a way as to prevent acid from flowing backward into the esophagus.
• This surgery is successful for more than 85% of people.

Many cases of heartburn can be prevented by simple lifestyle modifications in diet, activity, and habits.

• Watching what kinds of foods eaten and how much food is eaten can reduce symptoms.
• Also, pay attention to body position after eating. Don't lie down.
• Limit alcohol intake, quit smoking, and lose weight to improve not only heartburn symptoms but also overall health.

Most cases of heartburn are treated effectively with lifestyle modifications, antacids, or prescription drugs.

• However, relapse is common when treatment is stopped. Serious complications, such as bleeding or difficulty swallowing, are rare.
• Other possible problems caused by acid back-up include inflammation of the throat, voice box, and airways. If left untreated for years, chronic heartburn has been said to lead to Barrette's esophagus (a change in the lining cells of the esophagus) and, eventually, cancer of the esophagus.