Heartburn

Overview

That burning feeling

Gastroesophageal reflux disease (GERD), reflux esophagitis, peptic esophagitis, symptomatic hiatal hernia: these are the hard-to-pronounce clinical synonyms for that uncomfortable, burning sensation in your chest, accompanied by belching and the unpleasant splashing-up of food into your throat that leaves a bitter, metallic taste your mouth.

GERD, reflux, esophagitis … whatever you call it, its major symptom is heartburn. And if you've got it, it's no picnic. But you're not alone — between 25 and 50 million Americans suffer from it regularly and 65% of people have had it at some time. Luckily, it can be treated, and there are ways to prevent it. The downside, though, is that doing so may involve saying "no" to some of your favorite food treats. So hold that pepperoni pizza with extra onions….

Detailed Description

Gastroesophageal reflux disease (GERD), or heartburn, has nothing to do with the heart. It is the reflux, or splashing upwards, of gastroduodenal contents into the esophagus. Burning pain in the chest radiates upward into the neck and throat and, oftentimes, bitter gastric juices are regurgitated into the mouth.

The most common cause of heartburn is a weakening of the opening, or sphincter, at the lower end of your esophagus. This smooth muscle, the lower esophageal sphincter (LES), connects the esophagus to the stomach. It opens when food moves down the esophageal tube, allowing the food to enter the stomach. It then clamps shut to prevent stomach acid from refluxing into the esophagus. If the sphincter's muscle tone is weakened, it stays open instead of closing, and up comes the acid. The result is the searing pain of heartburn, the belching, and that familiar, uncomfortable bloated feeling.

This unpleasantness usually occurs after a meal, when the stomach secretes acidic gastric juices to activate digestion. Stomach contents are more likely to be pushed back up through the sphincter then because pressure inside the stomach builds up when it's full.

For some, heartburn is occasional and can be treated with over-the-counter antacids. Severe and chronic cases may be alleviated by prescription medication.

Characteristics of GERD

  • Burning sensation in the chest that spreads upward to neck, throat, and face
  • Belching
  • Regurgitation of stomach acid into the esophagus
  • Bitter, metallic taste in mouth (called "water brash")
  • Difficulty swallowing
  • Excessive salivation
  • Mild abdominal pain (for some people)
  • Vomiting/nausea (rare)

How Common Is GERD?

Roughly 65% of all Americans have suffered from heartburn at some point in their lives. About half of these people — 25 to 50 million Americans — have had it on a regular basis for several years. People of all ages suffer from heartburn, and it affects both men and women.

What You Can Expect

In most cases, heartburn can be treated with over-the-counter antacids combined with diet and lifestyle modifications. Recurrences are common, however. Chronic and severe cases may be alleviated by prescription medication. Severe heartburn may require surgery to correct complications like narrowing of the esophagus due to chronic inflammation. In rare cases, it is caused by a large hiatal hernia. Surgery may be necessary to repair it, or it may be treated endoscopically.

If chronic GERD is left untreated, precancerous changes may occur in the esophagus (a condition known as Barrett's esophagus) and cancer may then develop.

Conventional Treatment

Goals of Treatment

GERD is very treatable, although recurrences of its symptoms are common. Treatment goals include relieving symptoms, preventing their recurrence, preventing complications, and restoring digestion to its proper state. These are usually accomplished through diet and lifestyle changes in combination with antacids and/or prescription medications. Surgery, while rare, is sometimes necessary.

Treatment Options

Treating GERD and its major symptom, heartburn, is typically initiated with changes in diet and lifestyle accompanied by antacids and/or prescription medications. The initial aim is to stop the pain, prevent complications, promote healing of the esophagus, restore proper function of the lower esophageal sphincter (LES) muscle, and prevent these symptoms from recurring.

Self treatment

To prevent GERD symptoms, your doctor will usually advise you to avoid the following:

  • Lying down within three hours after meals
  • Stooping or bending over after meals
  • Wearing tight-fitting clothes such as girdles, belts, or snug pantyhose
  • Foods that relax the LES and stimulate your stomach to produce acid, like coffee, alcohol, and citrus products

The following actions may help to alleviate discomfort:

  • Neutralize stomach acid by taking an antacid one hour after meals and another at bedtime
  • Raise the head of your bed with blocks
  • Using a wedged pillow, sleep with your upper body in an elevated position
  • Lose weight
  • Eat smaller, more frequent meals
  • Avoid fatty foods

Drug Therapy

If lifestyle and diet changes combined with over-the-counter antacids have not helped your condition, your doctor may prescribe prescription medication. These drugs have been shown to be more effective for longer periods of time. They include the following:

H2 blockers

Axid

On-Label Efficacy

Pepcid

On-Label Efficacy

Zantac

On-Label Efficacy

Tagamet

On-Label Efficacy
Proton pump inhibitors

Aciphex

On-Label Efficacy

buy Esomeprazole

On-Label Efficacy

Prevacid

On-Label Efficacy

Prilosec

On-Label Efficacy

Protonix

On-Label Efficacy
Other

Reglan

On-Label Efficacy

Surgery

Surgery, while rare, may be needed for severe inflammation, bleeding, ulcers, narrowing of the esophagus, large hiatal hernias, or symptoms that have not responded to other treatments.

Appropriate Healthcare Settings
Treating GERD is almost always undertaken on a self-care, outpatient basis, unless hospitalization is required in extreme cases.

Physicians Who May Be Involved in Managing Your Condition

Usually, your primary care doctor can diagnose GERD and help alleviate its symptoms with medicine and lifestyle suggestions. However, if the condition persists, you may be referred to a gastroenterologist or surgeon.

Activity & Diet Recommendations

Activity

Try to shed some pounds if you are overweight.

Diet

  • Avoid alcohol, tobacco, coffee, chocolate, peppermint, onions, spicy tomato juice, acidic fruit juices, and high-fat foods. These substances are known to irritate GERD symptoms.
  • Modify your eating habits. Consume small meals frequently, eat slowly, and chew each bite thoroughly. Keep a food diary to pinpoint which foods provoke an attack. Drink liquids between meals instead of with them; water dilutes food and increases the volume of your stomach's contents, which makes it easier for reflux to happen.

Possible Complications

Untreated or chronic GERD can lead to the following health complications:

  • Peptic stricture
  • Ear, nose, or throat problems
  • Hemorrhage
  • Barrett's esophagus — a condition where cells in the esophagus change to become stomach cells, which can increase the likelihood of developing cancer
  • Asthma
  • Reflux esophagitis

Considerations for Women

Pregnancy
About 52% of heartburn flare-ups occur in the first trimester of pregnancy and 24% in the second. They tend to recur in subsequent pregnancies. If GERD is a problem, try the following suggestions: eat small meals frequently, don't lie down for two to three hours after eating, and elevate your upper body when you sleep.

Considerations for Children and Adolescents

Minimize a child's vocal activities. Discourage your child from shouting, crying, or singing, since these activities will only delay recovery.

Considerations for Older People

Certain anatomical abnormalities may cause reflux in a young child. These conditions may require surgery. Left untreated, chronic acid reflux may be drawn into the lungs and cause asthma.

Heartburn

Last updated 8 November 2011

Synonyms

  • Heartburn
  • Reflux
  • Hiatal hernia

Pronunciation

gas-tro-ee-sof-ah-JEE-il REE-flux dis-EASE


Causes

Established Causes

GERD is caused by an influx of stomach acid into the esophagus. It typically results from a weak sphincter muscle at the base of the esophagus.

Pregnancy can also lead to GERD. Certain hormones produced during pregnancy can cause the esophagus sphincter muscle to lose its pressure and delay gastric emptying.

Risk Factors

Since the weakening of the esophagus sphincter muscle and irritation of the esophagus cause heartburn, eating foods that irritate these conditions may increase the risk of having heartburn. Foods known to contribute to GERD include the following:

  • Fatty foods
  • Any onions
  • Chocolate
  • Peppermint
  • Citrus fruits
  • Spicy foods
  • Tomatoes

Other risks include smoking, consuming alcohol, and drinking coffee.

Risk factors are traits or behaviors that may make you statistically more likely than others in the general population to have a certain condition. They are not necessarily "causes" of the condition.


Symptoms & Diagnosis

The main symptom of GERD is heartburn, a burning sensation you may feel in your chest after a meal or at nighttime. It results from stomach acids creeping up into your esophagus. Other symptoms can include the following:

  • Vomiting (in some cases)
  • Chest pains
  • Laryngitis
  • Difficulty swallowing
  • Dental disease
  • Asthma
  • Cough

It is important not to assume chest pain only results from GERD. It could in fact be the symptom of a heart attack. See your doctor if you are experiencing chest pain for the first time or if it is persistent or different from pain you know as heartburn, especially if it gets worse with exercise.

Conditions That May Be Mistaken for GERD

  • Coronary artery disease
  • Ulcer disease
  • Esophageal infections
  • Esophageal diverticulum
  • Achalasia
  • Radiation injury
  • Crohn's disease (rarely)

How GERD Is Diagnosed

Usually, a diagnosis can be made based on your medical history, symptoms and lifestyle alone. However, further tests, such as pH probes and endoscopy, may be performed if your GERD is chronic or fails to respond to treatment. These tests are used to determine if a more serious condition exists. If your symptoms include chest pains, the possibility of coronary disease must also be ruled out.

Physical exam

Endoscopy may be used if you are experiencing difficulty swallowing or have chronic GERD. A thin, flexible tube with a camera on the end is swallowed (under sedation) so that the doctor may examine the lining of the upper gastrointestinal tract and possibly take a biopsy sample. Once you have been diagnosed with GERD, your doctor may want to perform an endoscopy once a year to keep an eye out for further complications.

Lab tests

A pH test can be performed, in which a small probe is inserted through the nose into the esophagus to measure its acid levels.

Imaging

Your doctor may do an upper GI series which requires that you swallow barium, a chalky substance that highlights your upper digestive system on X-rays. Any reflux of barium into the esophagus can be monitored via X-ray to determine if GERD is the correct diagnosis. This procedure is also be used to rule out such conditions as ulcers and hernias.

Self care & Prevention

Preventing GERD

A diet free of aggravating foods and substances is the best way for most people to avoid heartburn. Avoid alcohol and caffeine, as well as tobacco and aspirin. Other offenders include the following:

  • Fatty foods (like french fries)
  • Onions
  • Chocolate
  • Peppermint (which, paradoxically, can also ease symptoms in some cases)
  • Citrus fruits
  • Spicy foods
  • Tomatoes

Self-Care Measures

  • Relax when you eat, and chew your food well. Rushed eating can trigger heartburn and GERD.
  • Neutralize stomach acid by taking an antacid one hour after meals and another at bedtime.
  • If your heartburn or GERD tends to strike at night, don't eat during the few hours before bedtime.
  • Try keeping a heartburn diary. Record what you eat, and see if you can link the consumption of specific foods with getting heartburn a few hours later. Eliminate or cut back on offending items. Alcohol and milk cause problems for some people.
  • Don't recline after eating. Lying down weakens the lower esophageal sphincter, allowing painful acid reflux.
  • If nighttime attacks are a problem, elevate the head of your bed with a few bricks or blocks underneath the bed legs. Using a wedged pillow, sleep with your upper body in an elevated position.
  • If you smoke, stop. Smokers are at high risk of heartburn and GERD.