Heartburn

Heartburn symptoms typically include a burning sensation or discomfort in the chest after eating.

Heartburn is a disease that occurs when gastric contents flow backward from the stomach into the esophagus. It is also termed reflux and gastroesophageal reflux disease (GERD) or pyrosis. Heartburn may or may not be associated with mucosal injury; that disease, termed esophagitis, is addressed in a separate article.

Surveys suggest that as many as 25% to 40% of adults experience heartburn once a month, while about 7% to 10% have daily heartburn. Heartburn occurs more often in males and in people over the age of 40 years.

The cause of heartburn is the excessive flow of gastric contents back into the esophagus. Normally, there is an occasional backflow into the esophagus with no symptoms. The acidic gastric contents, when present in large amounts, irritate the esophagus (usually the lower part) and cause the symptoms of heartburn.

Symptoms of heartburn usually consist of a sensation of burning or discomfort after eating, located in the middle of the lower chest underneath the sternum (breastbone). The discomfort may increase when bending over or lying flat on the back. Some people experience dysphagia (difficulty swallowing) or feeling like food is stuck in the lower esophagus while others may have a cough or respiratory discomfort, although these symptoms occur less frequently.

About one-half of all pregnant women develop heartburn, especially during their second and third trimesters. Pregnant women should avoid the foods listed above and utilize the home remedies described above except for the OTC medications. They should discuss with their doctor what OTCs if any they should take. Although OTCs are generally safe for the fetus and mother, their use should be determined by the person's OB/GYN.

Generally, most people with heartburn are presumptively diagnosed on the basis of the patient's clinical history and the person's response to OTC medications.

However, more severe symptoms may be due to an underlying cause. The doctor then will schedule additional tests that may include an upper GI endoscopy, pH probe study (acid measurement), esophageal manometry (pressure test), upper GI series, or other tests, depending on the suspected underlying cause.

Certain foods and drinks should be avoided because they may lead to or worsen heartburn symptoms. Some common examples are as follows:

• Alcohol
• Coffee
• Citrus juice
• Soft drinks that have an acid pH
• Peppermint
• Chocolate
• Tomato products
• Chili peppers

This is not a complete list of all the offending agents; people can learn from experience what foods give them heartburn symptoms and then avoid those foods.

In addition to avoiding the foods listed above, there are several home remedies that can help people avoid and reduce the symptoms of heartburn. These include:

• Eating small meals
• Avoiding bending over (especially soon after eating)
• Waiting about 3 hours after a meal before lying down, elevating the head of your bed about 8 inches, and avoiding lying on your right side
• Losing weight if you are overweight
• Reducing stress by using relaxation techniques

Treatment of heartburn is often approached by taking small incremental steps, usually starting with home remedies and diet modifications, then to OTC medications. If these measures do not effectively control the heartburn symptoms, the next steps consist of using prescribed medications and other treatment options.

Common OTC antacids such as Rolaids, Tums, or Maalox are effective for some individuals; others may need H2 receptor antagonists such as:

• Ranitidine (Taladine, Zantac, Zantac 150, Zantac 300, Zantac 75, Zantac EFFERdose)
• Cimetidine (Tagamet, Tagament HB)
• Famotidine (Heartburn Relief, Leader Acid Reducer, Pepcid, Pepcid AC, Pepcid AC Maximum Strength)
• Nizatidine (Axid, Axid AR, Axid Pulvules)

Other people may do well with proton pump inhibitors (PPIs) such as:

• Omeprazole (Prilosec, Prilosec OTC)
• Lansoprazole (Prevacid, Prevacid OTC, Prevacid SoluTab)
• Rabeprazole (Aciphex)
• Esomeprazole (Nexium)
• Pantoprazole (Protonix)

Surgery for heartburn is rare; however, if heartburn is uncontrollable or complications like Barrett's esophagus develop, surgery may be considered by your doctors. The surgery may reduce the hiatal hernia, may narrow the esophageal hiatus, involve implantation of a device to augment the sphincter above the stomach, or other specialized procedures.

The prognoses for the large majority of people with heartburn is very good. Many people require no treatment or only treatment with OTCs. A small number of people will develop complications and their prognosis will vary from good to a more guarded.

As stated above, heartburn can be reduced or prevented by a stepwise treatment program that includes:

• Lifestyle changes
• Avoiding certain foods
• OTC medications
• Prescription medications
• Surgical intervention

In most people, heartburn lasts for a short period of time and stops quickly, especially with the use of certain medications. People should seek medical care if heartburn is increasing in frequency, occurring daily, not responsive to over-the-counter (OTC) medications, or if additional symptoms such as difficulty in swallowing, and frequent nausea and vomiting occur. Other symptoms, such as shortness of breath and/or chest pain, can be mistaken for heartburn; these symptoms should be evaluated emergently.