General Questions
What is heartburn?
Heartburn is a burning discomfort in the chest or throat that results when harsh stomach acid comes into contact with and irritates the delicate lining of the esophagus, the tube-like structure that connects the mouth to the stomach. The exact symptoms and sensations of heartburn vary from person to person, but its most common symptom is often described as a burning or vague feeling of discomfort in the chest just behind the breastbone.
What does heartburn feel like?
The symptoms of heartburn vary widely and can be difficult to describe. However, people with heartburn generally describe one or more of the following symptoms:
- a burning chest pain that begins at the breastbone and movesup toward the throat
- a feeling that food is coming back into the mouth
- an acid or bitter taste at the back of the throat
- an increase in severity of pain when lying down or bending over
What causes heartburn?
Juices that are produced by the stomach to help the body break down food contain an acid called hydrochloric acid. While the stomach is naturally protected from this potent acid, the esophagus does not share the same protective qualities as the stomach.
Heartburn is caused when this stomach acid refluxes—or flows backward—into the esophagus. This generally occurs when the lower esophageal sphincter (or the LES)—the natural valve that keeps stomach acid in the stomach and out of the esophagus —does not do its job properly.
When functioning normally, the LES opens like a door that allows food into the stomach but not back up the same way. However, at times the LES relaxes and allows stomach acid flow upward into the esophagus. This relaxation exposes the esophagus to the acid from the stomach and often results in the sensation known as heartburn.
Various lifestyle and dietary factors as well as certain medications can contribute to heartburn by increasing the relaxation of the LES, increasing the amount of acid produced in the stomach, increasing stomach pressure, or making the esophagus more sensitive to acid. These triggers vary from person to person. The most common contributing factors include the following:
Eating/Dietary Habits
- Eating foods such as citrus fruits, chocolate, peppermint, spearmint,tomatoes or tomato-based products, raw onions, garlic, black pepper,vinegar and fatty or spicy foods. Foods that are fatty or greasyslow down digestion, which means that acid and food are in thestomach longer. This gives the acid a greater opportunity to movebackwards into the esophagus. In addition, some foods, such aspeppermint, spearmint and chocolate cause the LES to loosen orrelax thus allowing acid to enter the esophagus.
- Drinking beverages such as coffee, citrus juices, and caffeinated,carbonated or alcoholic beverages. Beer and beverages withcaffeine such as coffee, tea and cola raise the level of acidityin the stomach, making stomach juices even more irritating. Citrusjuices, spicy foods and tomato products directly irritate theesophagus.
- Eating large portions — your stomach responds to largeportions by producing large amounts of acid at one time. Morestomach acid means a greater chance of acid reflux.
- Eating before bedtime — acid levels are high after mealtime .
Certain positions
Episodes of heartburn can also be precipitated by body position, certain movements, and/or exertion, such as lying down, bending over or strenuous exercise. One of the defense mechanisms limiting the reflux of gastric acid is gravity. In the upright position, gravity tends to prevent gastric contents from moving upward into the esophagus. When the body position is altered, the protective effect of gravity may be reduced. Lying down tends to decrease the effects of gravity. Bending over can also decrease the effects of gravity and increase abdominal pressure, increasing the potential for acid reflux.
Medical reasons Talk to your health care professional if you have any of the following conditions or if your medications may be contributing to your heartburn. Ask about alternatives, but never stop taking any prescription medication without checking with your doctor.
- Gastroesophageal reflux disease (GERD)
- Pregnancy — Hormones (progesterone) produced duringthe first trimester of pregnancy can loosen the LES. In addition,as the body makes room for the growing baby, organs such as thestomach become pushed up into the abdominal cavity and increasethe pressure on the LES. This increased pressure often resultsin acid reflux. If you're pregnant, consult your physician beforetaking any medication.
- Hiatal Hernia — When a hiatal hernia is present, part of the stomach is located in the chest rather than in the abdomen where it belongs. A hiatal hernia does not cause symptoms itself, but is often associated with a weak LES muscle and with acid reflux.
- Taking certain medications — some prescription and over-the-counter (OTC)medications can contribute to heartburn. These commonly includehigh blood pressure and heart medications. Asthma medicationscan both lower LES pressure and stimulate acid production contributingto heartburn. Antibiotics can be irritating to the esophagus.
Lifestyle habits
- Being overweight — excess weight increases abdominalpressure and increases pressure on the LES. Studies have shownthat even moderate weight loss can reduce symptoms.
- Smoking cigarettes, cigars or pipes — Smoking inhibitssaliva, one of the body's natural protective barriers againstdamage to the esophagus. Smoking also may stimulate acid productionand weaken the important valve that prevents stomach acid fromentering the esophagus.
- Certain types of exercise/ body positions — certaintypes of exercise that increase abdominal pressure can aggravateheartburn symptoms.
- Exercises that require you to be upright and "bounce" against gravity, such as jogging, aerobics or rope jumping. Bouncing jostles the contents of your stomach and can cause acid to back up into the esophagus.
- Lifting heavy objects or performing weight-bearing exercises. Tensed (clenched) stomach muscles are likely the cause.
- Sit ups or curls increase the pressure in the abdomen and may increase reflux of acid into the esophagus.
- Wearing restrictive clothing — Tight clothing can promote reflux of acid contents. Reduce abdominal pressureby not wearing tight belts or binding clothing.
I am pregnant and I have had heartburn since the beginning of my pregnancy. Is there any medication that is safe for me to use?
Discomfort from heartburn is common during pregnancy. In fact, between 30 and 50 percent of pregnant women experience heartburn. Consult your doctor to discuss the appropriate treatment for heartburn during pregnancy.
What does heartburn have to do with heat?
Many heartburn sufferers experience the burning sensation known as heartburn and associate the pain with intense heat. However, the pain is not caused by temperature but by the irritation resulting from the presence of acid in the esophagus.
How can I tell the difference between heartburn and a heart attack?
The pain caused by heartburn and heart attack can be so severe that both patients and doctors have a difficult time distinguishing one from the other. In fact, sophisticated equipment is generally necessary to determine whether patients are suffering from a heart attack or not. To complicate matters even more, the two problems share many of the same symptoms and are more likely to occur in people over forty.
If you have any chest pain that lasts for more than a few minutes—or any warning signs of a heart attack—seek immediate medical attention.
However, here are some possible differences between the two ailments.
Angina or Heart Attack
- A feeling of fullness, tightness or dull pressure or pain generallyin the center of the chest
- Pain may spread to the shoulders, neck, or arms
- Often responds quickly to nitroglycerin, a heart medication (unresponsiveness to nitroglycerin in the presence of angina or heart attack symptoms should be treated as a medical emergency)
- May be accompanied by a cold sweat
- Might experience lightheadedness, weakness or dizziness
- Shortness of breath
- Nausea and possible vomiting
See your doctor if you experience any warning signs of a heart attack.
Heartburn
- A sharp, burning sensation just below the breastbone or ribs
- Pain generally does not radiate to the shoulders, neck, or arms, but it can
- Pain usually comes after meals
- Symptoms usually respond quickly to antacids
- Rarely accompanied by a cold sweat, lightheadedness or dizziness
Is heartburn serious?
If heartburn is severe or persistent and does not respond to medication, it could be a symptom of a more serious condition called gastroesophageal reflux disease or GERD. If left untreated, GERD can cause or contribute to a wide range of problems. Fortunately, many of these complications can be avoided with proper monitoring from a health care professional.
Can heartburn lead to cancer?
Chronic heartburn sufferers who have GERD appear to have a higher risk of developing Barrett's esophagus, a condition marked by severe damage to the lining of the esophagus and possibly linked to an increased risk of cancer of the esophagus. Fortunately, both heartburn and GERD can be treated, and many of these complications can be avoided with proper monitoring by a physician.
Is Barrett's esophagus linked to esophageal cancer?
Studies indicate that Barrett's esophagus may be linked to an increased risk of esophageal cancer. However, for people who have Barrett's esophagus, the risk of getting cancer of the esophagus is still very small: less than 1 percent (0.4 percent to 0.5 percent) per year.Barrett's is marked by severe damage to the lining of the esophagus. This damage is caused by acid reflux from gastroesophageal reflux disease (GERD) or inflammation of the esophagus (esophagitis). (See "When should I consult a professional?" below for symptoms of GERD.)
How is Barrett's esophagus treated?
Currently there is no cure for Barrett's esophagus, but the goal of treatment is to prevent further damage to the esophagus. To stop acid reflux from entering into the esophagus, medications, such as H2 blockers or proton pump inhibitors (PPIs) can be prescribed. H2 blockers reduce acid production. Proton pump inhibitors are the most powerful inhibitors of acid production because they actually shut down the pumps that produce the acid. If these medications don't work, surgery to prevent acid reflux from occurring may become necessary.
Can heartburn medications cause cancer?
Conditions such as Barrett's esophagus and esophageal cancer are relatively rare and develop over many years. To date, no existing study conclusively links extended use of over-the-counter or prescription acid-reducing medication to increased incidence of such serious complications.
For long-term treatment of GERD and acid-related conditions, it's important to maintain a regular and ongoing discussion with one's health care professional. Patients using over-the-counter medications should follow label instructions that direct them to consult a physician if heartburn symptoms persist after 14 days of use.
What is hiatal hernia and how is it related to heartburn?
Hiatal hernia occurs when a part of the stomach is located in the chest rather than in the abdomen where it belongs. A hiatal hernia does not cause symptoms itself, but is often associated with a weak LES muscle and with acid reflux.
Over the years, people have equated hiatal hernia with heartburn and reflux, but the hernia itself is not at fault. Studies show that hiatal hernia results in retention of acid and other stomach contents above this opening. These substances can reflux easily into the esophagus. Some doctors also believe a hiatal hernia may weaken the LES, thereby allowing reflux.
Coughing, vomiting, straining or sudden physical exertion can cause increased pressure in the abdomen, resulting in hiatal hernia. Obesity and pregnancy also contribute to this condition. Many otherwise healthy people age 50 and over have a small hiatal hernia. Although considered a condition of middle age, hiatal hernias affect people of all ages. Hiatal hernias by themselves do not cause symptoms and so usually do not require treatment. However, surgical treatment may be necessary if the hernia is in danger of becoming strangulated (twisted in a way that cuts off blood supply, i.e., paraesophageal hernia) or is complicated by severe GERD or esophagitis (inflammation of the esophagus) that cannot be controlled with medication.
What is the best type of test my doctor can perform to determine if I have acid reflux?
Often a doctor can diagnose acid reflux solely based on symptoms. However in some cases, tests may be required to diagnose GERD or to determine its severity. There are several different tests to diagnose the severity of reflux. Each test provides your doctor with different information.
- Upper GI Endoscopy —The patient is given a sedative and a lighted, flexible tube called an endoscope with a video camera on the end, is passed into the esophagus and stomach to inspect the lining visually. If necessary, a biopsy can be taken for further testing. Endoscopy evaluates the esophagus for inflammation and Barrett's esophagus.
- Upper GI Series —The patient drinks liquid contrast to coat the esophagus and stomach, and x-rays are taken. An upper GI series evaluates the size and shape of the esophagus and can detect the presence of an hiatal hernia.
- Esophageal Manometry —A specialized tube is passed into the esophagus to measure esophageal muscle function and the function of the lower esophageal sphincter (LES) muscle. Esophageal manometry evaluates how well the esophagus and the LES work.
- 24-hour pH monitoring —A very thin tube is passed to the bottom of the esophagus to measure the amount of acid reflux. The test is performed for 24 hours while the patient goes about normal activities, including eating. The episodes of acid reflux can be compared with symptoms reported by the patient. PH monitoring evaluates how often acid reflux is occurring during the day and/or night. It also can determine if symptoms are caused by acid reflux and if treatment is adequate to control acid.
You should consult your doctor to determine which test is most appropriate for you, based on your symptoms.
To find a gastroenterologist in your area, log on to:
www.gastro.org/ypages/disclaim1 orwww.acg.gi.org/patientinfo/phylocator/index.html
To find an endoscopist in your area, log on to
www.asge.orgIs surgery an option for my heartburn?
Procedures exist to tighten the LES, the valve that connects the stomach and the esophagus, or to correct hiatal hernia. The FDA recently approved the first non-drug treatments for acid reflux. Doctors can now use two different medical procedures to send a tube down the throat to fix the actual cause of chronic heartburn, instead of suppressing painful stomach acids as medications do.
- One device, known as the Bard procedure, is like a tiny sewing machine that puts a few stitches in the faulty valve causing heartburn, creating little pleated gathers to strengthen it.
- Another procedure, known as the Stretta procedure, utilizes radio frequency energy, which causes the tissue to shrink over time, and creates a barrier to reflux.
- A third technique, the Enteryx procedure, strengthens and bulks-up the LES by injecting an inert polymer-type material into the valve.
