About 42% of the U.S. population has had heartburn at some point. (1)
Burning chest pain, particularly at night when lying flat.
Nocturnal cough, wheezing, or other respiratory symptoms.
Nicotine, caffeine, peppermint, alcohol, pregnancy and obesity
What Exactly is “Heartburn?”
Heartburn or gastroesophageal reflux disease (GERD) is a conditions in which the acidic contents normally contained within your stomach are allowed to flow in a retrograde or backward direction into the esophagus, the hollow tube which connects the back of your mouth or pharynx to your stomach during swallowing. The presence of such acidic contents in the thoracic cavity, or chest area, in addition to the irritation caused by such acidic contents to the esophagus, results in the symptoms frequently experienced by patient who suffer from heartburn. The pathophysiology of heartburn involves an abnormally relaxed lower esophageal sphincter, which normally closes once food has passed from the esophagus to the stomach. The decreased tone of this sphincter makes it “loose,” no longer preventing the retrograde flow of gastric contents responsible for heartburn.
What Causes and Precipitates Heartburn?
The retrograde flow of food into the esophagus may be exacerbated by several factors and conditions. An increase in intra-abdominal pressure, caused by indulging in heavy meals, pregnancy, or obesity may play a role in overcoming the pressure exerted by a weakened lower esophageal sphincter. The effect of gravity keeping food in the stomach may be minimized when going from a standing to a more supine position. This is particularly evident at night when lying flat, and many patients with heartburn experience more significant discomfort during this time. Other substances which relax the lower esophageal sphincter and may predispose to heartburn include:
- Spicy foods
- Fatty or fried foods
- Anatomic abnormalities of the lower esophageal sphincter (LES) such as a sliding hiatal hernia, where the esophagus and stomach are displaced upwards from their usual position into the chest cavity, may also predispose to heartburn.
What are the Symptoms of Heartburn?
The most common presentation of heartburn is a burning substernal (below the sternum) chest pain which typically occurs after eating heavy meals and at night when lying flat. The chest pain experienced by patients with heartburn may be mistaken or confused with that of more grave conditions, such as coronary artery disease (caused by narrowing of the vessels supplying oxygen to your heart.) To learn more about characterizing your pain, visit the Understanding Pain article. Patients may also experience a sour or acidic taste in the back of their throats due to the retrograde flow of acidic gastric contents. In addition, respiratory symptoms such as coughing or wheezing, particularly at night, are not uncommon.
How is Heartburn Diagnosed?
Heartburn is typically diagnosed clinically. This means that once your present at your doctor’s office with burning chest pain exacerbated by heavy meals or spicy meals and occurring particularly at night when lying flat, or any other characteristic presentation for heartburn, the diagnosis can be made with no further workup or investigations. A positive response to “acidity-lowering” medications such as antacids and others will also aid in affirming the correct diagnosis has been made. Although rarely required, a 24 pH monitoring may be employed in the case your presentations is not so typical and your physician would liek to confirm that heartburn is the cause of your symptoms.
Although gastroesophageal reflux is generally a benign condition, the presence of the acidic gastric contents in the esophagus in chronic or long standing reflux can lead to a condition known as Barrett’s Esophagus. Barrett’s esophagus is an example of “metaplasia,” a condition in which the cells normally present within tissues in the body undergo a transformation from their original cell type to a more “rigid” or specialized cell type to cope with stress exerted upon them. In gastroesophageal reflux, the normal squamous cells of the esophagus, which are similar to those found in the skin and oral mucosa, undergo a transformation towards columnar cells, which are normally present in the stomach. This condition may be diagnosed when a patient undergoes an upper gastrointestinal endoscopy, with a biopsy taken to demonstrate the presence of the columnar gastric-like tissue. The significance of Barrett’s esophagus is that it may predispose to esophageal cancer, and the degree of dysplasia, or irregularity of the nuclei within the lower esophageal cells, is used to assess the risk of subsequent transformation to esophageal cancer. Your physician may arrange for regular endoscopies every few years if you have Barrett’s esophagus to assess the degree of dysplasia, indicating whether and when further intervention may become necessary.
Management & Treatment of Heartburn
Before thinking of pharmacological treatment for your heartbrun, it is important to know that several lifestyle modifications may markedly improve your condition, and adhering to such changes may resolve your symptoms without the burden of medical or surgical intervention. So what can you do to manage your heartburn?
Avoid the Risk Factors
Since we have already discussed that alcohol, nicotine, caffeine, and spicy foods among others may decrease the tone of your lower esophageal sphincter and precipitate or exacerbate heartburn, it is important that you avoid such risk factors which you may be exposed to. In addition, heavy meals particularly just before bedtime may increase intra-abdominal pressure and exacerbate your symptoms. Try to allow at least 3 hours between the last meal of the day and bedtime.
Change how you Sleep
Since gravity helps us keep our acidic gastric contents in the stomach where they’re supposed to be, elevating your head approximately 6 inches with the use of pillows may help alleviate the nocturnal symptoms of heartburn.
If you suffer from obesity, you may be predisposed to heartburn. Although this is not as simple a risk factor to modify as is nicotine or caffeine intake, regular exercise and healthy eating will not only help you avoid this additional risk for heartburn, but will also improve overall health and well being, and decrease the risk of various health conditions such as coronary artery disease, osteoarthritis, hypertension, and Diabetes Mellitus.
If lifestyle modifications just don’t seem to be alleviating your symptoms, you may consider pharmacological management, or your physician may prescribe a trial of medication for you to use. Most medications used for heartburn act on reducing the acidity of the stomach thereby reducing the irritation of the lower esophagus which occurs with reflux. These include simple antacids, proton pump inhibitors such as omeprazole, lansoprazole, and the other -azoles, and H2 blockers such as cimetidine, famotidine, and ranitidine. Consult your physician to find out which medication is best for you.
Although seldom required, some patients with chronic heartburn symptoms not responding to treatment, or those with metaplasia of the lower esophagus due to uncontrolled heartburn, may either elect for or be recommended surgical intervention. One common procedure is called a Nissen Fundoplication, in which the lower esophageal sphincter is made tighter by wrapping the upper part of the stomach around the lower esophagus, strengthening the function and increasing the pressure of the lower esophageal sphincter, and reducing or eliminating the reflux of acidc gastric contents into the esophagus. This is usually performed laparoscopically, allowing a minimally invasive approach with less potential complications and shorter hospital stays than with open surgery. Again, consult your physician to discover if and which surgical intervention may be best suited for your condition.
Heartburn is an extremely common condition, and understanding the symptoms and causes of heartburn allow prompt identification and management of your symptoms. By understanding the risk factors and pathology involved, one may attempt a non-interventional approach to treating heartburn, such as avoiding risk factors, changing when, what, and how much you eat, and altering the way you sleep. Although generally benign, long-standing uncontrolled heartburn may cause pathological changes which in turn may predispose to more ominous conditions. If lifestyle changes are not working for you, consult your physician and seek relief for your symptoms today.
 Kushner PR (April 2010). “Role of the primary care provider in the diagnosis and management of heartburn”. Curr Med Res Opin 26 (4): 759–65.