Heartburn

September 13, 2011

Heartburn is a symptom of gastroesophageal reflux disease (GERD), which affects more than 60 million American adults at least once a month. About 25 million adults suffer daily from heartburn. Twenty-five percent of pregnant women experience daily heartburn. It is typically described as a burning sensation in the chest and throat. Gastroesophageal reflux disease is a digestive disorder that affects the lower esophageal sphincter (LES) that is a muscle around the bottom of the esophagus (food pipe). It protects the esophagus from the regurgitation or backup of acid and stomach contents into the esophagus during digestion. If acid backs up into the esophagus, the esophageal lining offers a weak defense, and heartburn and other symptoms can result.

There are multiple risk factors for the development of heartburn. These include eating patterns, pregnancy, alcohol, smoking, certain foods and medications, and anatomical factors. Eating pattern risk factors include lying down soon after eating or snacking at bedtime. Certain foods like chocolate, coffee and tea, carbonated beverages that can cause belching, peppermint, and fatty foods can contribute to the development of heartburn. Pregnant women can experience heartburn especially in the third trimester from pressure of the uterus on the stomach, impairing stomach emptying. Alcohol and cigarette smoke have both an irritant effect on the esophageal lining and an effect on the lower esophageal sphincter, impairing its function. Medications that can decrease the lower esophageal sphincter pressure and cause gastroesophageal reflux disease include calcium channel blockers, anticholinergics, beta adrenergics, sedatives, nitroglycerine, nicotine, theophylline, and dopaminergics. Anatomical factors that contribute to heartburn include the presence of a hiatal hernia, motility disorders of the esophagus, and poor emptying of the stomach. Other symptoms that can be attributed to reflux include asthma symptoms, chronic cough, hoarseness, regurgitation of sour material into the throat, persistent hiccups, and, less commonly, nausea and vomiting in more severe cases.

The complications of gastroesophageal reflux disease or heartburn include erosive esophagitis, or visible damage to the lining of the esophagus. Ulcerative esophagitis, or the development of ulcerations in an area or inflammation caused by acid reflux, can also occur. In a small percentage of patients with longstanding heartburn, a condition called Barrett’s esophagus may eventually develop. Extended exposure of the esophagus to gastric contents causes a change in the lining of the esophagus, which is considered precancerous. It is not clear which individuals with gastroesophageal reflux disease will develop Barrett’s esophagus, but once it is discovered, lifelong surveillance for the development of cancer is recommended by some experts. Individuals at highest risk of developing cancer appeared to be Caucasian males over the age of 50 years. Strictures, or abnormally narrowed areas of the esophagus, can develop over time in patients with longstanding heartburn due to repeated injury and scarring of the esophagus. These can be treated endoscopically by inserting dilators into the esophagus to mechanically tear the fibrotic tissue and open the lumen of the esophagus.

Diagnosis of gastroesophageal reflux disease or heartburn can be made if an individual’s symptoms improve with medical therapy or lifestyle modification or both. If the diagnosis is uncertain, an upper endoscopy or EGD (esophagogastroduodenoscopy) can be performed to look at the lining of the esophagus and, if necessary, take biopsies. Esophagogastroduodenoscopy requires placing a long flexible tube, with a light and a camera at its tip, into the patient’s stomach, after the patient is given sedative medications for comfort. This examination can also detect Barrett’s esophagus. If the esophagogastroduodenoscopy is normal, other tests such as a pH probe to monitor the acid in the esophagus, and manometry, to assess the pressures generated by the muscles of the esophagus, can also be performed. Individuals who develop alarm symptoms, such as difficulty swallowing, pain on swallowing, weight loss, anemia, or bleeding from the gastrointestinal tract, require immediate endoscopic evaluation, as these symptoms signal that a complication of heartburn has developed.

The management of heartburn starts with lifestyle modifications, including a change in diet to avoid foods that may contribute to heartburn, smoking and alcohol cessation, and staying upright after eating for at least 1-2 hours. Individuals should also avoid late-night snacks and consumption of large quantities of food at mealtimes. Medications such as over-the-counter antacids including ranitidine, famotidine, and cimetidine can be effective for patients with mild, intermittent heartburn. Individuals with more persistent or severe heartburn can benefit from more potent acid-suppressing agents, called proton-pump inhibitors, which can be prescribed by a physician. These medications, such as omeprazole, lansoprazole, rabeprazole, and pantoprazole, appear to be safe, have little in the way of side effects, and if taken daily can successfully eradicate heartburn symptoms.

Surgical treatments are also available for the treatment of heartburn that is well controlled with medical therapy in patients who do not wish to remain on lifelong medication for heartburn, or for patients with persistent regurgtation. The standard surgical procedure is a fundoplication that can be done as an open surgery or more commonly, laparoscopically. In this procedure, the upper part of the stomach is wrapped around the esophagus to form a collar. Complications include excessive tightness of the wrap, which can cause bloating, inability to belch, and difficulty swallowing, or breakdown or slippage of the wrap, all of which are indications for reoperation. Long-term failure rates are reported at up to 63% after 10 years.

SEE ALSO: Alcohol use, Asthma, Chest pain, Pregnancy, Smoking

Suggested Reading

  • American Medical Association. (2002, July). New considerations in the evaluation and management of gastroesophageal reflux disease (gastroesophageal reflux disease). Chicago: Author.
  • Kahrilas, P. J., & Pandolfino, J. E. Gastroesophageal reflux disease and its complications. In M. Feldman, M. H. Schlesinger, J. S. Fordtran, B. F. Scharschmidt, & L. S. Friedman (Eds.), Gastrointestinal and liver disease (7th ed., pp. 599-622). Philadelphia: Elsevier.
  • Scott, M. (1999). Gastroesophageal reflux disease: Diagnosis and management. American Family Physician, 59, 1161-1169.

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