The Everything Guide to Heartburn

by Charles Platkin, PhD

According to the British medical journal The Lancet, heartburn is pretty common. In fact, 25 percent of Americans report experiencing heartburn at least once a month, 12 percent at least once per week and 5 percent daily.

So what is heart burn? And what about gastroesophageal reflux disease (GERD)? Well, here’s a guide to provide a bit more understanding of that burning sensation in your chest.

Why is it called heartburn?
“Heartburn is often sensed as a burning feeling behind the middle of the lower to middle of the chest, giving the sense that it may be coming from the heart,” says Philip Jaffe, M.D., an associate professor of medicine at Yale University School of Medicine.

What is happening, biologically speaking, when someone has heartburn?
According to David A. Peura, M.D., a professor of medicine at the University of Virginia Health System, “Acid that’s normally produced by the stomach is washing back up into the esophagus [the swallowing tube that carries food from the mouth to the stomach] and irritating [burning] its lining. This is generally because the muscle between the stomach and esophagus is weak or not working properly.”

What does heartburn feel like?
Anyone who’s experienced heartburn knows the feeling. “The typical sensation is a burning in the lower chest that moves toward the neck and is often associated with a bitter taste in the back of the mouth. It typically occurs after eating a large meal, bending over at the waist, or lying down soon after eating, and usually improves shortly after standing upright, eating or drinking something, or taking an antacid,” says Jaffe.

What causes heartburn?
According to Jaffe, there are a variety of causes, but anything that either weakens or overwhelms the lower esophageal sphincter (the ring of muscle or “valve” at the lower end of the esophagus), decreases stomach emptying (a condition called “gastroparesis” or mechanical gastric outlet obstruction) and/or reduces the ability of the esophagus to push food down to the stomach can cause heartburn. Common causes are obesity, excessive alcohol use, fatty food intake, eating late at night, smoking, medications, hernias, pregnancy, diabetes mellitus and scleroderma.

What is GERD (gastroesophageal reflux disease)?
GERD is the condition that causes the burning sensation of heartburn. It occurs when the lower esophageal sphincter does not close properly and stomach contents leak back into the esophagus. The fluid may even be tasted in the back of the mouth, and this is called acid indigestion.

What causes GERD?
No one knows exactly why people get GERD. However, there is speculation that it is caused by a hiatal hernia, which means that the upper part of the stomach protrudes through the diaphragm. This may weaken the muscles in the area of the lower esophageal sphincter, which makes it easier for the acid to come up. However, some foods and behaviors can also cause burning and/or affect the lower esophageal sphincter. For instance, eating a large meal or fatty foods can delay emptying of the stomach, which increases the risk of reflux, says Peura.

Is it possible to have GERD without heartburn?
The primary symptoms are continual heartburn and “acid regurgitation”; however, you can have GERD without heartburn. Some people have pain in the chest, hoarseness in the morning, a cough, or trouble swallowing, adds Jaffe.

The following may also worsen heartburn and GERD:

  • Cigarette smoking
  • Coffee (both regular and decaffeinated) and other drinks that contain caffeine
  • Alcohol
  • Chocolate, mints or peppermints
  • Citrus fruits
  • Tomato products
  • Carbonated beverages
  • Fatty foods (fried foods) or spicy foods (pizza, chili, curry)
  • Garlic and onions
  • Excess weight
  • Aspirin or ibuprofen
  • Bending or lying down right after eating
  • Pregnancy
  • Prior stomach surgery, including gastric bypass operations
  • Eating large amounts of food before lying down

Medications sometimes contribute to GERD
According to Jaffe, the following medications my cause an increase of GERD:

  • asthma medications (e.g., Theo-Dur)
  • calcium channel blockers (e.g., Procardia and Cardizem)
  • heart medicines (e.g., Isordil and Ismo)
  • certain antidepressants in high doses (e.g., Elavil and trazodone).

In addition, certain medications may injure the esophagus and potentially contribute to esophagitis (inflammation) in people who have GERD or may mimic GERD in those without an acid reflux problem. These include arthritis drugs (e.g. aspirin, ibuprofen, Orudis, Motrin, Relafen, Indocin), antibiotics (e.g., tetracycline, doxycycline), osteoporosis drugs (e.g., Fosomax), potassium-replacement pills and high doses of vitamin C.

[Sources: National Institute of Diabetes and Digestive and Kidney Diseases, National Institutes of Health and Jaffe]

Do spicy foods cause heartburn and/or GERD?
Spicy foods can further irritate an esophagus that has already been damaged by acid reflux, and irritation of the lining of the esophagus is what causes the symptoms of heartburn. Most spices don’t contribute to acid reflux directly, but spices are often added to fatty foods, which can cause reflux by weakening the muscle at the end of the esophagus. Fatty foods also delay emptying of the stomach, and this, too, can promote acid reflux. The combination of fat and spices can be a double whammy for the esophagus in patients with GERD, says Stuart Spechler, M.D., chief, Division of Gastroenterology, Dallas VA Medical Center and professor of medicine at the University of Texas Southwestern Medical Center at Dallas.

Are there foods that help to relieve heartburn?
Unfortunately, no specific foods treat heartburn. “Milk can sometimes help but should not be considered a treatment. Swallowing most liquids will clear esophageal acid and give temporary relief. Chewing gum or sucking on hard candy may stimulate saliva, which contains bicarbonate — our natural antacid,” recommends Peura.

Also, foods that tend to empty more quickly from the stomach (i.e., low-fiber carbohydrates) may be better to eat than high-fiber or fatty meals, says Jaffe.

Can heartburn be dangerous?
“Severe heartburn that does not improve with over-the-counter medication and/or is associated with ‘warning signs or symptoms’ [weight loss, difficult or painful swallowing, vomiting blood, associated hoarseness or persistent cough or sore throat, abrupt onset at an older age, usually over 50] should be evaluated by a health care provider. Severe, persistent heartburn that is not responsive to treatment may signal underlying damage to the esophagus that could cause future problems,” says Peura.

Is it dangerous to take antacids every night?
Probably not, except in situations where the patient has renal or liver disease, says Michael D. Holzman, M.D., M.P.H., of the Vanderbilt University Medical Center.

Are there different types of heartburn? What are they?
There are various distinctions that have been made: erosive vs. nonerosive disease (i.e., those who have damage to the esophagus vs. those who have symptoms without esophagitis), upright vs. nocturnal (daytime vs. nighttime), and acid vs. non-acid (typically untreated vs. those who have bile and other non-acid material that continues to reflux after treatment with acid blockers) to name a few, says Jaffe.

Do people get heartburn at a specific time?
“Daytime heartburn, usually after meals, is probably more frequent, but most individuals also have some heartburn at night,” says Peura.

Do genetics have anything to do with who experiences GERD or heartburn?
There is some suggestion that GERD may be genetic, since it seems to run in families. “Studies in twins also show concordance. However, a similar lifestyle, diet, obesity, etc.— things associated with reflux — also run in families,” adds Dr. Peura.

Are you more likely to experience GERD or heartburn as you get older?
As you age, the lower esophageal sphincter may weaken. Plus, you tend to gain weight and become less physically active, all of which can increase the likelihood of reflux. However, according to the journal The Lancet, only one study suggested that the disease increases with age; most have found no association.

Does gender influence your likelihood of experiencing heartburn?
Women can develop heartburn during pregnancy. Men are more likely to develop complications of GERD, says Peura.

Does stress specifically induce heartburn and/or GERD?
“Very few studies have addressed this question specifically, and the results of those studies are not conclusive. Many patients have told me that their GERD symptoms are worse during periods of unusual emotional stress, and I believe them, but the mechanisms underlying this phenomenon are not clear. My opinion is that stress tends to make everything worse, and heartburn symptoms are no exception,” says Spechler.

Is there a cure for heartburn?
Some surgical treatments (fundoplication) may lead to long-term improvement without the need for medication, but they are not always effective, and symptoms usually recur over time, says Jaffe.

Weight reduction can also have tremendous benefits in reducing symptoms, explains Holzman. Medications just treat the symptoms and not the source.

How are GERD and heartburn treated?
Depending on severity, treatment may involve one or more of the following lifestyle changes, as well as medications or surgery.

A. Lifestyle Changes:

  • Quit smoking.
  • Minimize alcohol intake.
  • Minimize drinks with caffeine.
  • Lose weight if you are overweight or obese.
  • Eat small, low-fat meals.
  • Avoid bending at the waist and tight-fitting clothing that binds at the waistline.
  • Wait three hours before lying down after a meal.
  • Raise the head portion of your bed 6 to 8 inches. Use blocks of wood under the bedpost (not just pillows).
  • Limit chocolate, mints, tomato-based products, onions and fatty food intake.
  • Reduce late-night snacks.
  • Avoid foods that bring on your symptoms.

B. Medications: Check with your doctor to find out if any of your medications may be contributing to your symptoms. If so, find out if there are others you could take instead.

C. Antacids, such as Alka-Seltzer, Maalox, Mylanta, Pepto-Bismol, Rolaids and Riopan are usually the first drugs recommended to relieve heartburn and other mild GERD symptoms. Antacids use combinations of three basic salts — magnesium, calcium and aluminum — with hydroxide or bicarbonate ions to neutralize the acid. However, antacids can have side effects. For instance, the magnesium salt can lead to diarrhea, and aluminum salts and calcium carbonate antacids (e.g., Tums) can cause constipation.

D. Foaming agents, such as Gaviscon, work by covering your stomach contents with foam to prevent reflux. These drugs may help those who have no damage to the esophagus.

E. H2 blockers, such as cimetidine (Tagamet HB), famotidine (Pepcid AC), nizatidine (Axid AR) and ranitidine (Zantac 75), impede acid production. They are available in prescription strength and over the counter. These drugs provide short-term relief, but over-the-counter H2 blockers should not be used for more than a few weeks at a time. They are effective for about half of those who have GERD symptoms. Many people benefit from taking H2 blockers at bedtime in combination with a proton pump inhibitor.

F. Proton pump inhibitors include omeprazole (Prilosec), immediate release omeprazole (Zegerid), lansoprazole (Prevacid), pantoprazole (Protonix), rabeprazole (Aciphex) and esomeprazole (Nexium), all of which are available by prescription. Omeprazole (Prilosec OTC) is also available over the counter. Proton pump inhibitors are more effective than H2 blockers and can relieve symptoms in almost everyone who has GERD.

G. Prokinetics, another group of drugs, strengthen the esophageal sphincter and speed the emptying of the stomach. This group includes bethanechol (Urecholine) and metoclopramide (Reglan). Metoclopramide also improves muscle action in the digestive tract, but these drugs have frequent and sometimes serious side effects that limit their usefulness.

When symptoms are improved or relieved with lifestyle modification in combination with medications, these treatments often need to be continued for many months or years. This is because the problems that led to gastroesophageal reflux often continue despite effective management of symptoms while treatment is under way. So-called “maintenance therapy” may require a lower dose of medication and is an important part of long-term therapy, says Jaffe.

[Sources: National Institute of Diabetes and Digestive and Kidney Diseases, National Institutes of Health and Jaffe]

What are the long-term complications of GERD or heartburn?
GERD may sometimes cause serious complications. Inflammation of the esophagus from stomach acid can cause bleeding or ulcers. In addition, scars from tissue damage (“strictures”) can narrow the esophagus and make swallowing difficult. Also, studies have shown that “asthma, chronic cough and pulmonary fibrosis” (scarring of the lungs) may be irritated or even caused by GERD.

Some people develop Barrett’s esophagus, where the normal lining is replaced by one that can sometimes transform into cancer over time. Unlike bleeding from ulcers and difficulty swallowing food because of strictures, Barrett’s esophagus may develop in the absence of symptoms (aside from heartburn), and diagnosis requires specialized testing. “This testing is called ‘endoscopy,’ which involves the passage of a very narrow, flexible tube with a video camera on the end into the esophagus. This painless, quick, safe and extremely useful test is performed by gastrointestinal specialists (gastroenterologists). Small pinches of the esophageal lining (biopsies) can be obtained with this simple test to determine if Barrett’s esophagus has developed and whether precancerous changes are occurring,” says Jaffe.

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