Heartburn

Definition

Heartburn is a painful burning feeling just below or behind the breastbone. It usually comes from the esophagus. The pain often rises in your chest and may spread to your neck or throat.

Alternative Names

Pyrosis; Non-cardiac chest pain

Considerations

Common Causes

Almost everyone has heartburn sometimes. If you have heartburn very often, you may have gastroesophageal reflux disease (GERD).

Normally when food or liquid enters your stomach, a band of muscle at the end of your esophagus closes off the esophagus. This band is called the lower esophageal sphincter (LES). If this band does not close tightly enough, contents from the stomach can back up (reflux) into the esophagus. This partly digested material can irritate the esophagus, causing heartburn and other symptoms.

Heartburn is more likely if you have a hiatal hernia. A hiatal hernia is when the top part of the stomach sticks up into the chest cavity. This weakens the LES and makes it easier for acid to back up from the stomach into the esophagus.

Pregnancy and many medications can bring on heartburn or make it worse.

Drugs that can cause heartburn include:

• Anticholinergics (e.g., for sea sickness)
• Beta-blockers for high blood pressure or heart disease
• Calcium channel blockers for high blood pressure
• Dopamine-like drugs for Parkinson's disease
• Progestin for abnormal menstrual bleeding or birth control
• Sedatives for anxiety, or if you can't sleep (insomnia)
• Theophylline (for asthma or other lung diseases)
• Tricyclic antidepressants

If you think one of your medicines may be causing heartburn, talk to your doctor. Never change or stop taking medicine without talking to your doctor.

Home Care

Treat heartburn, especially if you often feel symptoms. Over time, reflux can damage the lining of your esophagus and cause serious problems. The good news is that changing your habits can help prevent heartburn and other symptoms of GERD.

The following tips will help you avoid heartburn and other GERD symptoms. If these measures do not work, talk to your doctor.

First, avoid foods and drinks that can trigger reflux, such as:

• Alcohol
• Caffeine
• Carbonated drinks
• Chocolate
• Citrus fruits and juices
• Peppermint and spearmint
• Spicy or fatty foods, full-fat dairy products
• Tomatoes and tomato sauces

Next, try changing your eating habits:

• Avoid bending over or exercising just after eating.
• Avoid eating or lying down within 3 - 4 hours of bedtime. Lying down with a full stomach cause the stomach contents to press harder against the lower esophageal sphincter (LES).
• Eat smaller meals.

Make other lifestyle changes as needed:

• Avoid tight-fitting belts or clothes that fit snugly around the waist. They squeeze the stomach, and may force food to reflux.
• Lose weight if you are overweight. Obesity increases pressure in the stomach. This pressure can push the stomach contents up into the esophagus. In some cases, GERD symptoms disappear after an overweight person loses 10 - 15 pounds.
• Sleep with your head raised about 6 inches. Sleeping with the head higher than the stomach helps prevent digested food from backing up into the esophagus. Place books, bricks, or blocks under the legs at the head of your bed. Or use a wedge-shaped pillow under your mattress. Sleeping on extra pillows does NOT work well for relieving heartburn because you can slip off the pillows during the night.
• Stop smoking. Chemicals in cigarette smoke weaken the LES.
• Reduce stress. Try yoga, tai chi, or meditation.

If you still do not have full relief, try over-the-counter medications:

• Antacids, like Maalox or Mylanta, help neutralize stomach acid.
• H2 blockers, like Pepcid AC, Tagamet, and Zantac, reduce stomach acid production.
• Proton pump inhibitors, like Prilosec OTC, stop nearly all stomach acid production.

Call your health care provider if

Get urgent medical care if:

• You vomit material that is bloody or looks like coffee grounds.
• Your stools are black (like tar) or maroon.
• You have a burning feeling and a squeezing, crushing, or pressure in your chest. Sometimes people who think they have heartburn are having a heart attack.

Call your doctor if:

• You have heartburn often or it doesn't go away with a few weeks of self-care.
• You lose weight that you didn't want to lose.
• You have trouble swallowing (food feels stuck as it goes down).
• You have a cough or wheezing that does not go away.
• Your symptoms get worse with antacids or H2 blockers.
• You think one of your medicines may be causing heartburn. Do NOT change or stop taking your medicine on your own without talking to your doctor first.

What to expect at your health care provider's office

Heartburn is usually easy to diagnose from the symptoms you describe to your doctor. Sometimes, heartburn can be confused with another stomach problem called dyspepsia. If the diagnosis is unclear, you may be sent to a doctor called a gastroenterologist for more testing.

First, your doctor will do a physical examination and ask questions about your heartburn, such as:

• When did it begin?
• How long does each episode last?
• Is this the first time you have had heartburn?
• What do you usually eat at each meal? Before you feel heartburn, have you eaten a spicy or fatty meal?
• Do you drink a lot of coffee, other drinks with caffeine, or alcohol? Do you smoke?
• Do you wear clothing that is tight in the chest or belly?
• Do you also have pain in the chest, jaw, arm, or somewhere else?
• What medications are you taking?
• Are you vomiting blood or black material?
• Do you have blood in your stools?
• Do you have black, tarry stools?
• Are there other symptoms with your heartburn?

The following tests may be done:

• Esophageal motility to measure the pressure of your LES
• Esophagogastroduodenoscopy (upper endoscopy) to look at the inside lining of your esophagus and stomach
• Upper GI series

If you have not been able to improve your symptoms with home care, your doctor may prescribe medicine to reduce acid. These are stronger than over-the-counter medicines. Any sign of bleeding will need more testing and treatment.

Prevention

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References

DeVault KR. Symptoms of esophageal disease. In: Feldman M, Friedman LS, Brandt LJ, eds. Sleisenger and Fordtran's Gastrointestinal and Liver Disease. 9th ed. Philadelphia, Pa: Saunders Elsevier; 2010:chap 12.

Kahrilas PJ, Shaheen NJ, Vaezi MF, Hiltz SW, Black E, Modlin IM. American Gastrointestinal Association Medical Position Statement on the management of gastroesophageal reflux disease. Gastroenterology. 2008;135:1383-1391.

Wilson JF. In the clinic: gastroesophageal reflux disease. Ann Intern Med. 2008;149:ITC2-1-ITC2-15.