Heartburn

Definition

Heartburn is a burning feeling in the neck, throat, or upper chest caused by irritation of stomach acid that occurs after eating (acid indigestion). Heartburn may get worse when lying down.

Description

The esophagus (food pipe) connects the throat and stomach. A thick band of muscles called the lower esophageal sphincter (LES) is located between the lower part of the esophagus and the upper part of the stomach. The LES opens when food empties into the stomach from the esophagus. Mucus lining the stomach is much thicker than the lining of the esophagus so when the LES weakens and fails to close properly or opens improperly, partially digested stomach contents that are usually acidic, leak into the esophagus (reflux). The burning feeling that results is called heartburn.

Demographics

About 30% of adults have occasional heartburn. Ten percent of adults experience heartburn daily. Approximately 25–50% of pregnant women have heartburn.

Causes and symptoms

Heartburn is caused by reflux of acidic stomach contents into the esophagus. Heartburn is associated with eating habits. Consumption of certain foods including citrus fruits, chocolate, tomatoes, pepper, and fatty or spicy foods is associated with heartburn because these foods relax the LES. Drinking coffee, tea, caffeinated drinks, and alcoholic beverages also causes heartburn.

Eating habits are thought to be the most significant factor contributing to heartburn. Overeating or eating too quickly can expand the stomach causing the LES to open improperly. Lying down after eating can cause the LES to open, which contributes to heartburn.

Certain medical conditions such as pregnancy, obesity , hiatal hernia, diabetes , gastritis, and peptic ulcers may cause heartburn. Pregnancy and obesity impair the ability of the LES to remain closed because of increased pressure on the abdomen. Larger amounts of the hormone progesterone are produced during pregnancy. Progesterone relaxes muscles, including the LES. A hiatal hernia is a projection of the stomach into the lower chest because of a weakness in the diaphragm. A hiatal hernia worsens heartburn because it further weakens the LES and increases reflux. Diabetes contributes to delayed stomach emptying, which exacerbates reflux. Gastritis and peptic ulcers occur when there is damage to the stomach lining and these conditions contribute to heartburn.

Some medications, such as blood pressure medicine, heart medications, and asthma medications, can loosen the LES. Lifestyle habits such as smoking , drinking alcohol, and increased stress can contribute to heartburn. Nicotine weakens the LES and irritates the lining of the esophagus, which can cause heartburn. Alcohol also irritates the esophageal lining. While stress does not directly cause heartburn, it can trigger behavior that contributes to heartburn such at overeating, eating fatty foods, smoking, or drinking alcohol.

The primary symptom of heartburn is burning in the lower chest area in the region of the lower breastbone, which may worsen when bending over or lying down. Other symptoms include frequent belching and a feeling of stomach bloating or fullness that generally occurs after meals. Regurgitation of food or liquid into the throat or mouth may leave an acid or sour taste. Frequent heartburn can damage the esophagus causing more serious symptoms requiring immediate medical attention such as difficult or painful swallowing, sore throat, hoarseness, coughing, shortness of breath, or vomiting blood or having blood in the stool.

Diagnosis

An internist may diagnose and treat heartburn.

Patients with frequent, persistent heartburn or heartburn that is hard to treat, may be referred to a gastroenterologist, a physician specialized in diseases and disorders of the gastrointestinal tract. After obtaining a complete medical history and performing a physical examination, certain tests may be ordered. These tests may include:

• Endoscopy: A procedure in which, after sedation, a flexible tube with a light and tiny camera is passed into the patient's stomach through the mouth so the physician can examine the esophagus and stomach for damage. During endoscopy, tissue samples (biopsy) may be taken to evaluate the severity of the damage.
• Upper gastrointestinal (UGI) series (or barium swallow): A barium x-ray study of the esophagus, stomach, and upper intestine to check for esophageal narrowing or inflammation, ulcers, hiatal hernia, or reflux.
• Esophageal pH monitoring: A 24-hour procedure in which a very narrow tube, the pH monitor, is passed through the patient's nose into the stomach to determine how much acid reaches the esophagus. During the procedure, the patient records the symptoms experienced and the physician correlates acid levels with symptoms.
• Esophageal manometry: A procedure in which a device similar to the pH monitor is passed into the esophagus to measure muscle contractions and evaluate functioning of the LES.

Treatment

For occasional, mild symptoms of heartburn, self-care measures may provide relief. Simple measures to minimize heartburn include:

• not overeating
• eating slowly
• avoiding foods that produce heartburn or worsen the symptoms of heartburn
• not lying down right after eating or within two to three hours of bedtime
• elevating the head of the bed 4–6 in (10–15 cm) to raise the head higher than the stomach allowing gravity to prevent reflux
• losing weight, if overweight
• stop smoking
• avoiding alcohol
• reducing stress

Check with a physician about any medications that may be causing heartburn.

Other treatments include over-the-counter (OTC) medication, prescription medicine, and surgical intervention. Medications include antacids, histamine receptor blockers (H-2 receptor blockers ), proton pump inhibitors , and prokinetic agents. Antacids (Maalox, Mylanta, Tums, Rolaids) are liquid or tablet OTC medicines that neutralize stomach acid. Antacids provide only short-term relief, do not repair damage to the esophagus caused by stomach acid, and do not prevent heartburn. Long-term use of antacids can cause diarrhea or constipation .

H-2 receptor blockers (Tagamet, Pepcid, Axid, Zantac) reduce acid production. These medications act more slowly than antacids but provide longer symptom control. Some of the medications are available OTC, but stronger and longer acting formulas are available only by prescription.

Proton-pump inhibitors (Prilosec, Prevacid, Nexium, Protonix) are medicines that inhibit acid production and allow damage to the esophagus to heal. Prilosec is a proton-pump inhibitor available for short-term use in an OTC form.

Prokinetic agents stimulate the LES to close more tightly keeping acidic stomach contents out of the esophagus. The effects of healing from these medications have not been determined.

Surgical treatment may include fundiplication. Fundiplicaiton is a procedure done to increase pressure on the LES by stretching and wrapping the top part of the stomach around the LES. The procedure is not always effective and its effectiveness may decrease with time.

Nutrition/Dietetic concerns

Several simple dietary changes and modifications can help prevent symptoms of heartburn:

• Avoid foods known to cause or worsen symptoms of heartburn.
• Eat more slowly and eat smaller, more frequent meals.
• Limit consumption of fatty, spicy, high-calorie foods.
• Restrict intake of fluids at mealtime.
• Eat a diet high in fiber to avoid constipation.
• If overweight, consult a physician or dietician for a healthy plan to lose weight.
• Do not smoke or drink alcohol.

Therapy

Some body positions may irritate symptoms of heartburn. They cause theLES to relax and acid reflux to worsen. When lying down, some relief may be achieved by raising the head of the bed 4–6 in (10–15 cm). People with heartburn should avoid lying down for two to three hours after a meal. Prolonged stooping or bending, especially after eating, can aggravate symptoms and should be avoided. Wearing loose-fitting clothes around the abdomen may also reduce symptoms.

Prognosis

Most cases of heartburn can be treated effectively with lifestyle modifications and OTC or prescription medication. Relapse is common when treatment is interrupted or discontinued.

Prevention

Many cases of heartburn can be prevented by changing diet and eating habits. Avoiding certain body positions after eating is also important.

Caregiver concerns

Making changes to lifestyle habits may prevent heartburn. Caregivers should be familiar with the

QUESTIONS TO ASK YOUR DOCTOR

• Is my heartburn mild or severe?
• What is causing my heartburn?
• What lifestyle changes should I make?
• Do I need OTC or prescription medication?
• If I take medication, what side effects might I experience?
• What if the medicines do not help?
• Will I need surgery?
• How can I tell if the symptoms are not caused by a more serious condition like a heart attack?

symptoms of heartburn and treatments available to provide relief. If the patient does not respond to OTC medications or self-care treatments, shows signs of weight loss or complains that symptoms are worse, a physician should be contacted. Medications prescribed for other medical conditions may cause or worsen heartburn symptoms. Caregivers may consult with a pharmacist or physician to learn how heartburn due to medications can be alleviated.

Seek medical attention immediately if the patient begins vomiting and the vomitus is bloody or black like coffee grounds, or they have stool that is black. Heartburn accompanied by shortness of breath, chest tightness or squeezing, crushing, or pressure, may in fact be symptoms of a heart attack , which are sometimes confused with heartburn. The caregiver should respond as though it were a heart attack and seek help immediately.

Resources

BOOKS

Minocha, Anil, and Christine Adamec. How to Stop Heartburn: Simple Ways to Heal Heartburn and Acid Reflux. New York: John Wiley & Sons, 2001.

OTHER

“Heartburn.” AGA Patient Center. [Cited April 12, 2008]. American Gastroenterological Association. http://www.gastro.org/wmspage.cfm?parm1=848.

“Heartburn.” Digestive System. May 25, 2007 [cited April 12, 2008]. MayoClinic.com. http://mayoclinic.com/health/heartburn-gerd/DS00095.

“Heartburn.” Medical Encyclopedia. May 3, 2007 [cited April 12, 2008]. MedlinePlus. http://www.nlm.nih.gov/medlineplus/ency/article/003114.htm.

“Heartburn: Overview.” Conditions A to Z. June 2007 [cited April 12, 2008]. Health A to Z. http://www.healthatoz.com/healthatoz/Atoz/common/standard/transform.jsp?requestURI=/healthatoz/Atoz/dc/caz/digs/hbrn/hbrn_gen_ovw.jsp.

“Heartburn Overview.” Self-care Tips. [Cited April 12, 2008]. National Heartburn Alliance. http://www.heartburnalliance.org/lifestyle_adjustments.php.

Heartburn/GERD Guide. WebMD. [Cited April 12, 2008]. http://www.webmd.com/heartburn-gerd/guide/default.htm.

“Managing Heartburn with Diet” Nutrition Care Guide. [Cited April 12, 2008]. University of Pennsylvania Health Systems. http://pennhealth.com/health_info/nutrition/heartburn.html.

Patel, Yesha. “Heartburn.” eMedicineHealth. August 10, 2005 [cited April 12, 2008]. http://www.emedicinehealth.com/heartburn/article_em.htm.

“Preventing and Managing Heartburn.” Cleveland Clinic for Consumer Health Information. November 12, 2007 [cited April 12, 2008]. Cleveland Clinic. http://www.clevelandclinic.org/health/health-info/docs/2500/2570.asp?index=9616.

June G. Borazjani RN, MSN, CPHQ