Heartburn: Causes, Symptoms, Diagnosis, Treatment and Medications

Heartburn is the painful, often very painful consequence of the acid in the stomach coming into contact with the lower oesophagus. This acid burning, sometimes described as acid indigestion, can often be stopped or controlled by lifestyle changes and the avoidance of acidic and fatty foods and drinks.

Heartburn Causes Symptoms Diagnosis Treatment and Medications
Heartburn Causes Symptoms Diagnosis Treatment and Medications

Heartburn can be caused by overeating, eating too quickly, eating very spicy food, eating very fatty food, consuming caffeine in tea and coffee, smoking and drinking alcohol.

As you can see, heartburn is often the result of lifestyle choices and heartburn can be managed or the symptoms of heartburn lessened by making simple changes to diet or lifestyle.

Heartburn

Heartburn or pyrosis is a painful or burning sensation in the oesophagus, just below the breastbone caused by the regurgitation of gastric acid up into the oesophagus from the stomach.

The pain from heartburn often rises in the chest and may radiate to the neck, throat, or angle of the jaw. Heartburn is also identified as one of the causes of asthma and chronic cough.

Heartburn actually has nothing to do with the heart; it is so-called because of a burning sensation in and around the breastbone, although some heart problems have a similar sensation to heartburn.

Pathophysiology of Heartburn

The sensation of heartburn is caused by exposure of the lower oesophagus to the acidic contents of the stomach. Normally, the lower oesophagal sphincter (LES) which separates the stomach from the oesophagus contracts to prevent this situation. If the lower oesophagal sphincter relaxes for any reason (as normally occurs during swallowing), stomach contents, mixed with gastric acid, can return to the oesophagus. This return is also known as reflux and may progress to gastroesophageal reflux disease (GERD) if it occurs frequently. Peristalsis, the rhythmic wave of muscular contraction in the oesophagus, normally moves food down and past the LES and is responsible for ultimately clearing refluxed stomach contents. In addition, gastric acid can be neutralized by buffers present in saliva.

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Causes of Heartburn

There are many foods in a general diet that may contribute to or cause heartburn. Alcohol, caffeine, spicy foods and fatty foods can all cause reflux leading to heartburn.

  • Alcohol
  • Coffee, tea, cola, and other caffeinated and carbonated beverages
  • Chocolate
  • Citrus fruits and juices
  • Tomatoes and tomato sauces (such as pizza and pasta sauce)
  • Spicy foods and fatty foods (including full-fat dairy products)
  • Peppermint and spearmint
  • Dry foods such as peanuts
  • Fatty foods such as ice cream
  • Heartburn and Stress
  • Heartburn can also be psychosomatic, primarily in relation to stress.

Diagnosis of Heartburn

Physicians typically diagnose gastroesophageal reflux disease (GERD) based on symptoms alone. When the clinical presentation is unclear, other tests can be performed to confirm the diagnosis or exclude other disorders. Confirmatory tests include:

Ambulatory pH Monitoring

A probe can be placed via the nose into the oesophagus to record the level of acidity in the lower oesophagus. Because some degree of variation in acidity is normal, and small reflux events are relatively common, such monitors must be left in place for at least a 24-hour period to confirm the diagnosis of GERD. The test is particularly useful when the patient’s symptoms can be correlated to episodes of increased oesophagal acidity.

Upper Gastrointestinal (GI) Series

A series of x-rays of the upper digestive system are taken after drinking a barium solution. These can demonstrate reflux of barium into the oesophagus, which suggests the possibility of gastroesophageal reflux disease. More accurately, fluoroscopy can be used to document reflux in real-time.

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Manometry

In this test, a pressure sensor (manometer) is passed through the mouth into the oesophagus and measures the pressure of the lower oesophagal sphincter directly.

Endoscopy

The oesophagal mucosa can be visualized directly by passing a thin, lighted tube with a tiny camera attached (an endoscope) through the mouth to examine the oesophagus and stomach. In this way, evidence of oesophagal inflammation can be detected, and biopsies were taken if necessary:

Biopsy

A small sample of tissue from the oesophagus is removed. It is then studied to check for inflammation, cancer, or other problems.

Treatment of Heartburn

Prevention of Heartburn

If heartburn occurs when lying down, raising the head with pillows or sitting up frequently provides relief – although care must be taken to avoid placing continuous strain on the neck. Avoidance of certain foods shortly before bedtime is frequently advised to avoid future heartburn attacks.

Medications for Heartburn

Antacids, H2-receptor antagonists and proton pump inhibitors are used (in that order) to treat heartburn.

Antacids

Daily treatment with Antacids is effective for 25-30% of people with GERD. Acid-blocking medications are the most effective for mild forms of the condition.

Water

Some have suggested that drinking a large glass of water dilutes the high pH levels in the stomach (since pure water has a neutral pH of 7) and allows the heartburn pain to temporarily subside. However, because pH is measured on a logarithmic scale (a shift of 1 on the pH scale corresponds to a change by a factor of 10), to substantially dilute the pH of stomach acid would mean drinking at least 10 times as much pure water as the volume of acid.

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H2-receptor antagonists

With the advent of proton-pump inhibitors, H2-receptor antagonists are not widely used.

Proton-pump Inhibitors

Proton pump inhibitors are a class of medications that can be effective for people who do not respond to antacid or acid blockers. Proton-pump inhibitors directly block acid production in the stomach cells and provide more effective relief than less powerful medications. In order to prevent heartburn, the medication disfigures and disables the proteins (proton pumps) that control the pH of the stomach, allowing the body to digest them.

Restricting Diet

Restricting diet is very important since 90-95% of sufferers of heartburn or oesophagal disorder can link their symptoms to specific foods. Therefore, it is important that heartburn sufferers manage their diets as a way to treat their heartburn. Sufferers should choose the kinds of foods and drinks which have little risk of causing acid reflux, while some kinds of foods or drinks should be avoided as they are major heartburn triggers.

Currently Available Proton Pump Inhibitors

PPIBrand nameDose, mgOTC
1OmeprazolePrilosec, Prilosec OTC10, 20, 40Yes
2EsomeprazoleNexium20, 40Yes
3LansoprazolePrevacid, Prevacid 24 hr15, 30Yes
4RabeprazoleAciphex10, 20No
5PantoprazoleProtonix20, 40No
6DexlansoprazoleDexilant30, 60No
7Omeprazole with sodium bicarbonateZegerid, Zegerid OTC20, 40Yes

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