Severe Heartburn | Reflux Disease

What Is Heartburn?

People experience heartburn in a variety of forms. Usually heartburn is a burning chest pain located behind the breastbone. Often there is a sensation of food coming back into the mouth, accompanied by an acid or bitter taste. Typically, heartburn occurs after meals and is a common source of complaints of indigestion. Fried or fatty foods, tomato products, citrus fruits and juices, chocolate, and coffee often cause heartburn. Usually the burning-type chest pain lasts for many minutes - sometimes as long as 2 hours - and often is worse when the sufferer is lying flat or bending over. Heartburn is usually described as a burning sensation, although it may not be considered painful by some people. In addition, heartburn is neither brought on by exercise nor relieved with rest; most people obtain relief by standing upright or by taking an antacid.

How Common Is Heartburn?

Approximately 10 percent of the U.S. population suffers daily from heartburn, and at least one-third of otherwise normal individuals have this symptom occasionally. It is a common complaint among pregnant women, of whom 25 percent experience daily heartburn and more than 50 percent have occasional distress. Recent studies indicate that similar problems in infancy are more common than was previously recognized and may produce recurrent vomiting, failure to thrive, or coughing and other lung symptoms.

Although heartburn is a common malady in our society, it is rarely life-threatening. It can, however, limit an individual's daily activities and productivity. With proper understanding of the causes of heartburn and a rational approach to treatment, most people will find relief.

What Causes Heartburn?

The esophagus is the tube-like structure that connects the mouth to the stomach. At the point where the esophagus joins the stomach, the esophagus is kept closed by a specialized muscle called the lower esophageal sphincter (LES). This muscle is important because the pressure in the stomach is normally higher than that in the esophagus. The muscle of the LES relaxes after swallowing to allow passage of food into the stomach, but then it quickly closes once again.

Does Heartburn Equal Acid Reflux?

Mainly, yes, since the backwash of stomach contents into the esophagus, commonly called reflux, occurs when the LES muscle is very weak or, more commonly, when it inappropriately relaxes. The reflux tends to be worse after big meals and when one lies down at night. The refluxed fluid irritates the esophageal lining (see figure).

The occurrence and severity of heartburn depend on LES dysfunction, but they also affected by the type and amount of fluid brought up from the stomach, by the clearing action of the esophagus, by the neutralizing action of saliva, and by other factors. Although heartburn is the most common manifestation of acid reflux, it is important to recognize that other, more serious problems can result from chronic reflux. Some of these complications such as esophageal bleeding ulcers, stricture may require more vigorous treatment.

Is Heartburn Caused by Hiatal Hernia?

For many years, heartburn seemed to be a result of hiatal hernia. It is now known that small hiatal hernias are common and usually innocent. Hiatal hernia is a condition in which a portion of the stomach slides up through the diaphragm and occupies a place in the chest cavity. In fact, the majority of people past the age 50 have evidence of a hiatal hernia after certain maneuvers during x-ray examination. Heartburn is not caused by such a hernia but, rather, results from the incompetent valve described above.

What Can You Do About Heartburn?

First of all, any chest pain (even burning) requires a medical evaluation. Chest pain is rarely caused by acid reflux. Other causes such as heart disease must be considered.

If acid reflux is suspected, certain specific steps may prevent symptoms of heartburn. Avoiding foods that cause symptoms may be of benefit. Although no studies proving that such modification relieves heartburn have been conducted, many physicians note that patients improve after they remove certain foods from their diets. In addition, decreasing the size or volume of a meal consumed can be helpful. Being overweight often contributes to symptoms, and many people find relief when their weight is below a certain point.

Cigarette smoking has been shown to decrease LES pressure dramatically. Therefore, reducing (or, preferably, stopping) smoking can be an important component of treatment.

Elevating the head of the bed on 6-inch blocks reduces heartburn by allowing the effect of gravity to minimize reflux of stomach contents into the esophagus at night. Antacids taken on a regular basis will neutralize the stomach acid and stop heartburn. Many patients have discovered that nonprescription antacids provide temporary or partial relief. Antacid combined with a foaming agent such as alginic acid can help some patients. These compounds are believed to form a foam barrier on the top of the gastric pool.

It should be recognized that there can be side effects from long-term use of antacids. These effects can include diarrhea, altered calcium metabolism, and magnesium retention. Magnesium retention can be serious for patients with kidney disease. As with other symptoms, if prolonged use of nonprescription antacids becomes necessary, a physician should be consulted.

What If Symptoms Persist?

People with severe acid reflux or with symptoms unresponsive to the measures described above may need more complete diagnostic evaluation. Usually an upper gastrointestinal (GI) series will be performed during the early phase of evaluation. An upper GI series is a special x-ray test that shows the esophagus, stomach, and duodenum. While this test provides limited information about possible acid reflux, it is performed to rule out other possible diagnoses such as peptic ulcer or to rule out complications such as esophageal ulcer.

A variety of tests and procedures are currently used to evaluate further the patient with heartburn. It is fair to say that the ideal test has not been developed and that no test is 100 percent accurate.

Endoscopy is an important procedure in heartburn patients. By looking through a small tube placed into the esophagus, the physician may see inflammation of the tissue lining the esophagus (esophagitis).

Biopsy (removal of a small sample of tissue) of the lining of the esophagus may be helpful if the findings of the endoscopy are negative or questionable.

The Bernstein test (dripping a mild acid through a tube placed in the midesophagus) is often performed as part of a complete evaluation. This test attempts to confirm that the symptoms are produced by contact of acid with the esophageal lining.

Pressure measurements of the esophagus (esophageal manometric studies) occasionally help to identify critically low pressure in the LES.

For those patients in whom the diagnosis is difficult to make, many doctors find it helpful to measure the acid levels inside the esophagus (pH testing). Newer techniques of long-term pH monitoring are improving diagnostic capability in this area.

What Medical Therapies Are Available?

Once the diagnosis of acid reflux has been confirmed, the physician may prescribe one of a number of new medications available to treat this problem. The most exciting of these new drugs are cimetidine and ranitidine, which suppress gastric acid secretion. Many studies have indicated that these drugs are effective in the short-term treatment of acute reflux symptoms.

Other approaches to medical therapy include the use of drugs to increase the LES pressure. This increase can be accomplished with either bethanechol or metoclopramide. Both of these drugs have been shown experimentally to be effective in treating heartburn.

Can Heartburn Require Surgery?

A few people may need surgery because of poor response to medical treatment. Surgical procedures intended to produce an effective LES have been developed in recent years. However, surgery should not be considered until all other measures have been tried.

What Are the Complications of Long-Term Heartburn?

Although heartburn itself does not cause complications, the acid reflux with which it is associated can occasionally result in serious complications. Gastrointestinal blood loss from damage to the esophagus can cause anemia, which occasionally may be severe. Scarring of the lower esophagus may result in narrowing of the opening of the esophagus (stricture), which can seriously interfere with swallowing. Reflux may be a cause of recurrent wheezing and other lung symptoms.

Current and Future Research

During the past decade, research into the mechanisms and therapy of heartburn in both animals and humans has been quite active. The newer therapeutic approaches discussed above represent some of the results of these research efforts.

Donald O. Castell, M.D., is a professor of medicine at the Bowman Gray School of Medicine, Wake Forest University, and an expert on esophageal disorders. In this fact sheet he has provided an overview of some current information; however, individual patients and their problems vary greatly.To obtain specific answers about yourself, you must consult your own doctor.