Heartburn

Heartburn is a burning feeling in the chest region caused by the reverse flow of the acid produced in the stomach. Commonly, it is known as acidity. It is a major symptom of GERD. It is also sometimes felt as a bitter or sour taste in the mouth. It is commonly encountered after eating a heavy meal and lying down. The feeling can last for a few minutes or a few hours. If it occurs frequently, then it may be a sign of some serious condition which may require medical care and further investigations.

What is Heartburn?

Heartburn (pyrosis) is defined as a retrosternal (behind the breastbone) burning pain that travels upwards towards the throat. It is also defined as a form of indigestion felt as a burning sensation in the chest, caused by acid reflux into the oesophagus.

Symptoms pertaining to heartburn are very few and easy to identify. They are:

• A burning pain in the chest region which usually occurs after eating mostly at night (as we tend to sleep after dinner).
• Pain or burning feeling that may increase in intensity when lying down or bending over after meals or on empty stomach.
• Bitter or acidic taste in the mouth.
• Dysphagia (difficulty in swallowing).
• A cough and persistent sore throat (due to acid reflux which causes irritation in the throat).
• Vomiting.
• ‘Water brash’ (excessive watering or salivation due to salivary gland stimulation as the stomach acid enters the oesophagus).
• Laryngitis due to irritation of the throat because of the stomach acid.
• Chest pain which can often be misunderstood as angina.

Causes

Occasional episodes of heartburn are common in our day-to-day life. A reflux episode is followed by oesophageal peristaltic waves (contractions and relaxations in the oesophagus to ease the movement of the food bolus) which effectively clears the food pipe. The saliva which is alkaline in nature (basic) neutralises the acid and the symptoms decrease slowly and completely. Heartburn occurs when the stomach and oesophagus are exposed to gastric acids for prolonged time resulting in persistent symptoms.

Other causes of heartburn are as follows:-

• GERD.
• Certain foods and drinks – coffee, alcohol, chocolates, fatty or spicy or sour foods.
• Obesity
• Smoking.
• Pregnancy.
• Stress and Anxiety.
• Medicines such as painkillers.
• A hiatus hernia (bulging of the stomach through the diaphragm in the chest cavity).
• Abnormalities of the lower oesophageal sphincter (ring of muscle which controls the entry of food from the oesophagus to the stomach).

Risk factors

Risk factors are conditions which can trigger the onset or aggravate a disease or disorder. The following risk factors can cause frequent heartburn:

• Daily intake of spicy foods.
• Excessive intake of pungent foods such as onions and garlic.
• Having citrus fruits.
• Tomato and its products like ketchup or purees.
• Fatty and fried foodstuffs.
• Chocolates.
• Alcohols, carbonated beverages (sodas and soft drinks).
• Coffee and other caffeine drinks.
• Large meals.
• Obesity.
• Pregnancy.

The most important step to tackle heartburn is to find out the exact cause. By making simple lifestyle changes, heartburn can be tackled easily. These include:

• Eat small and frequent meals so that the acid secreted by the stomach is utilised and accumulation is prevented which can trigger heartburn.
• Make adjustments in your sleeping posture by raising the level of your bed or by increasing the support beneath your head so as to make the chest and head rise above the waist level. In this way, the acid won’t be able to travel towards your throat.
• Try weight loss if obesity is the cause.
• Reduce stress and anxiety if it is the cause of heartburn.
• Avoid foods which can trigger your heartburn. Caffeine should be avoided.
• Have sufficient time-gap (3-4 hours) between meals and bedtime.
• Do not smoke or consume alcohol.
• Take prescribed medicines by consulting your doctor as sometimes some medicines can cause heartburn.
• Do not wear clothes that are tight around the waist.
  
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Young people who present typical symptoms of heartburn without any other complicated symptoms like unusual weight loss and anaemia can be treated without any major investigative procedure. Investigations are usually carried out in middle-aged or elderly patients if the symptoms are atypical or unusual. Some investigations which are usually carried out are:

• Endoscopy is the investigation of choice to rule out an upper gastrointestinal disease. A 24-hour pH monitoring is indicated if endoscopy doesn’t prove sufficient and further invasive procedures are under consideration. This involves tethering a slim catheter (tube) with terminal radiotelemetry pH-sensitive probe above the gastro-oesophageal junction. The intraluminal pH is recorded whilst the patient undergoes normal activities, and episodes of pain are noted and related to pH. A pH of less than 4 for more than 6-7% of the study time is diagnostic of reflux disease.
• X-rays (barium meal) are taken to view the shape and position of the stomach and oesophagus to rule out other causes.
• Manometry (oesophageal motility testing) is performed in some cases.

Simple lifestyle remedies are sufficient to ease heartburn. Mostly, over the counter medications such as antacid gels provide instant relief. Your doctor may prescribe you the following medications:

• Antacids (systemic and non-systemic) which help to neutralise the stomach acids. Example- aluminium hydroxide gel, sodium bicarbonate etc.
• H2-receptor antagonists (cimetidine, ranitidine, famotidine) which reduce the secretion of stomach acids.
• Proton pump inhibitors (PPI’s; omeprazole, pantoprazole, esomeprazole) also reduce stomach acids and also help to heal oesophagitis. These are better than H2-receptor antagonists and provide long-term effects.

Very rarely, surgery such as fundoplication is performed to alter the oesophagus.

Lifestyle management

Lifestyle changes are one of the best remedies to treat heartburn. These include the following:

• Lose weight. This helps in improving symptoms of GERD.
• Avoid tangy foods such as tomatoes or spicy foodstuffs, as well as fried and fatty foods.
• Elevate the head end of the bed to prevent reflux during sleep.
• Avoid late meals and eat smaller regular meals.
• Quit smoking as it is effective in improving heartburn and hyperacidity.
• Avoid excessive alcohol intake.
• Limit intake of sweets and chocolates as they can induce heartburn.
• Antibiotics and some prescribed medications can cause heartburn, these should be taken only after consultation with the physician.

Prognosis

Heartburn has a good outcome as it rarely causes any complications. It can also be treated effectively without any invasive procedures or complex drug regime. Simple changes in diet and lifestyle are sufficient. However, extreme cases of heartburn can be harmful and can lead to further complications. In such cases, the outcome is poor.

Complications

Complications of heartburn arise if it is not treated effectively and persists for a long period. Some complications which can arise are:

• Oesophagitis (inflammation with mild redness and further complications like severe bleeding from oesophagus).
• Barrett’s Oesophagus (the morphology of the lining of the oesophagus changes). It is undetected as it is asymptomatic until it presents as oesophageal cancer. Multiple biopsies are required to detect oesophageal cancer.
• Iron deficiency anaemia can occur insidiously as a result of chronic, gradual blood loss from long-standing oesophagitis. Almost all such patients have a large hiatus hernia and bleeding can occur from subtle erosions in the neck of the hernia sac.  
• Benign oesophageal stricture (narrowing) is caused due to long-standing oesophagitis. More so, it develops in elderly patients as they have poor oesophageal peristaltic activity. It leads to dysphagia (inability to swallow food).
• Gastric volvulus (twisting of the stomach) causes complete blockage of food entry from the oesophagus to the stomach and often presents as severe chest pain, vomiting, and dysphagia with blood in stool and in vomit.