Heartburn

Definition

Heartburn is a burning sensation in the chest that can extend to the neck, throat, and face. It usually occurs after eating and is worsened by bending, lifting, or lying down.

Description

Heartburn, sometimes called acid indigestion or gastroesophageal reflux, is very common. More than one third of the population suffers from occasional heartburn, as do about one half of pregnant women. Some 50 million adult Americans complain of frequent heartburn. The occurrence of heartburn generally increases with age; however, it is common—and often overlooked—in infants and children.

Heartburn occurs when digestive juices from the stomach move back up into the esophagus, the tube connecting the throat to the stomach. The upper third of the esophagus consists of skeletal muscle that propels the food downward. The lower two-thirds of the esophagus is smooth muscle. The lower esophageal sphincter (LES) is a thick band of muscle that encircles the esophagus just above the uppermost part of the stomach. This sphincter is usually tightly closed—opening only when food passes from the esophagus into the stomach—and prevents the contents of the stomach from moving back into the delicate esophageal tissue. The stomach has a thick mucous coating that protects it from the strong hydrochloric acid it secretes to digest food. However the much-thinner esophageal mucous coating does not protect against stomach acid. Thus, if the LES opens inappropriately or fails to close completely, stomach acids can back up and burn the esophagus, causing heartburn.

Occasional heartburn is usually harmless. However, frequent or chronic heartburn (recurring more than twice per week) is called gastroesophageal reflux disease (GERD) and requires early management. Repeated episodes of GERD can lead to esophageal inflammation (esophagitis). If the esophagus is repeatedly subjected to

stomach acid and digestive enzymes , ulcerations, scarring, and thickening of the esophageal walls can result. This causes a narrowing of the interior of the esophagus that can affect swallowing and the peristaltic movements that send food downward. Repeated esophageal irritation also can result in Barrett's syndrome—changes in the types of cells lining the esophagus. Barrett's esophagus can develop into esophageal cancer .

Nighttime heartburn, affecting about 80% of heartburn sufferers, is more damaging to the esophagus than daytime heartburn. It often interferes with sleep and may trigger symptoms in asthma sufferers.

Gastroesophageal reflux may occur in children under age one, particularly pre-term babies or those with cerebral palsy . It also may be a cause of some migraine headaches. In addition, chronic heartburn can be a symptom of a gastric ulcer or coronary artery disease.

Causes & symptoms

Causes

Heartburn is caused by:

• a relaxed LES that does not close properly
• over-production of stomach acid
• increased stomach pressure
• a damaged esophagus with increased acid sensitivity

Many factors can contribute to LES malfunction:

• irregular eating, skipping meals
• smoking
• caffeine
• stress
• some medications, including diazepam (Valium), meperidine (Demerol), theophylline, morphine, prostaglandins, calcium channel blockers, nitrate heart medications, progesterone, and anticholinergic and adrenergic drugs (drugs that limit nerve reactions)
• paralysis and scleroderma (an autoimmune disease that hardens body organs)
• large meals that distend the stomach and prevent the LES from closing
• alcohol, which lowers the pressure on the LES, allowing it to relax and open. Alcohol also may irritate the esophageal lining
• weakening LES and loss of LES muscle tone with increasing age

Hiatal hernias are common among pregnant women, smokers, the obese, and those over age 50. The hiatus is an opening in the diaphragm (the large muscle that separates the chest cavity and the abdomen) through which the esophagus connects to the stomach. If the hiatus loses its tautness and shape, the stomach may protrude through, forming a pocket just below the LES where stomach acid can be trapped. These hiatal hernias can cause the LES to relax and open. Hiatal hernias may result in frequent and severe heartburn and GERD.

Various factors can increase stomach pressure, causing gastroesophageal reflux:

• obesity
• lying down within one or two hours of eating
• tight clothing
• Pregnancy , which causes the enlarged uterus to displace the stomach, delaying the removal of stomach contents

Eating too fast, chewing insufficiently, and smoking all increase stomach acid production. Smoking also dries up saliva that protects the esophagus from acid.

Many foods are known to contribute to heartburn:

• greasy, fried, or fatty foods
• spicy foods
• black pepper
• such acidic foods as tomatoes, pickles, and vinegar
• chocolate
• coffee with or without caffeine
• Peppermint or other mints

Symptoms

Heartburn itself is a symptom of gastroesophageal reflux and GERD. Heartburn sufferers may salivate excessively or regurgitate stomach contents into their mouths, leaving a sour or bitter taste.

Other symptoms of GERD include:

• difficult or painful swallowing
• sore throat
• hoarseness, laryngitis, wheezing , coughing
• pneumonia
• gingivitis, bad breath
• earache

Diagnosis

Heartburn usually is diagnosed by patient histories, symptoms, and clinical assessments. Additional procedures may be used to confirm the diagnosis, assess damage to the esophagus, and monitor the healing progress. The following diagnostic procedures are appropriate for anyone with frequent, chronic, or difficult-to-treat heartburn, or complicating GERD symptoms as listed above.

Esophageal manometry uses a thin flexible catheter placed down the esophagus. Small openings in the catheter sense pressure at various points on the esophagus while the muscle is at rest and during swallowing. The pressures are transmitted to a computer that analyzes the wave patterns.

An upper gastrointestinal (GI) series, or "barium swallow," can reveal esophageal narrowing, ulcerations, tumors, hiatal hernia , or reflux episodes as they occur. X rays are taken after a patient swallows a barium (a chemical element) suspension. This procedure takes about 15 minutes. However, it cannot detect structural changes associated with different degrees of esophagitis.

Upper GI endoscopy uses a thin flexible tube to view the inside of the esophagus directly. It is performed by a gastroenterologist, a physician specializing in diagnosis and treatment of disorders of the gastrointestinal tract, or by a gastrointestinal endoscopist. Upper GI endoscopy enables the physician to distinguish the degree of esophagitis and provides an accurate profile of esophageal damage. This procedure may include a biopsy—the removal of a small piece of tissue—to examine for Barrett's syndrome or malignancies. Patients with Barrett's esophagus may have frequent examinations of the esophageal lining for early detection of precancerous cells.

Other diagnostic tests include measurements of esophageal acidity (pH), usually over a 24-hour period, using an ambulatory acid probe. The patient is given a large capsule containing an acid-sensing probe, a battery, and a transmitter. Acid in the esophagus is measured by the probe, which then transmits the information to a recorder that the patient is wearing on his belt.

Note: A burning sensation in the chest is usually heartburn and is not associated with the heart itself. About 15 percent of the annual six million U. S. emergency room visits for chest pain are due to heartburn. However, angina (one type of temporary chest pain, pressure, or discomfort) sometimes is mistaken for severe heartburn. Chest pain that radiates into the arms and is not accompanied by regurgitation is a warning sign of a possible serious heart problem. Persistent chest pain should always be evaluated by a physician.

Treatment

Herbal remedies

These herbal remedies may be used to treat heartburn:

• ginger (Zingiber officinalis ) as a tea or candied. (Ginger may cause heartburn in some people.)
• chamomile (Matricaria chamomilla ) tea
• slippery elm (Ulmus fulva ) tea
• cinnamon tea
• anise (Pimpinella anisum ), caraway, dill, and/or fennel seed tea
• cardamom (Elettaria cardamomum ) on buttered raisin toast
• turmeric (Curcuma domestica ) added to warm water
• marsh mallow root (Althaea officinalis )
• licorice (Glycyrrhiza glabra ), especially deglycyrrhizinated licorice (DGL) (The capsules or tablets may be dissolved in the mouth or in tea or two to four chewable 380-mg. wafers are taken about 20 minutes before eating. DGL should not be used more than three times per week, as repeated use can be toxic.)
• peppermint tea (Peppermint also can cause heartburn by relaxing the LES.)
• Ayurvedic (traditional East Indian) herbs

Homeopathic remedies

Homeopathic remedies for heartburn include:

• Calcarea carbonica
• Nux vomica after eating spicy foods
• Carbo vegetalis after eating rich foods
• Arsenicum album (for burning pain)
• Natrum muriaticum (for nervousness, tension, and pain)
• Zinc metallicum after eating too fast

Other remedies

A variety of other remedies and therapies may be used to treat heartburn:

• Sodium bicarbonate (baking soda) reduces esophageal acidity immediately. However, its effect is short-lived and it should not be used by people on sodium-restricted diets.
• Nutritional remedies include carrots, celery, angelica , fennel, and/or parsley . These can be combined in a juice taken before meals.
• Acupressure points Stomach 36, Spleen 6, Pericardium 6, and Conception Vessel 12. CV 12 should not be pressed just after eating or during pregnancy.
• In Chinese medicine, foods and herbs that balance and cool the qi (Chinese term for universal life energy), including radishes, radish seed, citrus fruit peels, and cardamom.
• Walking after a meal.
• Chewing gum after eating to help produce saliva for soothing the esophagus and washing acid back into the stomach.
• Relaxation therapy, visualization, and deep breathing.

Allopathic treatment

Drugs

Occasional heartburn is commonly treated with nonprescription antacids that neutralize the pH of stomach acid. The neutralized acid does not burn the esophagus. Antacids usually work within 15 minutes and their effects last one to two hours. Liquid or dissolving antacids usually act faster than tablets. However, antacids, if taken for too long, can cause side effects, including diarrhea or constipation .

Some antacids interfere with medications for kidney or heart disease . Heartburn sufferers with two or more episodes per week, or with an episode lasting more three weeks, should not rely on antacids as the sole treatment, since they may be at risk of kidney damage or other metabolic changes.

Common antacids include Maalox, Mylanta, Alka-Seltzer, Pepto-Bismol, Riopan, and Rolaids. The active ingredient in antacids such as Tums is calcium carbonate. Alginate (Gaviscon) is a foaming agent that coats the esophagus and the stomach to help prevent reflux. Other antacids are made from aluminum hydroxide, magaldrate, or magnesium hydroxide. Some antacids contain baking soda (sodium bicarbonate), which may interfere with vitamin and mineral absorption during pregnancy.

Histamine receptor (H2) blockers, such as famotidine (Pepcid), ranitidine (Zantac), nizatidine (Axid), and cimetidine (Tagamet), decrease stomach acid secretion. They relieve heartburn in about 75% of users. However, they take 30 to 45 minutes to act and usually are taken two to four times daily for several weeks. H2 blockers are both over-the-counter (OTC) and prescription medicines. They may have side effects or interactions with other medications.

Proton pump inhibitors (PPI) are for severe heartburn. They are the most effective drugs for inhibiting acid production and allowing the esophagus to heal in GERD. It may take up to five days for PPIs to take effect. They cannot be used by people with kidney or liver problems. Although it appears safe to take PPIs for at least 10 years, the lowest effective dosage reduces the risk of side effects that may include headache , diarrhea, stomach pain, and interactions with other medications. Common PPIs include lansoprazole (Prevacid), omeprazole (Prilosec), rabeprazole (Aciphex), pantoprazole (Protonix), and esomeprazole (Nexium). Prilosec OTC is available in 20-milligram doses to be taken once a day for 14 days to treat frequent heartburn.

Prokinetics are drugs that strengthen the LES (lower esophageal sphincter) and increase the rate of stomach emptying. These include metoclopramide (Reglan) and bethanechol (Urecholine). These drugs frequently have side effects.

Surgery

Laparoscopic Nissen fundoplication is a surgical procedure to increase pressure on the LES by stretching and wrapping the upper part of the stomach around it. It is performed under general anesthetic and takes one to two hours. The complete recovery period is less than two weeks.

GERD (gastroesophageal reflux disease) may be treated successfully by endoscopic suturing of the weakened LES to stop acid reflux. Studies have shown that symptoms usually improve with this procedure and the use of medications declines. Another procedure involves using electrodes to make tiny cuts in the LES tissues. The resulting scarring tightens the LES. These outpatient procedures take less than an hour. They are not used in cases of hiatal hernia or Barrett's esophagus.

If the esophagus has become narrowed and badly scarred from stomach acid, a procedure that stretches and widens the esophageal tissue may be used along with acid-suppressing medication. Enteryx is a liquid that can be injected into the LES where it forms a spongy muscle implant that strengthens the LES.

Prognosis

Occasional heartburn without esophageal damage has an excellent prognosis. Esophageal damage that is treated with a program that promotes healing also has an excellent prognosis. Infants usually outgrow gastroesophageal reflux by age one.

Untreated heartburn and GERD may lead to bleeding, esophageal ulcers, and infections . With treatment, the damaged tissue that forms ulcers can heal. About ten percent of patients with GERD experience esophageal narrowing from acid damage that leads to the formation of scar tissue in the lower esophagus. GERD also can cause laryngitis, bronchitis , and aspiration pneumonia. After five years of heartburn, the risk of developing Barrett's esophagus increases. About five percent of GERD patients have Barrett's syndrome. This condition is incurable and may lead to cancer. The prognosis for esophageal cancer is very poor. There is a strong likelihood of painful illness and a less than five percent chance of survival for more than five years.

Prevention

Due to the risk of GERD, Barrett's syndrome, and esophageal cancer, prevention of heartburn is very important. Heartburn usually is preventable with dietary and lifestyle changes.

Dietary adjustments to eliminate many causes of heartburn include:

• eating smaller, more frequent meals to reduce pressure on the LES
• eating slowly, chew thoroughly, and take deep breaths between bites
• avoiding caffeine, chocolate, onions, spicy foods, and mint, all of which tend to increase stomach acid and relax the LES
• avoiding fatty, fried, and greasy foods. Fatty foods relax the LES and slow stomach emptying, and fat consumption has been linked to GERD
• avoiding milk, garlic , peppers, and carbonated beverages
• avoiding nicotine
• avoiding citrus fruits and juices and tomato-based foods, which are acidic and can irritate an inflamed esophagus
• replacing meat at dinner with carbohydrates and easier-to-digest proteins such as rice, beans, and pastas
• avoiding alcohol
• adding the spice annato (Bix orellana ) or bouquet garni to foods
• drinking tea made with crushed caraway seeds with meals
• controling body weight

Lifestyle changes that can alleviate heartburn include:

• avoiding drugs known to contribute to heartburn, including aspirin or other nonsteroidal anti-inflammatories
• avoiding clothing that fits tightly around the abdomen
• not lying down until the stomach is empty—within about three hours of eating
• elevating the head of the bed six to nine inches to prevent nighttime heartburn
• avoiding strenuous exercise for two to three hours after a meal

Resources

BOOKS

Berkson, Lindsey. Healthy Digestion the Natural Way: Preventing and Healing Heartburn, Constipation, Gas, Diarrhea, Inflammatory Bowel and Gallbladder Diseases, Ulcers, Irritable Bowel Syndrome, Food Allergies and More. New York: Wiley, 2000.

Castleman, Michael. Blended Medicine: The Best Choices in Healing. Emmaus, PA: Rodale, 2000.

Cheskin, Lawrence J. and Brian E. Lacy. Healing Heartburn. Emmaus, PA: Rodale, 2000.

Goldmann, David R. and David A. Horowitz, editors. American College of Physicians Complete Home Medical Guide. 2nd ed. New York: DK, 2003.

Litin, Scott C., editor. Mayo Clinic Family Health Book. 3rd ed. New York: Harper Resource, 2003.

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

Shimberg, Elaine Fantle. Coping with Chronic Heartburn: What You Need to Know About Acid Reflux and GERD. New York: St. Martin's Press, 2001.

Sklar, Jill, and Annabel Cohen. Eating for Acid Reflux: A Handbook and Cookbook for Those with Heartburn. Emeryville, CA: Marlowe & Company, 2003.

PERIODICALS

"Gastrointestinal Reflux: New Guidelines Set Standard on Test to Diagnose Acid Reflux, Heartburn." Health & Medicine Week (December 22, 2003): 284–285.

"New Bard Endoscopic Suturing System Treats Chronic Heartburn." Journal of Clinical Engineering 28 (April-June 2003): 88–90.

Sadovsky, Richard. "Management of Refractory Heartburn: A Review." American Family Physician 69 (February 1, 2004): 698.

Savarino, Vincenzo and Pietro Dulbecco. "Optimizing Symptom Relief and Preventing Complications in Adults with Gastro-Oesophageal Reflux Disease." Digestion 69, Supplement 1 (2004): 9–16.

Urbach, David R., et al. "Whither Surgery in the Treatment of Gastroesophageal Relux Disease (GERD)?" Canadian Medical Association Journal 170 (January 20, 2004): 219–221.

ORGANIZATIONS

American Gastroenterological Association (AGA). 4930 Del Ray Avenue, Bethesda, MD 20814. (310 654-2055. <http://www.gastro.org/>.

National Digestive Diseases Information Clearinghouse. 2 Information Way, Bethesda, MD 20892–3570. (800) 891-5389. (301) 654-3810. nddic@info.niddk.nih.gov. <http://digestive.niddk.nih.gov/>.

The National Heartburn Alliance. 303 East Wacker Drive, Suite 440, Chicago, IL 60601. (877) 471-2081. nhbainformation@heartburnalliance.org. <http://www.heartburnalliance.org/>.

Margaret Alic, PhD

Heartburn

Definition

Heartburn is a burning sensation in the chest that can extend to the neck, throat, and face; it is worsened by bending or lying down. It is the primary symptom of gastroesophageal reflux, which is the movement of stomach acid into the esophagus. On rare occasions, it is due to gastritis (stomach lining inflammation).

Description

More than one-third of the population is afflicted by heartburn, with about one-tenth afflicted daily. Infrequent heartburn is usually without serious consequences, but chronic or frequent heartburn (recurring more than twice per week) can have severe consequences. Accordingly, early management is important.

Understanding heartburn depends on understanding the structure and action of the esophagus. The esophagus is a tube connecting the throat to the stomach. It is about 10 in (25 cm) long in adults, lined with squamous (plate-like) epithelial cells, coated with mucus, and surrounded by muscles that push food to the stomach by sequential waves of contraction (peristalsis). The lower esophageal sphincter (LES) is a thick band of muscles that encircles the esophagus just above the uppermost part of the stomach. This sphincter is usually tightly closed and normally opens only when food passes from the esophagus into the stomach. Thus, the contents of the stomach are normally kept from moving back into the esophagus.

The stomach has a thick mucous coating that protects it from the strong acid it secretes into its interior when food is present, but the much thinner esophageal coating doesn't provide protection against acid. Thus, if the LES opens inappropriately or fails to close completely, and stomach contents leak into the esophagus, the esophagus can be burned by acid. The resulting burning sensation is called heartburn.

Occasional heartburn has no serious long-lasting effects, but repeated episodes of gastroesophageal reflux can ultimately lead to esophageal inflammation (esophagitis) and other damage. If episodes occur more frequently than twice a week, and the esophagus is repeatedly subjected to acid and digestive enzymes from the stomach, ulcerations, scarring, and thickening of the esophagus walls can result. This thickening of the esophagus wall causes a narrowing of the interior of the esophagus. Such narrowing affects swallowing and peristaltic movements. Repeated irritation can also result in changes in the types of cells that line the esophagus. The condition associated with these changes is termed Barrett's syndrome and can lead to esophageal cancer.

Causes and symptoms

Causes

A number of different factors may contribute to LES malfunction with its consequent gastroesophageal acid reflux:

• The eating of large meals that distend the stomach can cause the LES to open inappropriately.
• Lying down within two to three hours of eating can cause the LES to open.
• Obesity, pregnancy, and tight clothing can impair the ability of the LES to stay closed by putting pressure on the abdomen.
• Certain drugs, notably nicotine, alcohol, diazepam (Valium), meperidine (Demerol), theophylline, morphine, prostaglandins, calcium channel blockers, nitrate heart medications, anticholinergic and adrenergic drugs (drugs that limit nerve reactions), including dopamine, can relax the LES.
• Progesterone is thought to relax the LES.
• Greasy foods and some other foods such as chocolate, coffee, and peppermint can relax the LES.
• Paralysis and scleroderma can cause the LES to malfunction.
• Hiatus hernia may also cause heartburn according to some gastroenterologists. (Hiatus hernia is a protrusion of part of the stomach through the diaphragm to a position next to the esophagus.)

Symptoms

Heartburn itself is a symptom. Other symptoms also caused by gastroesophageal reflux can be associated with heartburn. Often heartburn sufferers salivate excessively or regurgitate stomach contents into their mouths, leaving a sour or bitter taste. Frequent gastroesophageal reflux leads to additional complications including difficult or painful swallowing, sore throat, hoarseness, coughing, laryngitis, wheezing, asthma, pneumonia, gingivitis, bad breath, and earache.

Diagnosis

Gastroenterologists and internists are best equipped to diagnose and treat gastroesophageal reflux. Diagnosis is usually based solely on patient histories that report heartburn and other related symptoms. Additional diagnostic procedures can confirm the diagnosis and assess damage to the esophagus, as well as monitor healing progress. The following diagnostic procedures are appropriate for anyone who has frequent, chronic, or difficult-to-treat heartburn or any of the complicating symptoms noted in the previous paragraph.

X rays taken after a patient swallows a barium suspension can reveal esophageal narrowing, ulcerations or a reflux episode as it occurs. However, this procedure cannot detect the structural changes associated with different degrees of esophagitis. This diagnostic procedure has traditionally been called the "upper GI series" or "barium swallow" and costs about $250.00.

Esophagoscopy is a newer procedure that uses a thin flexible tube to view the inside of the esophagus directly. It should be done by a gastroenterologist or gastrointestinal endoscopist and costs about $700. It gives an accurate picture of any damage present and gives the physician the ability to distinguish between different degrees of esophagitis.

Other tests may also be used. They include pressure measurements of the LES; measurements of esophageal acidity (pH), usually throughout a 24-hour period; and microscopic examination of biopsied tissue from the esophageal wall (to inspect esophageal cell structure for Barrett's syndrome and malignancies).

New technology introduced by 2003 allows for continuous monitoring of pH levels to help determine the cause. A tiny wireless capsule can be delivered to the lining of the esophagus through a catheter and data recorder on a device the size of a pager that is clipped to the patient's belt or purse for 48 hours. The capsule eventually sloughs off and passes harmlessly through the gastrointestinal tract in seven to 10 days.

Note: A burning sensation in the chest is usually heartburn and is not associated with the heart. However, chest pain that radiates into the arms and is not accompanied by regurgitation is a warning of a possible serious heart problem. Anyone with these symptoms should contact a doctor immediately.

Treatment

Drugs

Occasional heartburn is probably best treated with over-the-counter antacids. These products go straight to the esophagus and immediately begin to decrease acidity. However, they should not be used as the sole treatment for heartburn sufferers who either have two or more episodes per week or who suffer for periods of more than three weeks. There is a risk of kidney damage and other metabolic changes.

H2 blockers (histamine receptor blockers, such as Pepsid AC, Zantac, Tagamet) decrease stomach acid production and are effective against heartburn. H2 blocker treatment also allows healing of esophageal damage but is not very effective when there is a high degree of damage. It takes 30-45 minutes for these drugs to take effect, so they must be taken prior to an episode. Thus, they should be taken daily, usually two to four times per day for several weeks. Six to 12 weeks of standard-dose treatment relieves symptoms in about one-half the patients. Higher doses relieve symptoms in a greater fraction of the population, but at least 25% of heartburn sufferers are not helped by H2 blockers.

Proton-pump inhibitors also inhibit acid production by the stomach, but are much more effective than H2 blockers for some people. They are also more effective in aiding the healing process. Esophagitis is healed in about 90% of the patients undergoing proton-pump inhibitor treatment.

The long-term effects of inhibiting stomach acid production are unknown. Without the antiseptic effects of a consistently very acidic stomach environment, users of H2 blockers or proton-pump inhibitors may become more susceptible to bacterial and viral infection. Absorption of some drugs is also lowered by this less-acidic environment.

Prokinetic agents (also known as motility drugs) act on the LES, stimulating it to close more tightly, thereby keeping stomach contents out of the esophagus. It is not known how effectively these drugs promote healing. Some of the early motility drugs had serious neurological side effects, but a newer drug, cisapride, seems to act only on digestive system nerve connections.

Surgery

Fundoplication, a surgical procedure to increase pressure on the LES by stretching and wrapping the upper part of the stomach around the sphincter, is a treatment of last resort. About 10% of heartburn sufferers undergo this procedure. It is not always effective and its effectiveness may decrease over time, especially several years after surgery. Dr. Robert Marks and his colleagues at the University of Alabama reported in 1997 on the long-term outcome of this procedure. They found that 64% of the patients in their study who had fundoplication between 1992 and 1995 still suffered from heartburn and reported an impaired quality of life after the surgery.

However, laparoscopy (an examination of the interior of the abdomen by means of the laparoscope) now provides hope for better outcomes. Fundoplication performed with a laparoscope is less invasive. Five small incisions are required instead of one large incision. Patients recover faster, and it is likely that studies will show they suffer from fewer surgical complications.

Alternative treatment

Prevention, as outlined below, is a primary feature for heartburn management in alternative medicine and traditional medicine. Dietary adjustments can eliminate many causes of heartburn.

Herbal remedies include bananas, aloe vera gel, chamomile (Matricaria recutita ), ginger (Zingiber officinale ), and citrus juices, but there is little agreement here. For example, ginger, which seems to help some people, is claimed by other practitioners to cause heartburn and is thought to relax the LES. There are also many recommendations to avoid citrus juices, which are themselves acidic. Licorice (Glycyrrhiza uralensis ) can help relieve the symptoms of heartburn by reestablishing balance in the acid output of the stomach.

Several homeopathic remedies are useful in treating heartburn symptoms. Among those most often recommended are Nux vomica, Carbo vegetabilis, and Arsenicum album. Acupressure and acupuncture may also be helpful in treating heartburn.

Sodium bicarbonate (baking soda) is an inexpensive alternative to use as an antacid. It reduces esophageal acidity immediately, but its effect is not long-lasting and should not be used by people on sodium-restricted diets.

Prognosis

The prognosis for people who get heartburn only occasionally or people without esophageal damage is excellent. The prognosis for people with esophageal damage who become involved in a treatment program that promotes healing is also excellent. The prognosis for anyone with esophageal cancer is very poor. There is a strong likelihood of a painful illness and a less than 5% chance of surviving more than five years.

Prevention

Given the lack of completely satisfactory treatments for heartburn or its consequences and the lack of a cure for esophageal cancer, prevention is of the utmost importance. Proponents of traditional and alternative medicine agree that people disposed to heartburn should:

• avoid eating large meals
• avoid alcohol, caffeine, fatty foods, fried foods, hot or spicy foods, chocolate, peppermint, and nicotine
• avoid drugs known to contribute to heartburn, such as nitrates (heart medications such as Isonate and Nitrocap), calcium channel blockers (e.g., Cardizem and Procardia), and anticholinergic drugs (e.g., Probanthine and Bentyl), and check with their doctors about any drugs they are taking

• avoid clothing that fits tightly around the abdomen
• control body weight
• wait about three hours after eating before going to bed or lying down
• elevate the head of the bed 6-9 inches to alleviate heartburn at night. This can be done with bricks under the bed or with a wedge designed for this purpose.

Preventing heartburn's switch to cancer begins with preventing heartburn in the first place. A study in Great Britain in 2004 also looked at using a combination of aspirin and an anti-ulcer drug to try to prevent Barrett's esophagus from forming in patients with long-term heartburn. Aspirin has been found in previous studies to reduce cases of esophageal cancer. However, since one of its side effects is an increased risk of stomach ulcers, the researchers were including an effective anti-ulcer drug for participants.

Resources

PERIODICALS

"Aspirin Trial Launched to Block Heartburn's Switch to Cancer." Drug Week January 23, 2004:188.

Bealfsky, Peter C., and William Halsey. "An Endoscopic View of a Wireless pH-Monitoring Capsule." Ear, Nose and Throat Journal April 2003: 254.

ORGANIZATIONS

The American College of Gastroenterology (ACG). PO Box 3099, Alexandria, VA 22302. (800) HRT-BURN. 〈http://www.healthtouch.com〉.

The American Gastroenterological Association (AGA). 7910 Woodmont Ave., 7th Floor, Bethesda, MD 20814. (310) 654-2055. 〈http://www.gastro.org/index.html〉.

American Society for Gastrointestinal Endoscopy. 13 Elm St., Manchester, MA 01944. (508) 526-8330. 〈http://www.asge.org/doc/201〉.

National Digestive Diseases Information Clearinghouse. 2 Information Way, Bethesda, MD 20892-3570. (800) 891-5389. 〈http://www.niddk.nih.gov/health/digest/nddic.htm〉.

KEY TERMS

Barrett's syndrome— Also called Barrett's esophagus or Barrett's epithelia, this is a condition where the squamous epithelial cells that normally line the esophagus are replaced by thicker columnar epithelial cells.

Digestive enzymes— Molecules that catalyze the breakdown of large molecules (usually food) into smaller molecules.

Esophagitis— Inflammation of the esophagus.

Fundoplication— A surgical procedure that increases pressure on the LES by stretching and wrapping the upper part of the stomach around the sphincter.

Gastroesophageal reflux— The flow of stomach contents into the esophagus.

Hiatus hernia— A protrusion of part of the stomach through the diaphragm to a position next to the esophagus.

Metabolic— Refers to the chemical reactions in living things.

Mucus— Thick, viscous, gel-like material that functions to moisten and protect inner body surfaces.

Peristalsis— A sequence of muscle contractions that progressively squeeze one small section of the digestive tract and then the next to push food along the tract, something like pushing toothpaste out of its tube.

Scleroderma— An autoimmune disease with many consequences, including esophageal wall thickening.

Squamous epithelial cells— Thin, flat cells found in layers or sheets covering surfaces such as skin and the linings of blood vessels and esophagus.

Ulceration— An open break in surface tissue.

Heartburn

Definition

Description

Causes and symptoms

Diagnosis

Treatment

Nutrition/Dietetic concerns

Prognosis

Prevention

Resources

Definition

Heartburn is a burning sensation in the chest that can extend to the neck, throat, and face; it is worsened by bending or lying down. It is the primary symptom of gastroesophageal reflux, which is the movement of stomach acid into the esophagus. On rare occasions, it is due to gastritis (stomach lining inflammation).

Description

More than one-third of the population is afflicted by heartburn, with about one-tenth afflicted daily. Infrequent heartburn is usually without serious consequences, but chronic or frequent heartburn (recurring more than twice per week) can have severe consequences. Accordingly, early management is important.

Understanding heartburn depends on understanding the structure and action of the esophagus. The esophagus is a tube connecting the throat to the stomach. It is about 10 in (25 cm) long in adults, lined with squamous (plate-like) epithelial cells, coated with

mucus, and surrounded by muscles that push food to the stomach by sequential waves of contraction (peristalsis). The lower esophageal sphincter (LES) is a thick band of muscles that encircles the esophagus just above the uppermost part of the stomach. This sphincter is usually tightly closed and normally opens only when food passes from the esophagus into the stomach. Thus, the contents of the stomach are normally kept from moving back into the esophagus.

The stomach has a thick mucous coating that protects it from the strong acid it secretes into its interior when food is present, but the much thinner esophageal coating doesn’t provide protection against acid. Thus, if the LES opens inappropriately or fails to close completely, and stomach contents leak into the esophagus, the esophagus can be burned by acid. The resulting burning sensation is called heartburn.

Occasional heartburn has no serious long-lasting effects, but repeated episodes of gastroesophageal reflux can ultimately lead to esophageal inflammation (esophagitis) and other damage. If episodes occur more frequently than twice a week, and the esophagus is repeatedly subjected to acid and digestive enzymes from the stomach, ulcerations, scarring, and thickening of the esophagus walls can result. This thickening of the esophagus wall causes a narrowing of the interior of the esophagus. Such narrowing affects swallowing and peristaltic movements. Repeated irritation can also result in changes in the types of cells that line the esophagus. The condition associated with these changes is termed Barrett’s syndrome and can lead to esophageal cancer.

KEY TERMS

Barrett’s syndrome —Also called Barrett’s esophagus or Barrett’s epithelia, this is a condition where the squamous epithelial cells that normally line the esophagus are replaced by thicker columnar epithelial cells.

Digestive enzymes —Molecules that catalyze the breakdown of large molecules (usually food) into smaller molecules.

Esophagitis —Inflammation of the esophagus.

Fundoplication —A surgical procedure that increases pressure on the LES by stretching and wrapping the upper part of the stomach around the sphincter.

Gastroesophageal reflux —The flow of stomach contents into the esophagus.

Hiatus hernia —A protrusion of part of the stomach through the diaphragm to a position next to the esophagus.

Metabolic —Refers to the chemical reactions in living things.

Mucus —Thick, viscous, gel-like material that functions to moisten and protect inner body surfaces.

Peristalsis —A sequence of muscle contractions that progressively squeeze one small section of the digestive tract and then the next to push food along the tract, something like pushing toothpaste out of its tube.

Scleroderma —An autoimmune disease with many consequences, including esophageal wall thickening.

Squamous epithelial cells —Thin, flat cells found in layers or sheets covering surfaces such as skin and the linings of blood vessels and esophagus.

Ulceration —An open break in surface tissue.

Causes and symptoms

Causes

A number of different factors may contribute to LES malfunction with its consequent gastroesophageal acid reflux:

• The eating of large meals that distend the stomach can cause the LES to open inappropriately.
• Lying down within two to three hours of eating can cause the LES to open.
• Obesity, pregnancy, and tight clothing can impair the ability of the LES to stay closed by putting pressure on the abdomen.
• Certain drugs, notably nicotine, alcohol, diazepam (Valium), meperidine (Demerol), theophylline, morphine, prostaglandins, calcium channel blockers, nitrate heart medications, anticholinergic and adrenergic drugs (drugs that limit nerve reactions), including dopamine, can relax the LES.
• Progesterone is thought to relax the LES.
• Greasy foods and some other foods such as chocolate, coffee, and peppermint can relax the LES.
• Paralysis and scleroderma can cause the LES to malfunction.
• Hiatus hernia may also cause heartburn according to some gastroenterologists. (Hiatus hernia is a protrusion of part of the stomach through the diaphragm to a position next to the esophagus.)

Symptoms

Heartburn itself is a symptom. Other symptoms also caused by gastroesophageal reflux can be associated with heartburn. Often heartburn sufferers salivate excessively or regurgitate stomach contents into their mouths, leaving a sour or bitter taste. Frequent gastroesophageal reflux leads to additional complications including difficult or painful swallowing, sore throat, hoarseness, coughing, laryngitis, wheezing, asthma, pneumonia, gingivitis, bad breath, and earache.

Diagnosis

Gastroenterologists and internists are best equipped to diagnose and treat gastroesophageal reflux. Diagnosis is usually based solely on patient histories that report heartburn and other related symptoms. Additional diagnostic procedures can confirm the diagnosis and assess damage to the esophagus, as well as monitor healing progress. The following diagnostic procedures are appropriate for anyone who has frequent, chronic, or difficult-to-treat heartburn or any of the complicating symptoms noted in the previous paragraph.

X rays taken after a patient swallows a barium suspension can reveal esophageal narrowing, ulcerations or a reflux episode as it occurs. However, this procedure cannot detect the structural changes associated with different degrees of esophagitis. This diagnostic procedure has traditionally been called the “upper GI series” or “barium swallow” and costs about $250.00.

Esophagoscopy is a newer procedure that uses a thin flexible tube to view the inside of the esophagus directly. It should be done by a gastroenterologist or gastrointestinal endoscopist and costs about $700. It gives an accurate picture of any damage present and gives the physician the ability to distinguish between different degrees of esophagitis.

Other tests may also be used. They include pressure measurements of the LES; measurements of esophageal acidity (pH), usually throughout a 24-hour period; and microscopic examination of biop-sied tissue from the esophageal wall (to inspect esophageal cell structure for Barrett’s syndrome and malignancies).

New technology introduced by 2003 allows for continuous monitoring of pH levels to help determine the cause. A tiny wireless capsule can be delivered to the lining of the esophagus through a catheter and data recorder on a device the size of a pager that is clipped to the patient’s belt or purse for 48 hours. The capsule eventually sloughs off and passes harmlessly through the gastrointestinal tract in seven to 10 days.

Note: A burning sensation in the chest is usually heartburn and is not associated with the heart. However, chest pain that radiates into the arms and is not accompanied by regurgitation is a warning of a possible serious heart problem. Anyone with these symptoms should contact a doctor immediately.

Treatment

Drugs

Occasional heartburn is probably best treated with over-the-counter antacids. These products go straight to the esophagus and immediately begin to decrease acidity. However, they should not be used as the sole treatment for heartburn sufferers who either have two or more episodes per week or who suffer for periods of more than three weeks. There is a risk of kidney damage and other metabolic changes.

H2 blockers (histamine receptor blockers, such as Pepsid AC, Zantac, Tagamet) decrease stomach acid production and are effective against heartburn. H2 blocker treatment also allows healing of esophageal damage but is not very effective when there is a high degree of damage. It takes 30–45 minutes for these drugs to take effect, so they must be taken prior to an episode. Thus, they should be taken daily, usually two to four times per day for several weeks. Six to 12 weeks of standard-dose treatment relieves symptoms in about one-half the patients. Higher doses relieve symptoms in a greater fraction of the population, but at least 25% of heartburn sufferers are not helped by H2 blockers.

Proton-pump inhibitors also inhibit acid production by the stomach, but are much more effective than H2 blockers for some people. They are also more effective in aiding the healing process. Esophagitis is healed in about 90% of the patients undergoing proton-pump inhibitor treatment.

The long-term effects of inhibiting stomach acid production are unknown. Without the antiseptic effects of a consistently very acidic stomach environment, users of H2 blockers or proton-pump inhibitors may become more susceptible to bacterial and viral infection. Absorption of some drugs is also lowered by this less-acidic environment.

Prokinetic agents (also known as motility drugs) act on the LES, stimulating it to close more tightly, thereby keeping stomach contents out of the esophagus. It is not known how effectively these drugs promote healing. Some of the early motility drugs had serious neurological side effects, but a newer drug, cisapride, seems to act only on digestive system nerve connections.

Surgery

Fundoplication, a surgical procedure to increase pressure on the LES by stretching and wrapping the upper part of the stomach around the sphincter, is a treatment of last resort. About 10% of heartburn sufferers undergo this procedure. It is not always effective and its effectiveness may decrease over time, especially several years after surgery. Dr. Robert Marks and his colleagues at the University of Alabama reported in 1997 on the long-term outcome of this procedure. They found that 64% of the patients in their study who had fundoplication between 1992 and 1995 still suffered from heartburn and reported an impaired quality of life after the surgery.

However, laparoscopy (an examination of the interior of the abdomen by means of the laparoscope) now provides hope for better outcomes. Fundoplication performed with a laparoscope is less invasive. Five small incisions are required instead of one large incision. Patients recover faster, and it is likely that studies will show they suffer from fewer surgical complications.

Nutrition/Dietetic concerns

Prevention, as outlined below, is a primary feature for heartburn management in alternative medicine and traditional medicine. Dietary adjustments can eliminate many causes of heartburn.

Herbal remedies include bananas, aloe vera gel, chamomile (Matricaria recutita), ginger (Zingiber officinale), and citrus juices, but there is little agreement here. For example, ginger, which seems to help some people, is claimed by other practitioners to cause heartburn and is thought to relax the LES. There are also many recommendations to avoid citrus juices, which are themselves acidic. Licorice (Glycyrrhiza uralensis)can help relieve the symptoms of heartburn by reestablishing balance in the acid output of the stomach.

Several homeopathic remedies are useful in treating heartburn symptoms. Among those most often recommended are Nux vomica, Carbo vegetabilis, and Arsenicum album Acupressure and acupuncture may also be helpful in treating heartburn.

Sodium bicarbonate (baking soda) is an inexpensive alternative to use as an antacid. It reduces esophageal acidity immediately, but its effect is not long-lasting and should not be used by people on sodium-restricted diets.

Prognosis

The prognosis for people who get heartburn only occasionally or people without esophageal damage is excellent. The prognosis for people with esophageal damage who become involved in a treatment program that promotes healing is also excellent. The prognosis for anyone with esophageal cancer is very poor. There is a strong likelihood of a painful illness and a less than 5% chance of surviving more than five years.

Prevention

Given the lack of completely satisfactory treatments for heartburn or its consequences and the lack of a cure for esophageal cancer, prevention is of the utmost importance. Proponents of traditional andalternative medicine agree that people disposed to heartburn should:

• avoid eating large meals
• avoid alcohol, caffeine, fatty foods, fried foods, hot or spicy foods, chocolate, peppermint, and nicotine
• avoid drugs known to contribute to heartburn, such as nitrates (heart medications such as Isonate and Nitrocap), calcium channel blockers (e.g., Cardizem and Procardia), and anticholinergic drugs (e.g., Pro-banthine and Bentyl), and check with their doctors about any drugs they are taking
• avoid clothing that fits tightly around the abdomen
• control body weight
• wait about three hours after eating before going to bed or lying down
• elevate the head of the bed 6-9 inches to alleviate heartburn at night. This can be done with bricks under the bed or with a wedge designed for this purpose

Preventing heartburn’s switch to cancer begins with preventing heartburn in the first place. A study in Great Britain in 2004 also looked at using a combination of aspirin and an anti-ulcer drug to try to prevent Barrett’s esophagus from forming in patients with long-term heartburn. Aspirin has been found in previous studies to reduce cases of esophageal cancer. However, since one of its side effects is an increased risk of stomach ulcers, the researchers were including an effective anti-ulcer drug for participants.

Resources

PERIODICALS

“Aspirin Trial Launched to Block Heartburn’s Switch to Cancer.” Drug Week January 23, 2004:188.

Bealfsky, Peter C, and William Halsey. “An Endoscopic View of a Wireless pH-Monitoring Capsule.” Ear, Nose and Throat Journal April 2003: 254.

ORGANIZATIONS

The American College of Gastroenterology (ACG). PO Box 3099, Alexandria, VA 22302. (800) HRT-BURN. http://www.healthtouch.com>.

The American Gastroenterological Association (AGA). 7910 Woodmont Ave., 7th Floor, Bethesda, MD 20814.(310) 654-2055. http://www.gastro.org/index.html>.

American Society for Gastrointestinal Endoscopy. 13 Elm St., Manchester, MA 01944. (508) 526-8330. http://www.asge.org/doc/201>.

National Digestive Diseases Information Clearinghouse. 2 Information Way, Bethesda, MD 20892 3570. (800) 891-5389. http://www.niddk.nih.gov/health/digest/nddic.htm>.

Lorraine Lica, PhD

Teresa G. Odle

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

Heartburn (Dyspepsia)

Does the Heart Burn When Someone Has Heartburn?

What Is Heartburn?

How Is Heartburn Diagnosed, Treated, and Prevented?

Resources

Heartburn and dyspepsia (dis-PEP-see-a) are two terms used interchangeably to describe a burning feeling in the chest and other symptoms caused by problems digesting food.

KEYWORDS

for seaching the Internet and other reference sources

Digestive system

Gastroenterology

Does the Heart Burn When Someone Has Heartburn?

Sarah’s grandfather always comes to her house for Sunday dinner. For several weeks in a row, he seemed uncomfortable after eating and did not lie down for his usual nap. Sarah heard him talking to her father about heartburn. This scared Sarah, who thought that her grandfather was having heart problems.

When Sarah asked her grandfather what was wrong with his heart, he explained that people with heartburn, also called acid indigestion, often complain of a burning feeling in the chest, close to where the heart is located. But heartburn usually does not have anything to do with the heart. The discomfort in the chest and throat occurs when the contents of the stomach, which includes acid and digestive enzymes*, moves backward and up into the esophagus, or food pipe. This stomach juice escapes when the muscular valve between the stomach and esophagus relaxes. The acidic juice irritates the lining of the esophagus and results in a burning feeling and a bitter, sour taste in the throat and mouth. Heartburn usually occurs after a meal and can last for several hours. It is often worse when lying down.

* enzymes

are proteins produced by cells to cause biological reactions, such as breaking down food into smaller parts.

What Is Heartburn?

Some people use the word “dyspepsia” to describe the symptoms experienced by Sarah’s grandfather. Dyspepsia comes from the Greek words for bad digestion, and it covers a wide range of stomach ailments, including stomachache, heartburn, nausea, gas, pain, belching, loss of appetite, changes in bowel habits, and indigestion in general.

More than 60 million adults in the United States experience these stomach problems at least once a month, and pregnant women and elderly people especially are prone to them. Children usually do not have heartburn. They might feel indigestion, though, after eating too many hot dogs. Stomach ailments are some of the most common reasons why people visit their doctors.

By themselves, dyspepsia and heartburn are not really diseases. They are just uncomfortable symptoms people get, usually because they ate too much or are feeling stressed, anxious, or depressed. However, people who keep getting the symptoms, or who get them often, should see their doctors promptly, because heartburn and dyspepsia may be signs of other disorders, including:

• Appendicitis is inflammation of the appendix, a small tube connected to the large intestine.
• Peptic ulcer is a sore in the lining of the stomach or small intestine.
• Hiatal hernia occurs when part of the stomach pushes up into the chest through an opening in the diaphragm, the muscle between the chest and the abdomen.
• Lactose intolerance is a problem in digesting lactose, a sugar found in milk and other dairy products.
• Gallbladder disease is inflammation or blockage in the gallbladder, a small organ of the digestive system.
• Gastroesophageal (gas-tro-e-sof-a-JEE-al) reflux disease (GERD) is a digestive condition in which the muscular valve (lower esophageal sphincter) between the esophagus and stomach does not work properly, allowing stomach acid to flow backward into the esophagus.
• True heart pain, which is also called angina pectoris (an-JY-na PEK-tor-is).

Before or After?

Two types of medication for heartburn are sold without a doctor’s prescription (over the counter).

Acid blockers interfere with histamines that signal stomach cells to produce acid. Acid blockers need about 30 minutes to take effect, but usually last for up to eight hours. To work correctly, acid blockers need to be taken before a meal.

Antacids are taken after a meal to neutralize acids already present in the stomach. People usually feel better right away, but relief lasts only a few hours.

How Is Heartburn Diagnosed, Treated, and Prevented?

Doctors use several different tests to diagnose heartburn. If they can rule out other diseases, as was true for Sarah’s grandfather, then over-the-counter antacid medications, dietary changes, and lifestyle changes can help most people feel better.

Guidelines for preventing heartburn include:

• avoiding chocolate, coffee, and alcohol
• avoiding greasy or spicy foods
• quitting smoking
• losing weight
• not eating right before bed
• finding ways to deal with stress.

See also

Appendicitis

Gallstones

Hernia

Lactose Intolerance

Pancreatitis

Peptic Ulcer

Resources

U.S. National Digestive Diseases Information Clearinghouse, 2 Information Way, Bethesda, MD 20892-3570. The NDDIC publishes information about digestive diseases for the public and for health care professionals.

The U.S. National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK) posts a fact sheet about heartburn and gastroesophageal reflux at its website. http://www.niddk.nih.gov/health/digest/pubs/heartbrn/heartbrn.htm

The American College of Gastroenterology has a toll-free telephone number that provides information about heartburn and other stomach problems. Telephone 800-HRT-BURN