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
gastroesophageal reflux, which is
the movement of stomach acid into the esophagus. Heartburn is generally related
to meals and posture. On rare occasions, it is due to gastritis (stomach lining
What causes Heartburn?:
Understanding heartburn depends on understanding the
structure and action of the esophagus. The esophagus is a tube connecting the
throat to the stomach. The esophagus carries food and liquid into the stomach.
At the lower end of the esophagus where it enters the stomach, there is a strong
muscular ring called the lower esophageal sphincter (LES). The LES should remain
tightly closed, except to allow food and liquid to pass into the stomach. Reflux
occurs when the
LES is not working properly. It may relax
for periods of time throughout the day and night, or it may be constantly too
weak to function effectively. This allows the stomach's acid juices to flow into
Heartburn and reflux are extremely
common, with 10 percent of the population experiencing them daily.
Twenty-five percent of pregnant women have heartburn. Even though heartburn
is common, it is rarely life threatening.
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. How severe
the disease becomes depends on how weakened the LES is, and the amount and
duration of acid refluxed into the esophagus.
contributing to Heartburn :
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
Lying down within two to three hours of eating
can cause the LES to
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
(medicines that slow the movement of calcium into the cells of the heart and
blood vessels.), nitrate heart medications, anticholinergic and adrenergic
drugs (drugs that limit nerve reactions), including dopamine, can relax the
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
A burning feeling in the chest
just behind the breastbone that occurs
eating and lasts a few minutes to several hours.
Chest pain, especially after bending over, lying down,
Burning in the throat -- or hot, sour, acidic, or
salty-tasting fluid at the back of the throat.
Feeling of food "sticking" in the middle of the chest
Other symptoms include:
Chronic sore throat
Difficulty or pain when swallowing
Waterbrash (sudden excess of saliva)
Sour taste in the mouth
Inflammation of the gums
Erosion of tooth enamel (the surface of the teeth)
NOTE: chest pain is also a symptom of heartburn.
However, it is often difficult to differentiate
chest pain due to heartburn/GERD
and chest pain due to heart disease. Therefore, be sure to get all chest pain
evaluated IMMEDIATELY by a health care professional
Heartburn Diagnosis :
The primary tests used to diagnose heartburn
Upper GI Endoscopy- The patient is mildly sedated
and a flexible
videoscope is inserted
into the esophagus to visually inspect it and the stomach.
Upper GI Series- The patient drinks liquid barium
and x-rays are taken of the esophagus and stomach showing how they
Esophageal manometry- The primary benefit of the
exam is that the physician has clear documentation of the muscle function of
the esophagus. With this information, a specific treatment program can be
outlined or reassurance provided if the exam is normal. There are really no
serious problems associated with manometry. Slight gagging is normal during
the exam, and a temporary sore throat may be present afterward.
24 hour Ambulatory pH (acid) Monitoring-
Ambulatory pH (acid) monitoring is considered the gold standard for
objectively assessing acid reflux activity and can confirm significant gastroesophageal reflux disease. pH monitoring is usually performed prior to
any antireflux procedure. Traditionally, a tiny tube is placed through the
nose and into the esophagus (food tube) above the lower esophageal
sphincter. The test runs for 24 hours and measures the number of times acid
enters the esophagus. A newer technology is now available called The BRAVO
System. It is a wireless transmitting capsule which is placed usually
following endoscopy. It is introduced through the mouth and attached to the
esophagus by way of a clipping system. It will measure acid reflux activity
for 48 hours and the capsule will usually fall off within 3 to 5 days and is
Lifestyle Changes- may include daily dietary
changes combined with day to day living.
usually recommend their patients try raising the head of the bed (about six
inches) or sleep on a specially designed wedge. If you cannot raise the head
of your bed, you can also slide blocks or books under the legs at the head
of the bed. Raising the head of the bed and avoiding heavy lifting
reduces heartburn by allowing gravity to minimize reflux of the stomach's
contents into the esophagus.
Taking off any
extra weight is advisable. You also
may want to loosen your belt and avoid wearing tight clothing.
usually recommended to help keep weight off and increase overall fitness.
lifting heavy objects or bending forward if possible.
Quitting smoking is also recommended because both
weaken the LES, (lower esophageal sphincter) and increase stomach acid
production and irritation.
Avoid foods and
beverages that can weaken or take pressure off the LES . It is important to
avoid food close to bedtime (usually 2-3
Eat more slowly. Downing a lot of food in a hurry can
cause the stomach to produce extra digestive acids.
Eat smaller and more frequent meals. After eating,
don't bend over, lie down, or go to sleep for two to four hours.
Eat more healthy including
fiber in your diet
Foods to be avoided:
Citrus and tomato products
Drinks that contain caffeine (coffee, tea, chocolate and some sodas)
Carbonated drinks, (diet and non-diet)
Over-the-counter (non-prescription) remedies such as
antacids may also offer some comfort. They are usually taken after meals or at
bedtime. Antacids, if taken regularly, can neutralize acid in the esophagus
and stomach and stop heartburn. Antacids usually provide at least temporary or
partial relief. Antacids can also be combined with a foaming agent such as alginic acid to bring relief. These compounds are believed to form a foam
barrier on top of the stomach that prevents acid reflux from occurring. If an
antacid has not provided relief in several weeks, it probably won't.
Long-term use of antacids can result in side effects,
including diarrhea, constipation, changes in the way your calcium metabolizes,
and a build-up of magnesium in the body. Persons with kidney disease should be
especially careful not to get too much
magnesium; if antacids are needed for
more than 3 weeks, a doctor should be consulted. Persons with high
pressure should also check with their doctor before taking antacids, since
they can be high in sodium.
If the symptoms continue, your doctor may prescribe
medicine that can cut down on stomach acid production or speed up
digestion.(H-2 blockers) These could include:
(Some of these medications are now available at lower dosage without a
Other medical approaches include increasing the strength
of the LES and quicken emptying of stomach contents with motility drugs that
act on the upper gastrointestinal tract. These drugs include cisapride,
bethanechol and metoclopramide.
Propulsid (cisapride), Reglan (metoclopramide) and
bethanechol chloride are usually used along with H-2 blockers. They strengthen
the squeezing action of the esophagus and tighten the LES to relieve GERD.
Metoclopramide has the added benefit of making the stomach empty faster.
Cisapride may cause some side effects including
abdominal cramps, constipation, diarrhea and increased nervousness.
Metoclopramide can cause fatigue, as well as other more serious side effects.
Bethanechol chloride can cause nausea and vomiting especially if it is taken
too soon after eating.
Another type of drug, the proton pump (or acid pump)
inhibitor omeprazole inhibits an enzyme ( protein in the acid-producing cells
of the stomach) necessary for acid secretion, and thus stops stomach acid
production. The acid pump inhibitor lansoprazole is being investigated as a
new treatment for GERD. These drugs are usually prescribed for short-term use.
They may cause side effects including stomach or abdominal pain, diarrhea and
Frequently, combinations of drugs are prescribed to
relieve your symptoms. Aspirin and anti-inflammatory drugs like ibuprofen
reduce the protective lining of your stomach, which can lead to more
irritation. Be sure to check with your doctor or pharmacist before taking any
new medicine to discuss other medicines you may be taking and how these new
medications might interact with them.
If you are having trouble swallowing, your doctor may
recommend that your esophagus be stretched by a medical procedure. The
procedure may need to be repeated over a period of a few days until your
esophagus is wide enough to pass solid food again. Larger tubes may be used to
stretch the esophagus and make the passageway wider if you continue having
trouble swallowing. While many patient report relief with this less invasive
treatment, it is not a cure and quite often symptoms reoccur.
Surgery may be an option:
If symptoms do not improve with medications or return
after medication is stopped.
If lifelong medication is needed.
If you are unwilling or unable to take medication
regularly for prolonged periods.
If reflux has severely damaged the esophagus.
Today, the procedure to relieve esophageal reflux
disease can be performed through the traditional open technique or through
minimally invasive surgery, also known as laparoscopy or laparoscopic fundoplication. Both surgical procedures increase pressure in the lower
esophagus by tightening or rebuilding the gastro-esophageal valve. This
surgery restores the stomach to its original position and strengthens the area
around the valve opening.
Laparoscopic surgery is performed through several small
incisions instead of a single long one, as in the traditional open procedure.
As a result, there is less pain, a quicker recovery time, a shorter hospital
stay, and a lower risk of infection.
Another treatment offered is a nonsurgical, minimally
invasive radiofrequency procedure that is done on an outpatient basis.
Patients go home the same day.
The treatment is delivered via an endoscope. A
balloon-tipped catheter is inserted into the esophagus. The miniature balloon
has tiny needle electrodes on its surface. The electrodes deliver a controlled
amount of radiofrequency energy to spots above and below the junction of the
stomach and esophagus. The radiofrequency energy causes tiny burns that heal
and form scar tissue. The scar tissue actually tightens the weak valve.