Heartburn/GERD
Overview
You've just eaten a big meal and leaned back in your favorite chair. Then it
happens. Your chest starts to hurt so much it feels like it's on fire.
Every day, more than 15 million Americans experience heartburn, which
produces a burning sensation behind the breastbone. You may also experience a
sour taste and the sensation of food re-entering your mouth (regurgitation). It
results from gastroesophageal reflux, a condition in which stomach acid or,
occasionally, bile salts back up into your food pipe (esophagus). When there's
also evidence of esophageal irritation or inflammation, you have
gastroesophageal reflux disease (GERD).
Normally, the lower esophageal sphincter blocks most acid from coming up into
the esophagus. This circular band of muscle at the lower end of the esophagus
doesn't open except when you swallow. If the sphincter relaxes abnormally or
weakens, stomach acid can back up and cause heartburn.
Most people can manage the discomfort of heartburn with lifestyle
modifications, such as improved diet, over-the-counter antacids and weight loss.
But if heartburn is severe, these remedies may offer only temporary or partial
relief. You may need newer, more potent medications to reduce
symptoms.
Signs and
symptoms
If you experience heartburn, you may also experience these signs and
symptoms:
- Chest pain, especially at night while lying down
- Difficulty swallowing (dysphagia)
- Coughing, wheezing, asthma, hoarseness or sore throat
- Regurgitated blood
- Stool that's black, which may mean it contains partially
digested blood
Causes
When you swallow, the lower esophageal sphincter — a circular band of muscle
around the bottom part of your esophagus — relaxes to allow food and liquid to
flow down into your stomach. When it relaxes at any other time, stomach acid
flows back up into your esophagus, even if you're in an upright position. The
acid backup is worse when you're bent over or lying down. Some factors that can
cause the sphincter to relax abnormally include:
- Fatty foods
- Chocolate, caffeine, onions, spicy foods, mint and some medications
- Alcohol
- Large meals
- Lying down soon after eating
- Tranquilizers, such as benzodiazepines including diazepam (Valium) and
alprazolam (Xanax)
- Theophylline (Elixophyllin), an asthma medication
Risk
factors
Conditions that cause difficulty with digestion can increase the risk of
heartburn. These include:
- Obesity. Excess weight puts extra
pressure on your stomach and diaphragm, the large muscle that separates your
chest and abdomen, forcing open the lower esophageal sphincter and allowing
stomach acids to back up into your esophagus. Eating very large meals or meals
high in fat may cause similar effects.
- Hiatal hernia. In this condition, also
called diaphragmatic hernia, part of your stomach protrudes into your lower
chest. If the protrusion is large, a hiatal hernia can worsen heartburn by
further weakening the lower esophageal sphincter muscle.
- Pregnancy. Pregnancy results in greater
pressure on the stomach and a higher production of the hormone progesterone.
This hormone relaxes many of your muscles, including the lower esophageal
sphincter.
- Asthma. Doctors aren't certain of the
exact relationship between asthma and heartburn. It may be that coughing and
difficulty exhaling lead to pressure changes in your chest and abdomen,
triggering regurgitation of stomach acid into your esophagus. Some asthma
medications that widen (dilate) airways may also relax the lower esophageal
sphincter and allow reflux. Or it's possible that the acid reflux that causes
heartburn may worsen asthma symptoms. For example, you may inhale small
amounts of the digestive juices from your esophagus and pharynx, damaging lung
airways.
- Diabetes. One of the many complications
of diabetes is gastroparesis, an uncommon disorder in which your stomach takes
too long to empty. Left in your stomach too long, stomach contents can
regurgitate into your esophagus and cause heartburn.
- Peptic ulcer. An open sore or scar near
the valve (pylorus) in the stomach that controls the flow of food into the
small intestine can keep this valve from working properly or can obstruct the
release of food. Food doesn't empty from your stomach as fast as it should,
causing stomach acid to build up and back up into your esophagus.
- Delayed stomach emptying. In addition
to diabetes or an ulcer, abnormal nerve or muscle functions can delay emptying
of your stomach, causing acid backup into the esophagus.
- Connective tissue disorders. Diseases
such as scleroderma that cause muscular tissue to thicken and swell can keep
digestive muscles from relaxing and contracting as they should, allowing acid
reflux.
- Zollinger-Ellison syndrome. One of the
complications of this rare disorder is that your stomach produces extremely
high amounts of acid, increasing the risk of acid reflux.
When to seek medical
advice
Most problems with heartburn are fleeting and mild. But if you have severe or
frequent discomfort, you may be developing complications that need more
intensive medical treatment and prescription medications. These problems
include:
- Heartburn several times a week
- Heartburn that returns soon after your antacid wears off
- Heartburn that wakes you up at night
In addition, you may need further medical care, possibly even surgery, if you
experience any of these:
- Symptoms that persist even though you're taking prescription medications
- Difficulty swallowing
- Regurgitated blood
- Stool that's black
- Weight loss
Screening and
diagnosis
Usually a description of your symptoms will be all your doctor needs to
establish the diagnosis of heartburn. However, if your symptoms are particularly
severe or don't respond to treatment, you may need to undergo other tests:
- Barium X-ray. This procedure requires
you to drink a chalky liquid that coats and fills the hollows of your
digestive tract. The coating allows your doctor to get a clear silhouette of
the shape and condition of your esophagus, stomach and upper intestine
(duodenum). X-rays can then reveal whether a hiatal hernia may be contributing
to your heartburn. They can also reveal an esophageal narrowing or stricture,
or a growth, which may cause difficulty swallowing.
- Endoscopy. A more direct test for
diagnosing the cause of heartburn is esophagogastroduodenoscopy (EGD). In this
test your doctor inserts a thin, flexible tube equipped with a light and
camera (endoscope) down your throat. The endoscope allows your doctor to see
if you have an ulcerated or inflamed esophagus or stomach (esophagitis or
gastritis, respectively). It can also reveal a peptic ulcer. During an EGD
your doctor can take tissue samples to test for Barrett's esophagus — a
condition in which precancerous changes occur in cells in your esophagus — or
esophageal cancer, two potential complications of severe heartburn. Analysis
of these samples may also reveal the presence of a bacterium that may cause
peptic ulcers.
- Ambulatory acid (pH) probe test. This
test measures acid levels in your upper and lower esophagus, and can help
determine the frequency and duration of acid reflux. While you're sitting, a
nurse or technician sprays your throat with a numbing medication. Then a thin,
flexible tube (catheter) is threaded through your nose into your esophagus.
This probe is positioned just above the lower esophageal sphincter. A second
probe may be placed in your upper esophagus. Attached to the other end of the
catheter is a small computer, which you wear around your waist and which
records acid measurements. Once the device is attached, you go about your
business and then come back the next day to have the device removed. Knowing
the frequency and duration of acid reflux can help your doctor determine how
best to treat the condition.
Complications
In addition to irritation and inflammation of your esophagus (esophagitis),
chronic reflux of stomach acid into your esophagus can lead to one or more of
the following conditions if left untreated:
- Esophageal narrowing (stricture).
Strictures occur in some people with GERD. Damage to cells in the lower
esophagus from acid exposure leads to formation of scar tissue. The scar
tissue narrows the food pathway, causing large chunks of food to get caught up
in the narrowing, and can interfere with swallowing.
- Esophageal ulcer. Stomach acid can
severely erode tissues in the esophagus, causing an open sore. The esophageal
ulcer may bleed, cause pain and make swallowing difficult.
- Barrett's esophagus. This is a serious,
though uncommon, complication of GERD. In Barrett's esophagus, the color and
composition of the tissue lining the lower esophagus change. Instead of pink,
the tissue turns a salmon color. Under a microscope, the tissue resembles that
of the small intestine. This cellular change is called metaplasia. Metaplasia
is brought on by repeated and long-term exposure to stomach acid and is
associated with an increased risk of esophageal cancer.
Treatment
Whether you have mild, moderate or severe heartburn, many treatment options
are available. The most common treatments involve medications, but surgical and
other procedures also are available.
Over-the-counter remedies
If you experience only
occasional, mild heartburn, you may get relief from an over-the-counter (OTC)
medication. OTC remedies include:
- Antacids. Antacids, such as Maalox,
Mylanta, Gelusil, Rolaids and Tums, neutralize stomach acid and can provide
quick relief. But antacids alone won't heal an inflamed esophagus damaged by
stomach acid. Overuse of some antacids can cause side effects such as diarrhea
or constipation.
- H-2-receptor blockers. H-2-receptor
blockers, such as cimetidine (Tagamet HB), famotidine (Pepcid AC), nizatidine
(Axid AR) or ranitidine (Zantac 75), are available at half the strength of
their prescription versions. Instead of neutralizing the acid, these
medications reduce the production of acid. They don't act as quickly as
antacids, but they provide longer relief. Take these medications before a meal
that you think may cause heartburn because it takes them about 30 minutes to
work. They're also effective in reducing reflux at night if taken at bedtime.
H-2-receptor blockers cause infrequent side effects, including bowel changes,
dry mouth, dizziness or drowsiness. In rare instances they can also react
dangerously with other medications.
- Proton pump inhibitors. These
medications block acid production and allow time for damaged esophageal tissue
to heal. Omeprazole (Prilosec) was previously available only by prescription,
but now is available in an over-the-counter form for treatment of heartburn.
Prescription-strength medications
If you have frequent
and persistent heartburn, you may have GERD, leading to an inflamed esophagus
(esophagitis). GERD usually requires prescription-strength medication.
Prescription medications can help reduce and eliminate GERD symptoms, as well as
help heal an inflamed esophagus — the result of continual exposure to stomach
acid. The main types of prescription drugs are:
- Prescription-strength H-2-receptor
blockers. These significantly reduce acid production and have few
side effects. They include prescription-strength Axid, Pepcid, Tagamet and
Zantac.
- Prescription-strength proton pump
inhibitors. These are long acting and are the most effective
medications for suppressing acid production. They're safe and have few side
effects for long-term treatment (at least 10 years). To prevent possible side
effects, such as stomach or abdominal pain, diarrhea or headaches, your doctor
will likely prescribe the lowest effective dose. Prescription-strength proton
pump inhibitors include esomeprazole (Nexium), lansoprazole (Prevacid),
omeprazole (Prilosec), pantoprazole (Protonix) and rabeprazole (Aciphex).
- Prokinetic agents. These don't reduce
acid production. Instead, they help your stomach empty more rapidly and may
help tighten the valve between the stomach and the esophagus. Because the
prokinetic agents thus far sometimes cause serious side effects, researchers
are working to develop safer versions.
Surgical and other procedures
Because of the
effectiveness of medications, surgery for GERD is uncommon. However, it may be
an option if you can't tolerate the medications, the medications are
ineffective, or you can't afford their long-term use. Your doctor also may
recommend surgery if you have any of these complications:
- Large hiatal hernia
- Severe esophagitis, especially with bleeding
- Recurrent narrowing (stricture) of the esophagus
- Barrett's esophagus, especially with progressive precancerous or cancerous
changes
- Severe pulmonary problems, such as bronchitis or pneumonia, due to acid
reflux
Before 1991, a procedure called open Nissen fundoplication was the surgery of
choice for severe GERD. Today, doctors are able to perform the same surgery with
similar success laparoscopically — through a few small abdominal incisions,
instead of one large one. The advantages of laparoscopic surgery are a shorter
recovery time and less discomfort.
Nissen fundoplication involves tightening the lower esophageal sphincter to
prevent reflux by wrapping the very top of the stomach around the outside of the
lower esophagus. During laparoscopic surgery, a surgeon makes three or four tiny
incisions in the abdomen and inserts small instruments, including a flexible
tube with a tiny camera, through the incisions. To provide more space for your
surgeon to see and work, your abdomen is inflated with carbon dioxide. The
surgery takes about 2 hours and typically requires an overnight hospital
stay.
More than 90 percent of the people who undergo Nissen fundoplication remain
free of GERD symptoms for at least 1 year. At least 60 percent are symptom-free
for several years. This success rate applies to both the laparoscopic and open
procedures.
Other surgical procedures include Toupet partial fundoplication, Hill repair
and the Belsey Mark IV operation. All involve restructuring the lower esophageal
sphincter to improve its strength and ability to prevent reflux. These surgeries
are done less often, and their success is often dependent on the skill of the
surgeon.
Complications from surgery generally are mild, but may include difficulty
swallowing, bloating, diarrhea and a sense of feeling full after eating only a
moderate amount (early satiety).
Newer, less invasive procedures
Your doctor may suggest
one of several procedures for tightening the lower esophageal sphincter. The
procedures generally take an hour or less to perform, they don't require any
incisions, and you can go home the same day. The procedures are performed
endoscopically through a long, flexible tube that's inserted into your mouth and
threaded through your esophagus. None of the procedures are recommended if you
have a hiatal hernia or Barrett's esophagus.
- EndoCinch endoluminal gastroplication.
This procedure uses a tool that's like a miniature sewing machine. It places
pairs of stitches (sutures) in the stomach near the weakened sphincter. The
suturing material is then tied together, creating barriers (plications) to
prevent stomach acid from washing into your esophagus. The barriers are
located at and just below the junction of the esophagus and stomach. The
procedure may cause a sore throat or chest pain. The long-term effectiveness
of the procedure is still unknown.
- Stretta procedure. This approach uses
controlled radiofrequency energy to heat and melt (coagulate) tissues within
the portion of the esophagus that contains the malfunctioning valve and at the
junction of the esophagus and upper stomach. The procedure appears to work by
creating scar tissue and altering the sensory nerves that respond to refluxed
acid. The procedure may cause a sore throat or chest pain. The long-term
effectiveness of the procedure is still unknown.
- Enteryx. This procedure involves the
injection of a compound called ethylene polyvinyl alcohol into the lower
esophageal sphincter, just within the stomach. The injection is done with
guidance from real-time X-ray. The compound is in liquid form outside the
body, but when it comes into contact with the tissues inside the body, it
turns into an expanding, spongy material. The procedure may cause a sore
throat or chest pain, and the long-term effectiveness of the procedure is
still unknown.
Prevention
You may eliminate or reduce the frequency of heartburn by making the
following lifestyle changes:
- Control your weight. Being overweight
is one of the strongest risk factors for heartburn. Excess pounds put pressure
on your abdomen, pushing up your stomach and causing acid to back up into your
esophagus.
- Eat smaller, more frequent meals. Three
smaller meals a day, with small snacks in between, will help you stop
overeating. Continual overeating leads to excess weight, which aggravates
heartburn.
- Loosen your belt. Clothes that fit
tightly around your waist put pressure on your abdomen and the lower
esophageal sphincter.
- Eliminate heartburn triggers. Everyone
has specific triggers. Common triggers such as fatty or fried foods, alcohol,
chocolate, peppermint, garlic, onion, caffeine and nicotine may make heartburn
worse.
- Avoid stooping or bending. Tying your
shoes is OK. Bending over for longer periods to weed your garden isn't,
especially soon after eating.
- Don't lie down after a meal. Wait at
least three to four hours after eating before going to bed, and don't lie down
right after eating.
- Raise the head of your bed. An
elevation of about 6 inches puts gravity to work for you. You can do this by
placing wooden or cement blocks under the feet at the head of your bed. If
it's not possible to elevate your bed, you can insert a wedge between your
mattress and box spring to elevate your body from the waist up. Wedges are
available at drugstores and medical supply stores. Raising your head only by
using pillows is not a good alternative.
- Don't smoke. Smoking may increase
stomach acid. The swallowing of air during smoking may also aggravate belching
and acid reflux. In addition, smoking and alcohol increase your risk of
esophageal cancer.
Complementary and
alternative medicine
Several home remedies exist for treating heartburn, but they provide only
temporary relief. They include drinking baking soda (sodium bicarbonate) added
to water or drinking other fluids such as soda pop or milk.
Although these liquids create temporary relief by neutralizing, washing away
or buffering acids, eventually they aggravate the situation by adding gas and
fluid to your stomach, increasing pressure and causing more acid reflux.
Further, adding more sodium to your diet may increase your blood pressure and
add stress to your heart, and excessive bicarbonate ingestion can alter the
acid-base balance in your body.
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By
Mayo Clinic staff
