Heartburn Explained

Heartburn
Synonym:	Pyrosis,^[1] cardialgia
Specialty:	Gastroenterology, family medicine, emergency medicine
Symptoms:	Burning, stabbing, or squeezing sensation in the chest, nausea, belching
Causes:	Gastroesophageal reflux disease
Risks:	Smoking, obesity
Diagnosis:	Physical examination, medical history, antacid response, imaging, manometry
Differential:	Chest pain, heart attack, gastritis, peptic ulcer disease, esophageal spasms, esophageal strictures, duodenitis, cancer, Crohn's disease
Prevention:	Avoid foods that are high in fats, spicy, high in artificial flavors. Avoid reclining 3–4 hours after a meal, heavy NSAID use, heavy alcohol consumption. Decrease peppermint consumption. Chew foods thoroughly between bites, consume meals with plenty of liquid, and ensure adequate time to eat meals in a non-hurried fashion
Treatment:	Antacids, weight loss, surgery
Medication:	Antacids

Heartburn, also known as pyrosis, cardialgia or acid indigestion,^[2] is a burning sensation in the central chest or upper central abdomen.^{[3] [4]} Heartburn is usually due to regurgitation of gastric acid (gastric reflux) into the esophagus. It is the major symptom of gastroesophageal reflux disease (GERD).^[5]

Other common descriptors for heartburn (besides burning) are belching, nausea, squeezing, stabbing, or a sensation of pressure on the chest. The pain often rises in the chest (directly behind the breastbone) and may radiate to the neck, throat, or angle of the arm. Because the chest houses other important organs besides the esophagus (including the heart and lungs), not all symptoms related to heartburn are esophageal in nature.^[6]

The cause will vary depending on one's family and medical history, genetics, if a person is pregnant or lactating, and age. As a result, the diagnosis will vary depending on the suspected organ and the inciting disease process. Work-up will vary depending on the clinical suspicion of the provider seeing the patient, but generally includes endoscopy and a trial of antacids to assess for relief.

Treatment for heartburn may include medications and dietary changes. Medication include antacids. Dietary changes may require avoiding foods that are high in fats, spicy, high in artificial flavors, heavily reducing NSAID use, avoiding heavy alcohol consumption, and decreasing peppermint consumption. Lifestyle changes may help such as reducing weight.

Definition

The term indigestion includes heartburn along with a number of other symptoms.^[7] Indigestion is sometimes defined as a combination of epigastric pain and heartburn.^[8] Heartburn is commonly used interchangeably with gastroesophageal reflux disease (GERD) rather than just to describe a symptom of burning in one's chest.^[9]

Differential diagnosis

Heartburn-like symptoms and/or lower chest or upper abdomen may be indicative of much more sinister and/or deadly disease.^[10] Of greatest concern is to confuse heartburn (generally related to the esophagus) with a heart attack as these organs share a common nerve supply.^[11] Numerous abdominal and thoracic organs are present in that region of the body. Many different organ systems might explain the discomfort called heartburn.

Heart

The most common symptom for a heart attack is chest pain.^[12] However, as many as 30% of people who receive cardiac catheterization for chest pain have findings that do not account for their chest discomfort. These are often defined as having "atypical chest pain" or chest pain of undetermined origin.^[13] Women experiencing heart attacks may also deny classic signs and symptoms^[14] and instead complain of GI symptoms.^{[12] [15] [16]} One article estimates that ischemic heart disease may appear to be GERD in 0.6% of people.^[11]

Esophagus

• GERD (most common cause of heartburn) – occurs when acid refluxes from the stomach and inflames the esophagus.^[3]
• Esophageal spasms – typically occur after eating or drinking and may be combined with difficulty swallowing.^[17]
• Esophageal strictures
• Esophageal cancers
• Mallory-Weis tears – tears of the superficial mucosa of the esophagus that are subsequently exposed to gastric acid commonly due to vomiting and/or retching
• Eosinophilic esophagitis – a disease commonly associated with other atopic diseases such as asthma, food allergies, seasonal allergies, and atopic skin disease
• Chemical esophagitis – related to the intake of caustic substances, excessive amounts of hot liquids, alcohol, or tobacco smoke
• Infectious esophagitis – especially CMV and certain fungal infections, most common in immunocompromised persons^[18]

Stomach

• Peptic ulcer disease^[19] – can be secondary to Helicobacter pylori infection or heavy NSAID use that weakens stomach mucosal layer. Pain often worsens with eating.
• Stomach cancer

Intestines

• Intestinal ulcers – generally secondary to other conditions such as H. pylori infection or cancers of the gastrointestinal tract. Pain often improves with eating.
• Duodenitis – inflammation of the small intestine. May be the result of several conditions.

Gallbladder

• Gallstones

Pancreas

• Pancreatitis – can be autoimmune, due to a gallstone obstructing the lumen, related to alcohol consumption.

Hematology

• Pernicious anemia – can be autoimmune, due to atrophic gastritis.^[20]

Pregnancy

Heartburn is common during pregnancy having been reported in as many as 80% of pregnancies.^[21] It is most often due to GERD and results from relaxation of the lower esophageal sphincter (LES), changes in gastric motility, and/or increasing intra-abdominal pressure.^{[22] [21]} The onset of symptoms can be during any trimester of pregnancy.

• Hormonal – related to the increasing amounts of estrogen and progesterone and their effect on the LES
• Mechanical – the enlarging uterus increasing intra-abdominal pressure, inducing reflux of gastric acid
• Behavioral – as with other instances of heartburn, behavioral modifications can exacerbate or alleviate symptoms

Unknown origin

Functional heartburn is heartburn of unknown cause.^[23] It is commonly associated with psychiatric conditions like depression and anxiety. It is also seen with other functional gastrointestinal disorders like irritable bowel syndrome and is the primary cause of lack of improvement post treatment with proton pump inhibitors (PPIs).^[23] Despite this, PPIs are still the primary treatment with response rates in about 50% of people.^[23] The diagnosis is one of elimination, based upon the Rome III criteria. It was found to be present in 22.3% of Canadians in one survey.

!!Rome III Criteria

1	Burning retrosternal discomfort
2	Elimination of heart attack and GERD as the cause
3	No esophageal motility disorders

Diagnostic approach

Heartburn can be caused by several conditions and a preliminary diagnosis of GERD is based on additional signs and symptoms. The chest pain caused by GERD has a distinct 'burning' sensation, occurs after eating or at night, and worsens when a person lies down or bends over.^[24] It also is common in pregnant women, and may be triggered by consuming food in large quantities, or specific foods containing certain spices, high fat content, or high acid content.^{[24] [25]} In young persons (typically <40 years) who present with heartburn symptoms consistent with GERD (onset after eating, when lying down, when pregnant), a physician may begin a course of PPIs to assess clinical improvement before additional testing is undergone.^[26] Resolution or improvement of symptoms on this course may result in a diagnosis of GERD.

Other tests or symptoms suggesting acid reflux is causing heartburn include:

• Onset of symptoms after eating or drinking, at night, and/or with pregnancy, and improvement with PPIs
• Endoscopy looking for erosive changes of the esophagus consistent with prolonged acid exposure (e.g. - Barrett's esophagus)^[26]
• Upper GI series looking for the presence of acid reflux^{[25] [27]}

GI cocktail

See main article: article and GI cocktail. Relief of symptoms 5 to 10 minutes after the administration of viscous lidocaine and an antacid increases the suspicion that the pain is esophageal in origin.^[28] This however does not rule out a potential cardiac cause^[29] as 10% of cases of discomfort due to cardiac causes are improved with antacids.^[30]

Biochemical

Esophageal pH monitoring

a probe can be placed via the nose into the esophagus to record the level of acidity in the lower esophagus. Because some degree of variation in acidity is normal, and small reflux events are relatively common, esophageal pH monitoring can be used to document reflux in real-time.^[31] Patients are able to record symptom onset to correlate lower esophageal pH with time of symptom onset.

Mechanical

Manometry

in this test, a pressure sensor (manometer) is passed via the mouth into the esophagus and measures the pressure of the LES directly.^[32]

Endoscopy

the esophageal mucosa can be visualized directly by passing a thin, lighted tube with a tiny camera known as an endoscope attached through the mouth to examine the oesophagus and stomach. In this way, evidence of esophageal inflammation can be detected, and biopsies taken if necessary. Since an endoscopy allows a doctor to visually inspect the upper digestive tract the procedure may help identify any additional damage to the tract that may not have been detected otherwise.^[33]

Biopsy

a small sample of tissue from the oesophagus is removed. It is then studied to check for inflammation, cancer, or other problems.^[32]

Treatment

Treatment plans are tailored to the specific diagnosis and etiology of the heartburn. Management of heartburn can be sorted into various categories.

Pharmacologic management

• Antacids (i.e. calcium carbonate and sodium bicarbonate) are often taken to treat the immediate problem^[34]
• H2 receptor antagonists or proton pump inhibitors are effective for the two most common causes of heartburn (e.g. gastritis and GERD)
• Antibiotics are used if H. pylori is present.

Behavioral management

• Taking medications 30–45 minutes before eating suppresses the stomach's acid generating response to food
• Avoiding chocolate, peppermint, caffeine intake, and foods high in fats ^[35]
• Limiting big meals, instead consuming smaller, more frequent meals
• Avoiding reclining 2.5–3.5 hours after a meal to prevent the reflux of stomach contents

Lifestyle modifications

• Early studies show that diets that are high in fiber may show evidence in decreasing symptoms of dyspepsia.^[36]
• Weight loss can decrease abdominal pressure that both delays gastric emptying and increases gastric acid reflux into the esophagus
• Smoking cessation

Alternative and complementary therapies

Symptoms of heartburn may not always be the result of an organic cause. Patients may respond better to therapies targeting anxiety, through medications aimed towards a psychiatric etiology, osteopathic manipulation, and acupuncture.

• Psychotherapy may show a positive role in treatment of heartburn and the reduction of distress experienced during symptoms.
• Acupuncture – in cases of PPI failure, adding acupuncture may be more effective than doubling the dose of PPIs.^[37]

Surgical management

In the case of GERD causing heartburn symptoms, surgery may be required if PPI is not effective.^[38] Surgery is not undergone if functional heartburn is the leading diagnosis.^[39]

Epidemiology

About 42% of the United States population has had heartburn at some point.^[40]

Notes and References

1. Web site: Pyrosis definition - MedicineNet - Health and Medical Information Produced by Doctors . MedicineNet . 19 November 2015 . live . https://web.archive.org/web/20140123014008/http://www.medterms.com/script/main/art.asp?articlekey=32175 . 23 January 2014 .
2. Web site: Gastroesophageal Reflux (GER) and Gastroesophageal Reflux Disease (GERD) in Adults . The National Institute of Diabetes and Digestive and Kidney Diseases . 2015-07-24 . live . https://web.archive.org/web/20150725032223/http://www.niddk.nih.gov/health-information/health-topics/digestive-diseases/ger-and-gerd-in-adults/Pages/overview.aspx . 2015-07-25 .
3. Book: Differential diagnosis in primary care . Wolters Kluwer Health/Lippincott Williams & Wilkins . Philadelphia . 2008 . 211 . 978-0-7817-6812-2 .
4. Web site: Pyrosis Medical Definition - Merriam-Webster Medical Dictionary. merriam-webster.com. 24 July 2015. live. https://web.archive.org/web/20150725013215/http://www.merriam-webster.com/medical/pyrosis. 25 July 2015.
5. Web site: Heartburn. live. https://web.archive.org/web/20160312161013/http://www.nlm.nih.gov/cgi/mesh/2005/MB_cgi?mode&term=heartburn. 2016-03-12. 2015-07-24. National Library of Medicine.
6. Book: Johnson K, Ghassemzadeh S . Chest Pain . 2024 . StatPearls . http://www.ncbi.nlm.nih.gov/books/NBK470557/ . 2024-04-28 . Treasure Island (FL) . StatPearls Publishing . 29262011 .
7. Book: Duvnjak M . Dyspepsia in clinical practice. 2011. Springer. New York. 9781441917300. 2. live. https://web.archive.org/web/20150621133125/https://books.google.ca/books?id=UGpATfS5-T8C&pg=PA2. 2015-06-21.
8. Delaney B, Ford AC, Forman D, Moayyedi P, Qume M . Initial management strategies for dyspepsia . The Cochrane Database of Systematic Reviews . 4 . CD001961 . October 2005 . 16235292 . 10.1002/14651858.CD001961.pub2 . Delaney B .
9. Book: Sajatovic, Loue S, Koroukian SM . Encyclopedia of aging and public health . Springer . Berlin . 2008 . 419 . 978-0-387-33753-1 .
10. Bautz B, Schneider JI . High-Risk Chief Complaints I: Chest Pain-The Big Three (an Update) . Emergency Medicine Clinics of North America . 38 . 2 . 453–498 . May 2020 . 32336336 . 10.1016/j.emc.2020.01.009 . 216556980 .
11. Kato H, Ishii T, Akimoto T, Urita Y, Sugimoto M . Prevalence of linked angina and gastroesophageal reflux disease in general practice . World Journal of Gastroenterology . 15 . 14 . 1764–1768 . April 2009 . 19360921 . 2668783 . 10.3748/wjg.15.1764 . free .
12. van Oosterhout RE, de Boer AR, Maas AH, Rutten FH, Bots ML, Peters SA . Sex Differences in Symptom Presentation in Acute Coronary Syndromes: A Systematic Review and Meta-analysis . Journal of the American Heart Association . 9 . 9 . e014733 . May 2020 . 32363989 . 7428564 . 10.1161/JAHA.119.014733 .
13. Web site: Heartburn and Regurgitation. dead. https://web.archive.org/web/20110116013416/http://www.uwgi.org/guidelines/ch_03/ch03txt.htm. 2011-01-16. 2010-06-21.
14. Waller CG . Understanding prehospital delay behavior in acute myocardial infarction in women . Critical Pathways in Cardiology . 5 . 4 . 228–234 . December 2006 . 18340239 . 10.1097/01.hpc.0000249621.40659.cf .
15. Patel H, Rosengren A, Ekman I . Symptoms in acute coronary syndromes: does sex make a difference? . American Heart Journal . 148 . 1 . 27–33 . July 2004 . 15215788 . 10.1016/j.ahj.2004.03.005 .
16. Kawamoto KR, Davis MB, Duvernoy CS . Acute Coronary Syndromes: Differences in Men and Women . Current Atherosclerosis Reports . 18 . 12 . 73 . December 2016 . 27807732 . 10.1007/s11883-016-0629-7 . 40109195 .
17. http://www.mayoclinic.com/health/esophageal-spasms/DS00763/DSECTION=symptoms MedlinePlus: Esophageal spasms
18. Book: Robbins basic pathology . 2018 . Kumar V, Abbas AK, Aster JC, Perkins JA . 978-0-323-35317-5 . Tenth . Philadelphia, Pennsylvania . Elsevier . 960844656.
19. Oustamanolakis P, Tack J . Dyspepsia: organic versus functional . Journal of Clinical Gastroenterology . 46 . 3 . 175–190 . March 2012 . 22327302 . 10.1097/MCG.0b013e318241b335 . 397315 .
20. Web site: Pernicious anemia: MedlinePlus Medical Encyclopedia . 2022-06-08 . medlineplus.gov . en.
21. Richter JE . Gastroesophageal reflux disease during pregnancy . Gastroenterology Clinics of North America . 32 . 1 . 235–261 . March 2003 . 12635418 . 10.1016/s0889-8553(02)00065-1 .
22. Van Thiel DH, Gavaler JS, Joshi SN, Sara RK, Stremple J . Heartburn of pregnancy . Gastroenterology . 72 . 4 Pt 1 . 666–668 . April 1977 . 14050 . 10.1016/S0016-5085(77)80151-0 . free .
23. Fass R . Functional heartburn: what it is and how to treat it . Gastrointestinal Endoscopy Clinics of North America . 19 . 1 . 23–33, v . January 2009 . 19232278 . 10.1016/j.giec.2008.12.002 .
24. http://www.mayoclinic.com/health/heartburn-gerd/DS00095 The Mayo Clinic Heartburn page
25. https://www.nlm.nih.gov/medlineplus/heartburn.html The MedlinePlus Heartburn page
26. Domingues G, Moraes-Filho JP, Fass R . Refractory Heartburn: A Challenging Problem in Clinical Practice . Digestive Diseases and Sciences . 63 . 3 . 577–582 . March 2018 . 29352757 . 10.1007/s10620-018-4927-5 . 3430229 .
27. http://digestive.niddk.nih.gov/ddiseases/pubs/uppergi/ National Digestive Diseases Information Clearinghouse (NDDIC): Upper GI Series
28. Book: Differential diagnosis in primary care . Wolters Kluwer Health/Lippincott Williams & Wilkins . Philadelphia . 2008 . 213 . 978-0-7817-6812-2 .
29. Swap CJ, Nagurney JT . Value and limitations of chest pain history in the evaluation of patients with suspected acute coronary syndromes . JAMA . 294 . 20 . 2623–2629 . November 2005 . 16304077 . 10.1001/jama.294.20.2623 . free .
30. Book: Hanke BK, Schwartz GR . Principles and practice of emergency medicine . Williams & Wilkins . Baltimore . 1999 . 656 . 978-0-683-07646-2 . registration .
31. Johnson LF, Demeester TR . Twenty-four-hour pH monitoring of the distal esophagus. A quantitative measure of gastroesophageal reflux . The American Journal of Gastroenterology . 62 . 4 . 325–332 . October 1974 . 4432845 .
32. Web site: Gastroesophageal Reflux Disease. The Lecturio Medical Concept Library . 23 July 2021.
33. Encyclopedia: Endoscopy . British Medical Association Complete Family Health Encyclopedia . 1990 . Dorling Kindersley Limited .
34. Web site: What Are Antacids? - TUMS®. www.heartburn.com. 29 April 2018. live. https://web.archive.org/web/20170302110554/http://www.heartburn.com/ReliefAndManagement/Antacids.aspx. 2 March 2017.
35. Web site: Q.D. Pham Co . September 1, 2018 . Dyspepsia and GERD . 2024-04-14 . Canadian Pharmacists Association (CPS).
36. Morozov S, Isakov V, Konovalova M . Fiber-enriched diet helps to control symptoms and improves esophageal motility in patients with non-erosive gastroesophageal reflux disease . World Journal of Gastroenterology . 24 . 21 . 2291–2299 . June 2018 . 29881238 . 5989243 . 10.3748/wjg.v24.i21.2291 . free .
37. Dickman R, Schiff E, Holland A, Wright C, Sarela SR, Han B, Fass R . Clinical trial: acupuncture vs. doubling the proton pump inhibitor dose in refractory heartburn . Alimentary Pharmacology & Therapeutics . 26 . 10 . 1333–1344 . November 2007 . 17875198 . 10.1111/j.1365-2036.2007.03520.x . 23118600 .
38. Spechler SJ, Hunter JG, Jones KM, Lee R, Smith BR, Mashimo H, Sanchez VM, Dunbar KB, Pham TH, Murthy UK, Kim T, Jackson CS, Wallen JM, von Rosenvinge EC, Pearl JP, Laine L, Kim AW, Kaz AM, Tatum RP, Gellad ZF, Lagoo-Deenadayalan S, Rubenstein JH, Ghaferi AA, Lo WK, Fernando RS, Chan BS, Paski SC, Provenzale D, Castell DO, Lieberman D, Souza RF, Chey WD, Warren SR, Davis-Karim A, Melton SD, Genta RM, Serpi T, Biswas K, Huang GD . Randomized Trial of Medical versus Surgical Treatment for Refractory Heartburn . The New England Journal of Medicine . 381 . 16 . 1513–1523 . October 2019 . 31618539 . 10.1056/NEJMoa1811424 . 204757299 . free .
39. Fass R, Zerbib F, Gyawali CP . AGA Clinical Practice Update on Functional Heartburn: Expert Review . Gastroenterology . 158 . 8 . 2286–2293 . June 2020 . 32017911 . 10.1053/j.gastro.2020.01.034 . 211036316 .
40. Kushner PR . Role of the primary care provider in the diagnosis and management of heartburn . Current Medical Research and Opinion . 26 . 4 . 759–765 . April 2010 . 20095795 . 10.1185/03007990903553812 . 206964899 .