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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.

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

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.

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.

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.

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


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