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| 5 July 2004 | 2004-07-05T00:00:00.0000000+02:00 |
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Heartburn and its underlying causes
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While the vast majority of sufferers only experience occasional and mild symptoms, in some people symptoms can be frequent and severe, and may signal that other, more serious conditions could be the underlying cause of heartburn. In such cases, a visit to the doctor may be advisable to gain a complete diagnostic evaluation.
What is heartburn?
Heartburn is the most common symptom of a condition called gastroesophageal reflux or acid reflux. It is a rising, burning sensation that is felt in the chest behind the breastbone and may also be accompanied by the uncomfortable feeling that food or liquid is rising up the oesophagus from the stomach, particularly when bending over or lying down. Apart from the burning sensation, heartburn sufferers may also feel discomfort at the same place/area in the midline of the back.
The burning sensation is caused by corrosive digestive juices escaping from the stomach and irritating the sensitive lining of the oesophagus, which connects the stomach to the mouth. Although the stomach walls are naturally shielded from the corrosive effects of digestive juices, the oesophagus does not share this protective lining.
Acid reflux occurs when the valve that enables food to enter the stomach, but prevents digestive juices from entering the oesophagus, called the lower oesophageal sphincter, does not function correctly. Although this can happen from time to time in most people, the reason why this muscle fails to work properly on occasion is not fully understood.
What causes heartburn to occur?
A variety of lifestyle factors can contribute to the occurrence of heartburn by increasing the amount of digestive acids produced in the stomach, causing the oesophagus to become more sensitive to stomach acid, increasing pressure on the stomach, and causing the lower oesophageal sphincter to become more relaxed, therefore allowing stomach juices to escape into the oesophagus.
Although the triggers that cause heartburn can vary from one person to the next, the main ones include:
Diet and eating habits
Meals containing fatty and/or spicy ingredients.
Large portions, which fill up the stomach forcing the contents closer to the lower oesophageal sphincter, and cause the stomach to produce more digestive acid.
Beverages, such as coffee, acidic fruit juices, carbonated drinks, and alcohol.
Eating quickly and not chewing enough, which will also cause the stomach to produce more acid to digest the contents.
Eating immediately before going to bed.
Foods such as chocolate, peppermint or spearmint, which may cause the oesophageal sphincter to relax.
Posture and clothing
Lying down after eating will force the contents of the stomach nearer to the oesophageal valve.
Bending down after eating will put pressure on the digestive tract.
Tight restrictive garments.
Pregnancy
Lifestyle
Medicines
Can heartburn indicate the presence of a more severe condition?
Heartburn is usually a mild symptom and occurs infrequently in most people, but, in some individuals, it can be severe and/or frequent, indicating the presence of a more severe condition, such as gastroesophageal reflux disease (GERD).
GERD is usually characterised by persistent heartburn and acid regurgitation. However, some people with GERD may not experience heartburn, but instead feel a pain in the chest, hoarseness, or problems swallowing. The condition may also cause bad breath and a dry cough.
If not treated, GERD can cause or lead to a variety of problems, such as inflammation and ulceration of the oesophagus – a condition called oesophagitis. Some people who have oesophagitis can also develop strictures, which result in a narrowing of the oesophagus due to scar tissue and may lead to problems swallowing food and medication.
Furthermore, people with severe GERD are at an increased risk of developing Barrett’s oesophagus, a condition characterised by damage to the lining of the oesophagus, which has also been linked to the possible development of cancer of the oesophagus.
In addition, frequent heartburn may be a symptom of a condition called hiatus hernia. This is caused by a small part of the stomach rising into the opening where the oesophagus passes through the diaphragm – the muscle sheet that separates the stomach from the chest. Hiatus hernia can be identified on an X-ray or endoscopy (see Diagnosis section).
Diagnosis
If symptoms have become persistent or severe, it is advisable to visit a doctor who may initially recommend a number of medications or lifestyle changes such as those mentioned earlier. If symptoms still persist, then the doctor may wish to perform one, or a variety of tests to identify the problem including:
Endoscopy – in which a flexible plastic tube containing a tiny camera is used to examine the inside surface of the oesophagus for any damage or abnormalities. A tissue sample (biopsy) may also be taken for further examination.
An extended ph monitoring examination – a tiny tube is placed in the oesophagus and left there for 24 hours to measure acidity levels while the patient carries on with their daily life.
A barium swallow radiograph – which uses -X-rays to identify severe inflammation of the oesophagus or hiatus hernia. However, this type of investigation is not specific enough to get a clear picture of what is going on in oesophagus.
Treatments
When lifestyle changes are not enough, there are a variety of medications that can be taken to ease heartburn.
Antacids, which can be bought over the counter at the pharmacy, are medications that come in tablet or liquid form and are usually taken by people with occasional or episodic heartburn. Antacids are usually the first drugs to be recommended for heartburn and work by neutralising acid in the stomach.
Foaming medications, which help fight heartburn by covering the contents of the stomach with foam to help prevent reflux.
H2 antagonists that partially block the product of stomach acid, the effects of which usually last for around 12 hours.
Proton pump inhibitors (PPIs), which also lower the amount of acid in the stomach, are usually prescribed when heartburn is severe and tend to be the most effective medications for GERD symptom relief. PPIs usually last for up to 24 hours.
Prokinetics, which help strengthen the lower oesophageal sphincter to prevent acid reflux, and lessen the time it takes for the stomach to empty. However, prokinetics may cause side-effects in some people, such as drowsiness, restlessness and muscle spasms or involuntary movements.
When both medication and lifestyle changes do not work, surgery may be recommended to correct a hiatus hernia or prevent acid reflux. However, as with all surgical procedures, surgery to prevent GERD may carry some risks and is not always permanently successful.
Get professional advice
It is important to remember that, although common, heartburn can seriously affect some people's productivity at work, daily routines and general quality of life. In such cases, it is advised that sufferers should consult a health professional to help diagnose any underlying problems and to discuss various treatment options.
A doctor will be able to recommend certain changes in diet and lifestyle, as well as a vast range of over-the-counter medications and prescription drugs that should provide relief for most sufferers.
Further information:
The Digestive Disorders Foundation
www.digestivedisorders.org.uk
The US Heartburn Alliance
www.heartburnalliance.org
The US National Institute of Diabetes and Digestive and Kidney Diseases
www.niddk.nih.gov
The British Society of Gastroenterology
www.bsg.org.uk
NHS direct
www.nhsdirect.nhs.uk
References:
An evidence-based appraisal of reflux disease management – the Genval Workshop Report. Gut 1999; 44: 1S-16.
Predictive factors of the long-term outcome in gastro-oesophageal reflux disease: six year follow up of 107 patients. Gut 1994; 35: 8-14.
Acid suppression in the management of gastro-oesophageal reflux disease—an appraisal of treatment options in primary care. Alimentary Pharmacology & Therapeutics 2001; 15: 765-772.
Natural course of gastroesophageal reflux disease: 17-22 year follow-up of 60 patients. American Journal of Gastroenterology 1997; 92: 37-41.
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