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What Is Heartburn?

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 your heart is on fire.

Every day, as many as 10 percent of adults have heartburn, which is characterized by a burning sensation behind the breastbone. Often this feeling is accompanied by a sour taste and the sensation of food reentering the mouth (regurgitation). It results from gastroesophageal reflux, a condition in which stomach acid or bile salts back up into the food pipe (esophagus). When there is evidence of esophageal irritation or inflammation, the condition is called gastroesophageal reflux disease (GERD).

Normally acid is blocked from coming up into the esophagus by the lower esophageal sphincter. This circular band of muscle at the lower end of the esophagus remains closed except during swallowing. If the sphincter relaxes abnormally or becomes weakened, stomach acid can back up, causing heartburn.

Most people can manage the discomfort of heartburn with diet changes, over-the-counter antacids and weight loss. But if heartburn is severe, these remedies may offer only temporary or partial relief. Newer, more potent medications may be needed to reduce symptoms.

Digestive Center

Signs and Symptoms

If you experience heartburn, you may also experience some of the following associated symptoms:
Difficulty swallowing (dysphagia)

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 the wrong time, stomach acid flows back up into your esophagus, even though 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:
Risk Factors

Conditions that cause difficulty with digestion can increase the risk of heartburn. These include:
When to Seek Medical Advice

Most problems with heartburn are fleeting and mild. But if you have severe or frequent discomfort, don't ignore your symptoms. You may be developing complications that need more intensive medical treatment and prescription medications if you have any of these warning signs: In addition, you may need further medical care, possibly even surgery, if you experience any of these:
Screening and Diagnosis

Usually a description of your symptoms will be all your physician needs to establish the diagnosis of heartburn. However, if your symptoms are particularly severe or don't respond to treatment, tests such as a barium X-ray of the esophagus and stomach or, more likely, an endoscopic examination may be necessary.

A barium X-ray, which requires you to drink a chalky liquid that coats and fills the hollows of your digestive tract, allows your physician to get a clear silhouette of the shape and condition on your esophagus, stomach and upper intestine (duodenum). These 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.

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) through 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 the doctor can take tissue samples to test for Barrett's 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.

Complications

Left untreated, chronic reflux of stomach acid into the esophagus can cause scarring, which narrows the esophagus and makes swallowing difficult. Moreover, severe heartburn can lead to Barrett's esophagus, a condition in which cells similar to stomach lining develop in the lower esophagus, a process called metaplasia. Barrett's esophagus is linked with an increased risk of esophageal cancer. About 5 percent of people with GERD have Barett's esophagus.

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 (OTC) remedies

If you experience only occasional, mild heartburn, you may get relief from an over-the-counter (OTC) medication. The two most common OTC remedies are: 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 repeated exposure to stomach acid). The three main types of prescription drugs are: Surgical and Other Procedures

Both surgical and nonsurgical procedures have been developed to treat problems related to heartburn. Endoscopic procedures, which are nonsurgical, are less invasive than surgery. Doctors usually will consider less invasive measures first.

Nonsurgical procedures include: The Food and Drug Administration approved the endoscopic suturing system and Stretta system in April 2000. Both procedures are less invasive and are intended for people with uncomplicated GERD who prefer minimally invasive procedures to medications. Neither procedure is recommended if you have a hiatal hernia or Barrett's esophagus. The long-term effects of each treatment are unknown.

For a small percentage of people with severe heartburn, medications don't provide relief. In that case surgery may be a solution.

In a surgery known as fundoplication, surgeons wrap part of the stomach around the lower esophagus. This places more pressure on the sphincter to help keep it closed. Most people remain free of heartburn 10 years after surgery. Yet the surgery is major, requiring an abdominal incision and a long hospital stay and recovery period.

Doctors can perform this same operation using laparoscopic surgery. In laparoscopic fundoplication, your doctor cuts small holes in your abdomen and inserts miniature surgical instruments and a tiny video camera. This allows your doctor to wrap part of your stomach around the lower esophagus without a major incision. Recovery is rapid. You can resume all activities after just one week, instead of the 4 to 6 weeks with traditional surgery. Although laparoscopic surgery appears to work well, it's still relatively new, and doctors don't completely know the long-term effects.

Prevention

You may eliminate or reduce the frequency of heartburn by making the following lifestyle changes:
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 can affect your kidneys, increase your blood pressure and add stress to your heart.

— September 17, 2001 —