Heartburn
- Overview
- How we get heartburn
- Symptoms
- Risk factors
- Complications
- When to seek medical advice
- Treatment
- Prevention & self care
Heartburn occurs when the acid contents of the stomach pass backwards up into the food pipe (called the gullet or oesophagus). This is also known as stomach acid reflux.
Most people have stomach acid reflux at some point in their lives, either as heartburn or acid regurgitation.
Heartburn typically occurs after eating a large meal or drinking a lot of alcohol. Some people get heartburn when they bend over or lie down.
The frequency of stomach acid reflux varies from one person to another. For most people, it happens very rarely. But weekly or daily incidents of heartburn or acid regurgitation may occur.
When you swallow, the lower oesophageal sphincter, a circular band of muscle around the bottom part of your oesophagus, relaxes to allow food and liquid to flow down into your stomach. Then it closes again.
However, if this valve relaxes abnormally or weakens, stomach acid can flow back up into your oesophagus, causing frequent heartburn. The acid backup is worse when you are bent over or lying down.
This constant backwash of acid can irritate the lining of your oesophagus, causing it to become inflamed.
Chest pain
A burning feeling is experienced in the upper part of the stomach and this feeling tends to move upwards behind the breastbone. The pain may be felt only in this area or occasionally it may be felt right up to the throat.
Sometimes the pain can come on suddenly and severely and even radiate to the back and arms, symptoms that are very similar to those experienced during a heart attack.
Regurgitation of food or sour liquid
This is caused by the food and acid contents in the stomach flowing back up as far as the throat.
Difficulty in swallowing
This is caused by a mechanical blockage in the oesophagus. This can be caused by scarring because of long-term reflux of acid resulting in damage and therefore narrowing of the oesophagus.
Coughing, wheezing, asthma, hoarseness or sore throat
Stomach acid can also wash back up the oesophagus and into the respiratory tract, causing asthma, hoarseness, chronic cough, sore throat, or tooth damage (acid eats the enamel on teeth).
Age
The symptoms or reflux and oesophagitis occur more commonly in people aged fifty five and over. Heartburn is not a condition normally experienced in childhood, although symptoms can occur in young adults.
Obesity and diet
Excess weight puts extra pressure on your stomach and diaphragm (the large muscle that separates your chest and abdomen). This forces open the lower oesophageal sphincter and allows stomach acids to back up into your oesophagus. Eating very large meals or meals high in fat may cause similar effects.
Hiatus hernia
In this condition part of your stomach protrudes into your lower chest. If the protrusion is large, a hiatus hernia can worsen heartburn by further weakening the lower oesophageal 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 oesophageal sphincter.
Asthma
Doctors are not 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 oesophagus. Some asthma medications that widen airways may also relax the lower oesophageal sphincter and allow reflux. Or it is 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 oesophagus and pharynx, damaging lung airways.
Diabetes
One of the many complications of diabetes is results in a disorder in which your stomach takes too long to empty (this is caused by nerve damage). If left in your stomach too long, stomach contents can regurgitate into your oesophagus 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 from the stomach. Food doesn’t empty from your stomach as fast as it should, causing stomach acid to build up and back up into your oesophagus.
Medication
Some medication, used to treat heart disease, asthma, schizophrenia and depression can cause heartburn.
Other disease states
Other, more unusual disease states affecting stomach emptying, stomach acid production and the muscles of the stomach and oesophagus can also lead to heartburn.
In addition to irritation and inflammation of your oesophagus, long-term reflux of stomach acid into your oesophagus can lead to one or more of the following conditions if left untreated:
Oesophageal narrowing (stricture)
Damage to cells in the oesophagus 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.
Oesophageal ulcer
Stomach acid can severely damage tissues in the oesophagus, causing an open sore to form (an ulcer). The oesophageal ulcer may bleed, cause pain and make swallowing difficult.
Barrett’s oesophagus
In Barrett’s oesophagus, the long-term reflux of acid causes a change in the lining of the oesophagus. Because of this people with Barrett’s oesophagus are at increased risk of developing oesophageal cancer and have to be checked regularly by doctors.
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. Talk to your doctor if you have:
- Heartburn several times a week
- Heartburn that returns soon after an antacid wears off
- Heartburn that causes night awakening.
- Use of H2antagonist preparations for longer than two weeksPain that radiates into the jaw or arms and that is experienced when exercising or on exertion (this may be angina)
- Symptoms that persist even though you’re taking prescription medications
- Difficulty swallowing
- Regurgitated blood
- Stools that are black
- Weight loss
The symptoms of occasional heartburn respond well to treatments which are available over-the-counter. Many over-the-counter preparations are not suitable for those who are pregnant or for children under two years of age and may not be suitable for other individuals, so it is always important to talk to your pharmacist when buying preparation for heartburn over-the-counter.
The treatments available may contain more than one ingredient but are formulated as either liquids or tablets.
Antacids
These are alkaline salts which neutralize the acid in the stomach and can be very effective in controlling the symptoms of heartburn and reflux.
Many people find tablet preparations more convenient as they can be carried about in pockets or bags, but wherever possible it is best to use a liquid preparation as they are more effective antacids.
Antacids are best taken about an hour after meals, because the emptying of the stomach has then slowed and the antacid will therefore remain in the stomach for longer.
Antacids may affect the body’s absorption of many drugs, including some antibiotics, anti-fungals, tablets with special coatings (for example those used in inflammatory bowel conditions and some types of aspirin), iron and lithium. If antacids are taken at different times to these drugs no problem will arise but it is important to discuss any medication you may be on with your pharmacist before buying antacid preparations. If there is a possible problem your pharmacist will be able to advise you of the best way to take your medication and antacids.
Examples are:-
Sodium Bicarbonate
This is a short-acting and effective neutralizer of acid and is most often available with other longer-acting antacids. Any antacids containing sodium should not be taken by people whose sodium intake has to be kept to a minimum (i.e. in people with high blood pressure or pregnant women especially those whose blood pressure is rising with pregnancy). Because of long-term side-effects antacids containing sodium bicarbonate are most suitable for short-term or occasional use.
Aluminium and magnesium salts (e.g. aluminium hydroxide, magnesium trisilicate)
Aluminium-based antacids are effective neutralizers of acid but tend to be constipating. This can be useful if someone is suffering from a stomach-bug and has diarrhoea but is not useful when used in someone with heartburn who may already be slightly constipated (e.g. in the elderly).
Magnesium-based antacids are also effective neutralizers of acid but have the tendency to cause diarrhoea. This can be useful if someone is suffering from heartburn and is also slightly constipated. However, when magnesium and aluminium salts are used in combination they cause little bowel disturbance and therefore these preparations are very effective and have few side-effects when used in heartburn.
Calcium Carbonate
This is an effective neutralizer of acid which acts quickly and has a long period of effectiveness. However, if taken on a regular basis it can cause the stomach to produce more acid. This and other side-effects with long-term use make the product most suitable for short-term or occasional use.
Alginates
These are most often included in preparations that also contain the antacid sodium bicarbonate or potassium bicarbonate. These salts not only neutralize acid in the stomach but also release carbon dioxide gas. The alginate forms a “raft” that floats to the top of the stomach because of the release of carbon dioxide gas. This “raft” then sits on top of the stomach contents and stops the acid washing back up the oesophagus. The sodium content of some such preparations may make it unsuitable for those suffering with high blood pressure or pregnant women.
H2 antagonists (e.g. ranitidine and famotidine)
These reduce the amount of acid the stomach produces and are the most effective preparations available for use in heartburn and indigestion. They are available as tablets and some preparations also contain an antacid.
When food is known to make symptoms of heartburn worse these preparations are best taken before food.
H2 antagonists should not be used for longer than two weeks for the symptoms of heartburn or indigestion.
Brand name of preparations available and their ingredients
Antacids
Rennie Rap-Eze chewable tablets
Remegel chewy tablets contain calcium carbonate
Bisodol chewable tablets contain calcium carbonate, light magnesium carbonate and sodium bicarbonate
Bisodol powder contains sodium bicarbonate, light magnesium carbonate and heavy magnesium carbonate.
Andrews Antacid
Rennie chewable tablets both contain calcium carbonate and heavy magnesium carbonate.
Maalox tablets and liquid contain aluminium hydroxide and magnesium hydroxide. Maalox plus tablets and liquid contain the same ingredients with the additional ingredient of simethicone, which is a surfactant and aids the breakdown of air bubbles in the intestines, so is useful when heartburn is accompanied by gas and wind.
All contain alkaline salts that neutralise excess acid in the stomach. They are effective for mild and occasional heartburn. Liquid preparations are always more effective than tablet ones in relieving heartburn or indigestion. None of the products cause drowsiness.
Antacids containing alginates
Gaviscon tablets contain alginic acid, sodium bicarbonate and aluminium hydroxide gel.
Liquid contains sodium alginate, sodium bicarbonate and calcium carbonate.
Advance liquid contains sodium alginate and potassium bicarbonate (a longer acting antacid).
Infant contains sodium alginate and magnesium alginate.
The antacid portion of these products helps to neutralize excess acid in the stomach and the alginate portion forms a raft that sits on top of the stomach content and so reduces the washing of acid up the oesophagus (that leads to discomfort and belching). Liquid preparations are always more effective than tablet ones in relieving heartburn or indigestion. None of the products cause drowsiness.
H2Antagonists
Pepcid AC tablets contain famotidine
Zantac tablets contain ranitidine
Pepcid Two tablets contain famotidine, calcium carbonate and magnesium hydroxide.
These reduce the acid production in the stomach and in Pepcid Two the addition of antacids also means acids in the stomach are neutralized. They are the most effective preparation for heartburn or indigestion and can be used in occasional heartburn where the use of antacids or antacids with alginates has not been effective. They do not cause drowsiness.
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 weight puts pressure on your abdomen, pushing up your stomach and causing acid to back up into your oesophagus.
Eat smaller meals
This reduces pressure on the lower oesophageal sphincter, helping to prevent the valve from opening and acid from washing back into your oesophagus.
Avoid tight-fitting clothes
Clothes that fit tightly around your waist put pressure on your abdomen and the lower oesophageal sphincter.
Eliminate heartburn 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
Bending over for long periods especially after meals may increase the risk of heartburn.
Don’t lie down after a meal
Wait at least three to four hours after eating before going to bed and do not lie down directly after eating.
Raise the head of your bed
An elevation of the head of the bed by about six to nine inches means gravity helps stop acid reflux. You can do this by placing wooden or concrete blocks under the feet at the head of your bed. If it is not possible to elevate your bed, you can insert a wedge between your mattress and the base of your bed to elevate your body from the waist up. Raising your head only by using pillows is not a good alternative.
Stop smoking.
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 oesophageal cancer.