Heartburn
Pyrosis; GERD (gastroesophageal reflux disease); Esophagitis
Heartburn is a painful burning feeling just below or behind the breastbone. Most of the time, it comes from the esophagus. The pain often rises in your chest from your stomach. It may also spread to your neck or throat.
The esophagus, stomach, large and small intestine, aided by the liver, gallbladder and pancreas convert the nutritive components of food into energy and break down the non-nutritive components into waste to be excreted.
This X-ray shows the upper portion of the stomach protruding through the diaphragm (hiatal hernia).
A hiatal hernia occurs when part of the stomach protrudes up into the chest through the sheet of muscle called the diaphragm. This may result from a weakening of the surrounding tissues and may be aggravated by obesity and/or smoking.
A band of muscle fibers, the lower esophageal sphincter, closes off the esophagus from the stomach. If the sphincter does not close properly, food and liquid can move backward into the esophagus and cause heartburn and other symptoms known as gastroesophageal disease (GERD). To alleviate symptoms dietary changes and medications are prescribed. For a patient who has persistent symptoms despite medical treatment, an anti-reflux operation may be an option.
Causes
Almost everyone has heartburn at some time. If you have heartburn very often, you may have gastroesophageal reflux disease (GERD).
Normally when food or liquid enters your stomach, a band of muscle at the lower end of your esophagus closes off the esophagus. This band is called the lower esophageal sphincter (LES). If this band does not close tightly enough, food or stomach acid can back up (reflux) into the esophagus. The stomach contents can irritate the esophagus and cause heartburn and other symptoms.
Heartburn is more likely if you have a hiatal hernia. A hiatal hernia is a condition which occurs when the top part of the stomach pokes into the chest cavity. This weakens the LES so that it is easier for acid to back up from the stomach into the esophagus.
Pregnancy and many medicines can bring on heartburn or make it worse.
Medicines that can cause heartburn include:
- Anticholinergics (such as medicines used for sea sickness)
- Beta-blockers for high blood pressure or heart disease
- Bronchodilators for asthma or other lung diseases
- Calcium channel blockers for high blood pressure
- Dopamine-like drugs for Parkinson disease
- Progestin for abnormal menstrual bleeding or birth control
- Sedatives for anxiety or sleep problems (insomnia)
- Theophylline (for asthma or other lung diseases)
- Tricyclic antidepressants
Talk to your health care provider if you think one of your medicines may be causing heartburn. Never change or stop taking medicine without talking to your provider first.
Do you feel a burning in your chest not long after you eat or lie down? If so, you may have Gastroesophageal reflux disease, or GERD. When we swallow food, it travels down our esophagus into the stomach, where it's greeted by a rush of Hydrochloric acid in the stomach to begin digestion. This acid is so powerful, it could eat the paint right off your car! Fortunately, there's a band of muscle between the stomach and the esophagus - called the Lower Esophageal Sphincter or L-E-S, that clamps down to prevent the stomach contents from moving or refluxing upward and burning the lining of the esophagus. If that band of muscle does not adequately clamp down, this backwash causes the irritation and burning that's known as heartburn or GERD. Maintaining good tight L-E-S muscle tone is the key to preventing this condition. Causes of GERD include being overweight, smoking, and drinking too much alcohol. Certain foods, like chocolate and peppermint and if you're a woman, pregnancy can bring on GERD. To determine if you have GERD, your doctor may request an upper endoscopy exam to look into your esophagus and stomach to diagnose reflux. Other tests can measure the acid and amount of pressure in your esophagus, or if you have blood in your stool. If you do have GERD, lifestyle changes can help. First, avoid foods that cause problems for you and avoid eating large meals. If you're a little on the heavy side, try to lose some weight. Since most GERD symptoms are experienced lying down in bed, let gravity help. Elevating the head of your bed 4 to 6 inches using blocks of wood may help. If symptoms continue, see your doctor or a Gastroenterologist for evaluation and an upper endoscopy exam. Your doctor may suggest you take over-the-counter antacids or may prescribe stronger medications. Call your doctor if you are bleeding, feel like you are choking, have trouble-swallowing, or experience sudden weight loss. The good news is most people who have GERD do not need surgery. For the worst cases, surgeons may perform a laparoscopic procedure to tighten a weak L-E-S muscle. If you have occasional heartburn, antacid tablets can be used as needed. However! If you're having heartburn more than 3 to 4 times a week, see your doctor & take the prescribed medication to prevent this condition.
Home Care
You should treat frequent heartburn (heartburn that occurs 2 or more days per week) because reflux can damage the lining of your esophagus. This can cause serious problems over time. Changing your habits can be helpful in preventing heartburn and other symptoms of GERD.
The following tips will help you avoid heartburn and other GERD symptoms. Talk to your provider if you are still bothered by heartburn after trying these steps.
First, avoid foods and drinks that can trigger reflux, such as:
- Alcohol
- Caffeine
- Carbonated drinks
- Chocolate
- Citrus fruits and juices
- Peppermint and spearmint
- Spicy or fatty foods, full-fat dairy products
- Tomatoes and tomato sauces
Next, try changing your eating habits:
- Avoid bending over or exercising just after eating.
- Avoid eating within 3 to 4 hours of bedtime. Lying down with a full stomach causes the stomach contents to press harder against the lower esophageal sphincter (LES). This allows reflux to occur.
- Eat smaller meals.
Make other lifestyle changes as needed:
- Avoid tight-fitting belts or clothes that are snug around the waist. These items can squeeze the stomach, and may force food to reflux.
- Lose weight if you are overweight. Obesity increases pressure in the stomach. This pressure can push the stomach contents into the esophagus. In some cases, GERD symptoms go away after an overweight person loses 10 to 15 pounds (4.5 to 6.75 kilograms).
- Sleep with your head raised about 6 inches (15 centimeters). Sleeping with the head higher than the stomach helps prevent digested food from backing up into the esophagus. Place books, bricks, or blocks under the legs of the head of your bed. You can also use a wedge-shaped pillow under your mattress. Sleeping on extra pillows does NOT work well for relieving heartburn because you can slip off the pillows during the night.
- Stop smoking or using tobacco. Chemicals in cigarette smoke or tobacco products weaken the LES.
- Reduce stress. Try yoga, tai chi, or meditation to help relax.
If you still do not have full relief, try over-the-counter medicines:
- Antacids, like Maalox, Mylanta, or Tums help neutralize stomach acid.
- H2 blockers, like Pepcid AC, Tagamet HB, and Axid AR reduce stomach acid production.
- Proton pump inhibitors, like Prilosec OTC, Prevacid 24 HR, Nexium 24 HR, and Zegerid OTC stop nearly all stomach acid production.
When to Contact a Medical Professional
Get urgent medical care if:
- You vomit material that is bloody or looks like coffee grounds.
- Your stools are black (like tar) or maroon.
- You have a burning feeling and a squeezing, crushing, or pressure in your chest. Sometimes people who think they have heartburn are having a heart attack.
Contact your provider if:
- You have heartburn often or it does not go away after a few weeks of self-care.
- You lose weight that you did not want to lose.
- You have trouble swallowing (food feels stuck as it goes down).
- You have a cough or wheezing that does not go away.
- Your symptoms get worse with antacids, H2 blockers, or other treatments.
- You think one of your medicines may be causing heartburn. DO NOT change or stop taking your medicine on your own.
What to Expect at Your Office Visit
Heartburn is easy to diagnose from your symptoms in most cases. Sometimes, heartburn can be confused with another stomach problem called dyspepsia. If the diagnosis is unclear, you may be sent to a doctor called a gastroenterologist for more testing.
First, your provider will do a physical exam and ask questions about your heartburn, such as:
- When did it begin?
- How long does each episode last?
- Is this the first time you have had heartburn?
- What do you usually eat at each meal? Before you feel heartburn, have you eaten a spicy or fatty meal?
- Do you drink a lot of coffee, other drinks with caffeine, or alcohol? Do you smoke?
- Do you wear clothing that is tight in the chest or belly?
- Do you also have pain in the chest, jaw, arm, or somewhere else?
- What medicines are you taking?
- Have you vomited blood or black material?
- Do you have blood in your stools?
- Do you have black, tarry stools?
- Are there other symptoms with your heartburn?
Your provider may suggest one or more of the following tests:
- Esophageal motility to measure the pressure of your LES
- Esophagogastroduodenoscopy (EGD or upper endoscopy) to look at the inside lining of your esophagus and stomach
- Upper GI series (most often done for swallowing problems)
If your symptoms do not get better with home care, you may need to take medicine to reduce acid that is stronger than over-the-counter medicines. Any sign of bleeding will need more testing and treatment.
References
DeVault KR. Symptoms of esophageal disease. In: Feldman M, Friedman LS, Brandt LJ, eds. Sleisenger and Fordtran's Gastrointestinal and Liver Disease. 11th ed. Philadelphia, PA: Elsevier; 2021:chap 13.
Mayer EA. Functional gastrointestinal disorders: irritable bowel syndrome, dyspepsia, chest pain of presumed esophageal origin, and heartburn. In: Goldman L, Schafer AI, eds. Goldman-Cecil Medicine. 26th ed. Philadelphia, PA: Elsevier; 2020:chap 128.
Version Info
Last reviewed on: 1/30/2023
Reviewed by: Michael M. Phillips, MD, Emeritus Professor of Medicine, The George Washington University School of Medicine, Washington, DC. Also reviewed by David C. Dugdale, MD, Medical Director, Brenda Conaway, Editorial Director, and the A.D.A.M. Editorial team.
