Heartburn

Heartburn, also know as acid reflux, is a painful and burning sensation in the esophagus, just behind the breastbone usually associated with regurgitation of gastric acid (gastric reflux). The pain often rises in the chest and may radiate to the neck, throat, or angle of the jaw. Heartburn is a major symptom of gastroesophageal reflux disease, otherwise known as GERD; acid reflux is also identified as one of the causes of chronic cough, and may even mimic asthma. Despite its name, heartburn actually has nothing to do with the heart; it is so called because of a burning sensation near to where the heart is located – although some heart problems may give rise to a similar burning sensation.

The pain associated with acid reflux is due to the presence of acid in the esophagus. Acid is produced in the stomach as an aid to digestion and is not intended to be present in the esophagus. Unlike the stomach's lining that can tolerate very high concentrations of acid, the presence of acid in the esophagus, eats away at the lining of the esophagus and causes pain. Acid reflux does not occur because there is too much acid created by the stomach, but because the muscular barrier or valve between the esophagus and the stomach opens prematurely allowing acid, bile and other stomach contents into the esophagus. The name of this muscular barrier is the Lower Esophageal Sphincter (LES). Other sphincters in the body include the anal and bladder sphincters, in addition to the mouth and the eye. Each of them closes in circumference around a radius. When the LES doesn't stay closed or when it opens at the wrong time, reflux can occur.

In many cases, acid reflux medications known as PPI's (proton pump inhibitors such as Nexium, Prilosec, etc) work well enough at reducing acid levels that the pain goes away. Unfortunately PPI's don't help reinforce the LES and in some cases surgery may be required. According to research conducted by the American Gastroenterological Association, 38% of PPI users experience break-through pain while taking PPI's.

The LES is also sometimes referred to as the cardiac sphincter, referring to a part of the stomach referred to as the cardia and not, as might be thought, to the heart, lending some additional confusion to the term "heartburn".

Diagnosis

Biochemical

• Esophageal pH Monitoring

A probe can be placed via the nose into the esophagus to record the level of acidity in the lower esophagus. Because some degree of variation in acidity is normal, and small reflux events are relatively common, esophageal pH Monitoring can be used to document reflux in real-time.

Mechanical

• Manometry

In this test, a pressure sensor (manometer) is passed through the mouth into the esophagus and measures the pressure of the lower esophageal sphincter directly.

• Endoscopy

The esophageal mucosa can be visualized directly by passing a thin, lighted tube with a tiny camera known as an endoscope attached through the mouth to examine the esophagus and stomach. In this way, evidence of esophageal inflammation can be detected, and biopsies taken if necessary. Since an endoscopy allows a doctor to visually inspect the upper digestive tract the procedure may help identify any additional damage to the tract that may not have been detected otherwise.

• Biopsy

A small sample of tissue from the esophagus is removed. It is then studied to check for inflammation, cancer, or other problems.

Prevention

Relief is often found by raising the head of the bed, raising the upper body with pillows, or sleeping sitting up. Avoid pillows that raise the head only, as this does little for heartburn and places continuous strain on the neck. Eating a big meal causes excess stomach acid production, and attacks can be minimized by eating small frequent meals instead of large meals especially for dinner. To minimize attacks, a sufferer may benefit from avoiding certain foods that stimulate excess acid secretion and/or relax the opening between the stomach and esophagus. Acid fruit or juice, fatty foods, pretzels, coffee, tea, onions, peppermint, chocolate, or highly spiced foods are to be avoided, especially shortly before bedtime.[2] While there are clearly other health-related benefits associated with dietary interventions a zealous[specify] recommendation for dietary restrictions is not evidence-based, and there is stronger support for reducing the symptoms of acid reflux found in behavioral changes such as eating less and elevating one's head while sleeping. Tight clothing around the abdomen can also increase the risk for heartburn because it puts pressure on the stomach, which can cause the food and acids in the stomach to reflux to the lower esophageal sphincter.

Treatment

Medications

Antacids, H2-receptor antagonists, alginates, proton pump inhibitors, and other alternative treatments are used to treat heartburn.

• Antacids

Antacids work by using bases to ease pain. Although stomach acid will still splash into the esophagus, it will be neutralized, leading to decreased or absent heartburn symptoms. Antacids provide fast relief of symptoms, but relief typically lasts only for a short time.

Examples of antacids include:

Alka-Seltzer
Quick-Eze
Tums, Alka-2, Titralac, Surpass Gum
Milk of Magnesia
Amphojel, Alternagel
Maalox, Mylanta, Rolaids, Gelusil, Gaviscon
Pepto-Bismol

• Sodium bicarbonate

Sodium bicarbonate is a base; when introduced to the stomach, this compound acts as an antacid. A simple and relatively harmless way to treat a one-off heartburn is to drink a solution of a small amount of sodium bicarbonate (baking soda) mixed with water, which quickly neutralizes the acid that causes the pain. Excess sodium intake, however, is thought to raise blood pressure and cause other health problems.

• H2-receptor antagonists

Often called H2 blockers, H2-receptor antagonists work by decreasing the amount of acid the body releases into the stomach. H2s are systemic, meaning they require absorption into the bloodstream in order to work. Therefore, H2s can often take 30 minutes or longer before they start working, and therefore are often taken to prevent heartburn rather than for fast relief of symptoms.

• Alginates

Alginates work differently than antacids and H2 blockers, by forming a protective barrier in the stomach that prevents stomach acid from refluxing back up into the esophagus. Alginic acid is naturally derived (from brown seaweed) and is non-systemic. Alginates provide faster relief than H2-receptor antagonists and PPIs, and longer-lasting relief than antacids. This is also known to have a better overall outcome for relief.[citation needed]

• Proton-pump inhibitors

Proton pump inhibitors, called PPIs, are a class of medications which can be effective for people who do not respond to antacid or acid blockers. Proton-pump inhibitors are systemic and directly block acid production in the stomach cells. In order to prevent heartburn the medication disfigures and disables the proteins (proton pumps) that control the pH of the stomach, allowing the body to digest them. Proton-pump inhibitors are not fast-acting, but provide long-lasting relief. PPIs are intended to be short-term medications only.

Restricting diet

Restricting diet is very important, since approximately 90-95% of sufferers of heartburn or esophageal disorder can link their symptoms to specific foods. Therefore, it is important that heartburn sufferers manage their diets as a way to treat their heartburn. Sufferers should choose the kinds of foods and drinks which have little risk of causing acid reflux, while some kinds of foods or drinks should be avoided as they are major heartburn triggers. Specifically, it has been shown that fatty foods and caffeinated beverages can cause the symptoms of heartburn.

Drinking milk is not a recommended treatment to heartburn. A glass of milk can provide quick relief; however, milk contains calcium and protein, which both stimulate more acid production in the stomach. Consequently, shortly after drinking a glass of milk, a harsher heartburn can return.

Positional therapy

Sleeping on the left side has been shown to reduce nighttime reflux episodes in patients.

A meta-analysis suggested that elevating the head of bed is an effective therapy, although this conclusion was only supported by nonrandomized studies. The head of the bed can be elevated by plastic or wooden bed risers that support bed posts or legs, a therapeutic bed wedge pillow, or a wedge or an inflatable mattress lifter that fits in between mattress and box spring. The height of the elevation is critical and must be at least 6 to 8 inches (15 to 20 cm) to be at least minimally effective to prevent the backflow of gastric fluids. Some innerspring mattresses do not work well when inclined and may cause back pain; some prefer foam mattresses. Some practitioners use higher degrees of incline than provided by the commonly suggested 6 to 8 inches (15 to 20 cm) and claim greater success.

Surgery

In some cases, laparoscopic surgery of the esophagus may be a possible alternative treatment.