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Heartburn

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This article is about the medical condition. For other uses, see Heartburn (disambiguation).
"Cardialgia" redirects here. For the meaning "pain in or near the heart", see Heart pain and Chest pain.
Heartburn
Other namesPyrosis,[1] cardialgia
SpecialtyGastroenterology, family medicine, emergency medicine
SymptomsBurning, stabbing, or squeezing sensation in the chest, nausea, belching
CausesGastroesophageal reflux disease
Risk factorsSmoking, obesity
Diagnostic methodPhysical examination, medical history, antacid response, imaging, manometry
Differential diagnosisChest pain, heart attack, gastritis, peptic ulcer disease, esophageal spasms, esophageal strictures, duodenitis, cancer, Crohn's disease
PreventionAvoid foods that are high in fats, spicy, high in artificial flavors. Avoid reclining 3-4 hours after a meal, heavy NSAID use, heavy alcohol consumption, decrease peppermint consumption. Chew foods thoroughly between bites, consume meals with plenty of liquid, and ensure adequate time to eat meals in a non-hurried fashion
TreatmentAntacids, weight loss, surgery
MedicationAntacids

Heartburn, also known as pyrosis, cardialgia or acid indigestion,[2] is a burning sensation in the central chest or upper central abdomen.[3][4][5] Heartburn is usually due to regurgitation of gastric acid (gastric reflux) into the esophagus. It is the major symptom of gastroesophageal reflux disease (GERD).[6]

Other common descriptors for heartburn (besides burning) are belching, nausea, squeezing, stabbing, or a sensation of pressure on the chest. The pain often rises in the chest (directly behind the breastbone) and may radiate to the neck, throat, or angle of the arm. Because the chest houses other important organs besides the esophagus (including the heart and lungs), not all symptoms related to heartburn are esophageal in nature.[citation needed]

The cause will vary depending on one's family and medical history, genetics, if a person is pregnant or lactating, and age. As a result, the diagnosis will vary depending on the suspected organ and the inciting disease process. Work-up will vary depending on the clinical suspicion of the provider seeing the patient, but generally includes endoscopy and a trial of antacids to assess for relief.[citation needed]

Treatment for heartburn may include medications and dietary changes.[3] Medication include antacids. Dietary changes may require avoiding foods that are high in fats, spicy, high in artificial flavors, heavily reducing NSAID use, heavy alcohol consumption, and decreasing peppermint consumption.[3] Lifestyle changes may help such as reducing weight.

Definition

The term indigestion includes heartburn along with a number of other symptoms.[7] Indigestion is sometimes defined as a combination of epigastric pain and heartburn.[8] Heartburn is commonly used interchangeably with gastroesophageal reflux disease (GERD) rather than just to describe a symptom of burning in one's chest.[9]

Differential diagnosis

Heartburn-like symptoms and/or lower chest or upper abdomen may be indicative of much more sinister and/or deadly disease.[10] Of greatest concern is to confuse heartburn (generally related to the esophagus) with a heart attack as these organs share a common nerve supply.[11] Numerous abdominal and thoracic organs are present in that region of the body. Many different organ systems might explain the discomfort called heartburn.[citation needed]

Heart

The most common symptom for a heart attack is chest pain.[12] However, as many as 30% of chest pain patients undergoing cardiac catheterization have findings that do not account for their chest discomfort. These are often defined as having "atypical chest pain" or chest pain of undetermined origin.[13] Women experiencing heart attacks may also deny classic signs and symptoms[14] and instead complain of GI symptoms.[12][15][16] One article estimates that ischemic heart disease may appear to be GERD in 0.6% of people.[11]

Esophagus

Esophagitis[18]

Stomach

Intestines

  • Intestinal ulcers – generally secondary to other conditions such as H. Pylori infection or cancers of the GI tract. Pain often improves with eating.
  • Duodenitis – inflammation of the small intestine. May be the result of several conditions

Gallbladder

Pancreas

  • Pancreatitis – can be autoimmune, due to a gallstone obstructing the lumen, related to alcohol consumption.

Hematology

Pregnancy

Heartburn is common during pregnancy having been reported in as high as 80% of pregnancies.[21] It is most often due to GERD and results from relaxation of the lower esophageal sphincter (LES), changes in gastric motility, and/or increasing intra-abdominal pressure.[22][21] The onset of symptoms can be during any trimester of pregnancy.

  • Hormonal – related to the increasing amounts of estrogen and progesterone and their effect on the LES
  • Mechanical – the enlarging uterus increasing intra-abdominal pressure, inducing reflux of gastric acid
  • Behavioral – as with other instances of heartburn, behavioral modifications can exacerbate or alleviate symptoms

Unknown origin

Functional heartburn is heartburn of unknown cause.[23] It is commonly associated with psychiatric conditions like depression, anxiety, and panic attacks. It is also seen with other functional gastrointestinal disorders like irritable bowel syndrome and is the primary cause of lack of improvement post treatment with proton pump inhibitors (PPIs).[23] Despite this, PPIs are still the primary treatment with response rates in about 50% of people.[23] The diagnosis is one of elimination, based upon the Rome III criteria. It was found to be present in 22.3% of Canadians in one survey.[23]

Rome III Criteria
1 Burning retrosternal discomfort
2 Elimination of heart attack and GERD as the cause
3 No esophageal motility disorders[23]

Diagnostic approach

Heartburn can be caused by several conditions and a preliminary diagnosis of GERD is based on additional signs and symptoms. The chest pain caused by GERD has a distinct 'burning' sensation, occurs after eating or at night, and worsens when a person lies down or bends over.[24] It also is common in pregnant women, and may be triggered by consuming food in large quantities, or specific foods containing certain spices, high fat content, or high acid content.[24][25] In young persons (typically <40 years) who present with heartburn symptoms consistent with GERD (onset after eating, when laying down, when pregnant), a physician may begin a course of PPIs to assess clinical improvement before additional testing is undergone.[26] Resolution or improvement of symptoms on this course may result in a diagnosis of GERD.[citation needed]

Other tests or symptoms suggesting acid reflux is causing heartburn include:

  • Onset of symptoms after eating or drinking, at night, and/or with pregnancy, and improvement with PPIs
  • Endoscopy looking for erosive changes of the esophagus consistent with prolonged acid exposure (e.g. - Barrett's esophagus)[26]
  • Upper GI series looking for the presence of acid reflux[25][27]

GI cocktail

Main article: GI cocktail

Relief of symptoms 5 to 10 minutes after the administration of viscous lidocaine and an antacid increases the suspicion that the pain is esophageal in origin.[28] This however does not rule out a potential cardiac cause[29] as 10% of cases of discomfort due to cardiac causes are improved with antacids.[30]

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.[31] Patients are able to record symptom onset to correlate lower esophageal pH with time of symptom onset.

Mechanical

Manometry: in this test, a pressure sensor (manometer) is passed via the mouth into the esophagus and measures the pressure of the LES directly.[32]

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 oesophagus 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.[33]

Biopsy: a small sample of tissue from the oesophagus is removed. It is then studied to check for inflammation, cancer, or other problems.[32]

Treatment

Treatment plans are tailored to the specific diagnosis and etiology of the heartburn. Management of heartburn can be sorted into various categories.

Pharmacologic management

Behavioral management

  • Taking medications 30–45 minutes before eating suppresses the stomach's acid generating response to food
  • Avoiding spicy foods, foods high in fats, peppermint, and chocolate [citation needed]
  • Avoiding reclining 2.5–3.5 hours after a meal to prevent the reflux of stomach's contents

Lifestyle modifications

  • Early studies show that diets that are high in fiber may show evidence in decreasing symptoms of dyspepsia.[35]
  • Weight loss can decrease abdominal pressure that both delays gastric emptying and increases gastric acid reflux into the esophagus

Alternative and complementary therapies

Symptoms of heartburn may not always be the result of an organic cause. Patients may respond better to therapies targeting anxiety and symptoms of hyper-vigilance, through medications aimed towards a psychiatric etiology, osteopathic manipulation and acupuncture.[23]

  • Psychotherapy may show a positive role in treatment of heartburn and the reduction of distress experienced during symptoms.[23]
  • Acupuncture - in cases of functional heartburn (e.g. heartburn of unknown origin) acupuncture may be as effective if not more than PPIs alone.[36]

Surgical management

In the case of GERD causing heartburn symptoms, surgery may be required if PPI is not effective.[37] Surgery is not undergone if functional heartburn is the leading diagnosis.[38]

Epidemiology

About 42% of the United States population has had heartburn at some point.[39]

References

  1. ^ "Pyrosis definition - MedicineNet - Health and Medical Information Produced by Doctors". MedicineNet. Archived from the original on 23 January 2014. Retrieved 19 November 2015.
  2. ^ "Gastroesophageal Reflux (GER) and Gastroesophageal Reflux Disease (GERD) in Adults". The National Institute of Diabetes and Digestive and Kidney Diseases. Archived from the original on 2015-07-25. Retrieved 2015-07-24.
  3. ^ a b c "heartburn" at Dorland's Medical Dictionary
  4. ^ a b Differential diagnosis in primary care. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins. 2008. p. 211. ISBN 978-0-7817-6812-2.
  5. ^ "Pyrosis Medical Definition - Merriam-Webster Medical Dictionary". merriam-webster.com. Archived from the original on 25 July 2015. Retrieved 24 July 2015.
  6. ^ "Heartburn". National Library of Medicine. Archived from the original on 2016-03-12. Retrieved 2015-07-24.
  7. ^ Duvnjak, Marko, ed. (2011). Dyspepsia in clinical practice. New York: Springer. p. 2. ISBN 9781441917300. Archived from the original on 2015-06-21.
  8. ^ Delaney B, Ford AC, Forman D, Moayyedi P, Qume M (2005). Delaney B (ed.). "Initial management strategies for dyspepsia". Cochrane Database Syst Rev (4): CD001961. doi:10.1002/14651858.CD001961.pub2. PMID 16235292. (Retracted, see doi:10.1002/14651858.cd001961.pub3. If this is an intentional citation to a retracted paper, please replace {{retracted|...}} with {{retracted|...|intentional=yes}}.)
  9. ^ Sajatovic, Martha; Loue, Sana; Koroukian, Siran M. (2008). Encyclopedia of aging and public health. Berlin: Springer. p. 419. ISBN 978-0-387-33753-1.
  10. ^ Bautz, Benjamin; Schneider, Jeffrey I. (May 2020). "High-Risk Chief Complaints I: Chest Pain-The Big Three (an Update)". Emergency Medicine Clinics of North America. 38 (2): 453–498. doi:10.1016/j.emc.2020.01.009. ISSN 1558-0539. PMID 32336336. S2CID 216556980.
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  19. ^ Oustamanolakis, Pantelis; Tack, Jan (March 2012). "Dyspepsia: organic versus functional". Journal of Clinical Gastroenterology. 46 (3): 175–190. doi:10.1097/MCG.0b013e318241b335. ISSN 1539-2031. PMID 22327302. S2CID 397315.
  20. ^ "Pernicious anemia: MedlinePlus Medical Encyclopedia". medlineplus.gov. Retrieved 2022-06-08.
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  22. ^ Van Thiel, D. H.; Gavaler, J. S.; Joshi, S. N.; Sara, R. K.; Stremple, J. (April 1977). "Heartburn of pregnancy". Gastroenterology. 72 (4 Pt 1): 666–668. doi:10.1016/S0016-5085(77)80151-0. ISSN 0016-5085. PMID 14050.
  23. ^ a b c d e f g Fass R (January 2009). "Functional heartburn: what it is and how to treat it". Gastrointest. Endosc. Clin. N. Am. 19 (1): 23–33, v. doi:10.1016/j.giec.2008.12.002. PMID 19232278.
  24. ^ a b The Mayo Clinic Heartburn page Archived 2010-05-23 at the Wayback Machine.Accessed May 18, 2010.
  25. ^ a b The MedlinePlus Heartburn page Archived 2016-04-25 at the Wayback Machine Accessed May 18, 2010.
  26. ^ a b Domingues, Gerson; Moraes-Filho, Joaquim Prado P.; Fass, Ronnie (March 2018). "Refractory Heartburn: A Challenging Problem in Clinical Practice". Digestive Diseases and Sciences. 63 (3): 577–582. doi:10.1007/s10620-018-4927-5. ISSN 1573-2568. PMID 29352757. S2CID 3430229.
  27. ^ National Digestive Diseases Information Clearinghouse (NDDIC): Upper GI Series Archived 2010-05-27 at the Wayback Machine Accessed May 18, 2010.
  28. ^ Differential diagnosis in primary care. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins. 2008. p. 213. ISBN 978-0-7817-6812-2.
  29. ^ Swap CJ, Nagurney JT (November 2005). "Value and limitations of chest pain history in the evaluation of patients with suspected acute coronary syndromes". JAMA. 294 (20): 2623–9. doi:10.1001/jama.294.20.2623. PMID 16304077.
  30. ^ Hanke, Barbara K.; Schwartz, George Robert (1999). Principles and practice of emergency medicine. Baltimore: Williams & Wilkins. pp. 656. ISBN 978-0-683-07646-2.
  31. ^ Johnson LF, Demeester TR (October 1974). "Twenty-four-hour pH monitoring of the distal esophagus. A quantitative measure of gastroesophageal reflux". Am. J. Gastroenterol. 62 (4): 325–32. PMID 4432845.
  32. ^ a b "Gastroesophageal Reflux Disease". The Lecturio Medical Concept Library. Retrieved 23 July 2021.
  33. ^ "Endoscopy". British Medical Association Complete Family Health Encyclopedia. Dorling Kindersley Limited. 1990.
  34. ^ "What Are Antacids? - TUMS®". www.heartburn.com. Archived from the original on 2 March 2017. Retrieved 29 April 2018.
  35. ^ Morozov, Sergey; Isakov, Vasily; Konovalova, Mariya (2018-06-07). "Fiber-enriched diet helps to control symptoms and improves esophageal motility in patients with non-erosive gastroesophageal reflux disease". World Journal of Gastroenterology. 24 (21): 2291–2299. doi:10.3748/wjg.v24.i21.2291. ISSN 2219-2840. PMC 5989243. PMID 29881238.{{cite journal}}: CS1 maint: unflagged free DOI (link)
  36. ^ Dickman, R.; Schiff, E.; Holland, A.; Wright, C.; Sarela, S. R.; Han, B.; Fass, R. (2007-11-15). "Clinical trial: acupuncture vs. doubling the proton pump inhibitor dose in refractory heartburn". Alimentary Pharmacology & Therapeutics. 26 (10): 1333–1344. doi:10.1111/j.1365-2036.2007.03520.x. ISSN 0269-2813. PMID 17875198. S2CID 23118600.
  37. ^ Spechler, Stuart J.; Hunter, John G.; Jones, Karen M.; Lee, Robert; Smith, Brian R.; Mashimo, Hiroshi; Sanchez, Vivian M.; Dunbar, Kerry B.; Pham, Thai H.; Murthy, Uma K.; Kim, Taewan (2019-10-17). "Randomized Trial of Medical versus Surgical Treatment for Refractory Heartburn". The New England Journal of Medicine. 381 (16): 1513–1523. doi:10.1056/NEJMoa1811424. ISSN 1533-4406. PMID 31618539. S2CID 204757299.
  38. ^ Fass, Ronnie; Zerbib, Frank; Gyawali, C. Prakash (June 2020). "AGA Clinical Practice Update on Functional Heartburn: Expert Review". Gastroenterology. 158 (8): 2286–2293. doi:10.1053/j.gastro.2020.01.034. ISSN 1528-0012. PMID 32017911. S2CID 211036316.
  39. ^ Kushner PR (April 2010). "Role of the primary care provider in the diagnosis and management of heartburn". Curr Med Res Opin. 26 (4): 759–65. doi:10.1185/03007990903553812. PMID 20095795. S2CID 206964899.
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