Heartburn

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Heartburn
Other namesPyrosis, [1] cardialgia
Specialty Gastroenterology, family medicine, emergency medicine
Symptoms Burning, stabbing, or squeezing sensation in the chest, nausea, belching
Causes Gastroesophageal reflux disease
Risk factors Smoking, obesity
Diagnostic method Physical examination, medical history, antacid response, imaging, manometry
Differential diagnosis Chest pain, myocardial infarction, 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
Treatment Antacids, weight loss, surgery
Medication Antacids

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]

Contents

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. [7]

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, avoiding 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. [8] Indigestion is sometimes defined as a combination of epigastric pain and heartburn. [9] Heartburn is commonly used interchangeably with gastroesophageal reflux disease (GERD) rather than just to describe a symptom of burning in one's chest. [10]

Differential diagnosis

Heartburn-like symptoms and/or lower chest or upper abdomen may be indicative of much more sinister and/or deadly disease. [11] Of greatest concern is to confuse heartburn (generally related to the esophagus) with a heart attack as these organs share a common nerve supply. [12] Numerous abdominal and thoracic organs are present in that region of the body. Many different organ systems might explain the discomfort called heartburn. [7]

Heart

The most common symptom for a heart attack is chest pain. [13] However, as many as 30% of people who receive cardiac catheterization for chest pain 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. [14] Women experiencing heart attacks may also deny classic signs and symptoms [15] and instead complain of GI symptoms. [13] [16] [17] One article estimates that ischemic heart disease may appear to be GERD in 0.6% of people. [12]

Esophagus

Stomach

Intestines

Gallbladder

Pancreas

Hematology

Pregnancy

Heartburn is common during pregnancy having been reported in as many as 80% of pregnancies. [22] 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. [23] [22] The onset of symptoms can be during any trimester of pregnancy.

Unknown origin

Functional heartburn is heartburn of unknown cause. [24] It is commonly associated with psychiatric conditions like depression and anxiety. 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). [24] Despite this, PPIs are still the primary treatment with response rates in about 50% of people. [24] 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. [24]

Rome III Criteria
1Burning retrosternal discomfort
2Elimination of heart attack and GERD as the cause
3No esophageal motility disorders [24]

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. [25] 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. [25] [26] In young persons (typically <40 years) who present with heartburn symptoms consistent with GERD (onset after eating, when lying down, when pregnant), a physician may begin a course of PPIs to assess clinical improvement before additional testing is undergone. [27] 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:

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. [29] This however does not rule out a potential cardiac cause [30] as 10% of cases of discomfort due to cardiac causes are improved with antacids. [31]

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. [32] 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. [33]

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. [34]

Biopsy: a small sample of tissue from the oesophagus is removed. It is then studied to check for inflammation, cancer, or other problems. [33]

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

Lifestyle modifications

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, through medications aimed towards a psychiatric etiology, [24] osteopathic manipulation, and acupuncture.

Surgical management

In the case of GERD causing heartburn symptoms, surgery may be required if PPI is not effective. [39] Surgery is not undergone if functional heartburn is the leading diagnosis. [40]

Epidemiology

About 42% of the United States population has had heartburn at some point. [41]

Related Research Articles

<span class="mw-page-title-main">Antacid</span> Substance that relieves stomach problems

An antacid is a substance which neutralizes stomach acidity and is used to relieve heartburn, indigestion, or an upset stomach. Some antacids have been used in the treatment of constipation and diarrhea. Marketed antacids contain salts of aluminum, calcium, magnesium, or sodium. Some preparations contain a combination of two salts, such as magnesium carbonate and aluminum hydroxide.

<span class="mw-page-title-main">Gastroenterology</span> Branch of medicine focused on the digestive system and its disorders

Gastroenterology is the branch of medicine focused on the digestive system and its disorders. The digestive system consists of the gastrointestinal tract, sometimes referred to as the GI tract, which includes the esophagus, stomach, small intestine and large intestine as well as the accessory organs of digestion which include the pancreas, gallbladder, and liver.

<span class="mw-page-title-main">Esophageal achalasia</span> Inability of the sphincter between the esophagus and stomach to open

Esophageal achalasia, often referred to simply as achalasia, is a failure of smooth muscle fibers to relax, which can cause the lower esophageal sphincter to remain closed. Without a modifier, "achalasia" usually refers to achalasia of the esophagus. Achalasia can happen at various points along the gastrointestinal tract; achalasia of the rectum, for instance, may occur in Hirschsprung's disease. The lower esophageal sphincter is a muscle between the esophagus and stomach that opens when food comes in. It closes to avoid stomach acids from coming back up. A fully understood cause to the disease is unknown, as are factors that increase the risk of its appearance. Suggestions of a genetically transmittable form of achalasia exist, but this is neither fully understood, nor agreed upon.

An esophageal motility disorder (EMD) is any medical disorder resulting from dysfunction of the coordinated movement of esophagus, which causes dysphagia.

<span class="mw-page-title-main">Gastroesophageal reflux disease</span> Flow of stomach contents into the esophagus

Gastroesophageal reflux disease (GERD) or gastro-oesophageal reflux disease (GORD) is a chronic upper gastrointestinal disease in which stomach content persistently and regularly flows up into the esophagus, resulting in symptoms and/or complications. Symptoms include dental corrosion, dysphagia, heartburn, odynophagia, regurgitation, non-cardiac chest pain, extraesophageal symptoms such as chronic cough, hoarseness, reflux-induced laryngitis, or asthma. In the long term, and when not treated, complications such as esophagitis, esophageal stricture, and Barrett's esophagus may arise.

<span class="mw-page-title-main">Barrett's esophagus</span> Precancerous tissue formation in the esophagus

Barrett's esophagus is a condition in which there is an abnormal (metaplastic) change in the mucosal cells lining the lower portion of the esophagus, from stratified squamous epithelium to simple columnar epithelium with interspersed goblet cells that are normally present only in the small intestine and large intestine. This change is considered to be a premalignant condition because of its potential to further transition to esophageal adenocarcinoma, an often-deadly cancer.

<span class="mw-page-title-main">Esophagitis</span> Inflammation of the esophagus

Esophagitis, also spelled oesophagitis, is a disease characterized by inflammation of the esophagus. The esophagus is a tube composed of a mucosal lining, and longitudinal and circular smooth muscle fibers. It connects the pharynx to the stomach; swallowed food and liquids normally pass through it.

<span class="mw-page-title-main">Hiatal hernia</span> Entrance of abdominal organs into the middle chest through the diaphragm

A hiatal hernia or hiatus hernia is a type of hernia in which abdominal organs slip through the diaphragm into the middle compartment of the chest. This may result in gastroesophageal reflux disease (GERD) or laryngopharyngeal reflux (LPR) with symptoms such as a taste of acid in the back of the mouth or heartburn. Other symptoms may include trouble swallowing and chest pains. Complications may include iron deficiency anemia, volvulus, or bowel obstruction.

Coffee ground vomitus refers to a particular appearance of vomit. Within organic heme molecules of red blood cells is the element iron, which oxidizes following exposure to gastric acid. This reaction causes the vomitus to look like ground coffee.

<span class="mw-page-title-main">Nissen fundoplication</span> Surgical procedure to treat gastric reflux and hiatal hernia

A Nissen fundoplication, or laparoscopic Nissen fundoplication when performed via laparoscopic surgery, is a surgical procedure to treat gastroesophageal reflux disease (GERD) and hiatal hernia. In GERD, it is usually performed when medical therapy has failed; but, with a Type II (paraesophageal) hiatus hernia, it is the first-line procedure. The Nissen fundoplication is total (360°), but partial fundoplications known as Thal, Belsey, Dor, Lind, and Toupet fundoplications are alternative procedures with somewhat different indications and outcomes.

<span class="mw-page-title-main">Achlorhydria</span> Lack of hydrochloric acid production in the digestive organs

Achlorhydria and hypochlorhydria refer to states where the production of hydrochloric acid in gastric secretions of the stomach and other digestive organs is absent or low, respectively. It is associated with various other medical problems.

Indigestion, also known as dyspepsia or upset stomach, is a condition of impaired digestion. Symptoms may include upper abdominal fullness, heartburn, nausea, belching, or upper abdominal pain. People may also experience feeling full earlier than expected when eating. Indigestion is relatively common, affecting 20% of people at some point during their life, and is frequently caused by gastroesophageal reflux disease (GERD) or gastritis.

<span class="mw-page-title-main">Eosinophilic esophagitis</span> Allergic inflammatory condition of the esophagus

Eosinophilic esophagitis (EoE) is an allergic inflammatory condition of the esophagus that involves eosinophils, a type of white blood cell. In healthy individuals, the esophagus is typically devoid of eosinophils. In EoE, eosinophils migrate to the esophagus in large numbers. When a trigger food is eaten, the eosinophils contribute to tissue damage and inflammation. Symptoms include swallowing difficulty, food impaction, vomiting, and heartburn.

Esophageal dysphagia is a form of dysphagia where the underlying cause arises from the body of the esophagus, lower esophageal sphincter, or cardia of the stomach, usually due to mechanical causes or motility problems.

Stretta is a minimally invasive endoscopic procedure for the treatment of gastroesophageal reflux disease (GERD) that delivers radiofrequency energy in the form of electromagnetic waves through electrodes at the end of a catheter to the lower esophageal sphincter (LES) and the gastric cardia – the region of the stomach just below the LES. The energy heats the tissue, ultimately causing it to swell and stiffen; the way this works was not understood as of 2015, but it was thought that perhaps the heat causes local inflammation, collagen deposition and muscular thickening of the LES and that it may disrupt the nerves there.

Esophageal spasm is a disorder of motility of the esophagus.

<span class="mw-page-title-main">Nutcracker esophagus</span> Excessively strong or long contractions of the esophagus

Nutcracker esophagus, jackhammer esophagus, or hypercontractile peristalsis, is a disorder of the movement of the esophagus characterized by contractions in the smooth muscle of the esophagus in a normal sequence but at an excessive amplitude or duration. Nutcracker esophagus is one of several motility disorders of the esophagus, including achalasia and diffuse esophageal spasm. It causes difficulty swallowing (dysphagia) with both solid and liquid foods, and can cause significant chest pain; it may also be asymptomatic. Nutcracker esophagus can affect people of any age but is more common in the sixth and seventh decades of life.

<span class="mw-page-title-main">Esophageal pH monitoring</span> Method of diagnosing and measuring gastric acid reflux

In gastroenterology, esophageal pH monitoring is the current gold standard for diagnosis of gastroesophageal reflux disease (GERD). It provides direct physiologic measurement of acid in the esophagus and is the most objective method to document reflux disease, assess the severity of the disease and monitor the response of the disease to medical or surgical treatment. It can also be used in diagnosing laryngopharyngeal reflux.

Transoral incisionless fundoplication (TIF) is an endoscope treatment designed to relieve symptoms of gastroesophageal reflux disease (GERD). The TIF procedure, similar to Nissen fundoplication, alleviates GERD symptoms by wrapping a portion of the stomach around the esophagus.

<span class="mw-page-title-main">Acid peptic diseases</span> Overview of the acid peptic diseases of the stomach and gastrointestinal tract

Acid peptic diseases, such as peptic ulcers, Zollinger-Ellison syndrome, and gastroesophageal reflux disease, are caused by distinct but overlapping pathogenic mechanisms involving acid effects on mucosal defense. Acid reflux damages the esophageal mucosa and may also cause laryngeal tissue injury, leading to the development of pulmonary symptoms.

References

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  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. 1 2 3 "heartburn" at Dorland's Medical Dictionary
  4. 1 2 Differential diagnosis in primary care. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins. 2008. p. 211. ISBN   978-0-7817-6812-2.
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  24. 1 2 3 4 5 6 Fass R (January 2009). "Functional heartburn: what it is and how to treat it". Gastrointestinal Endoscopy Clinics of North America. 19 (1): 23–33, v. doi:10.1016/j.giec.2008.12.002. PMID   19232278.
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  35. ↑ "What Are Antacids? - TUMS®". www.heartburn.com. Archived from the original on 2 March 2017. Retrieved 29 April 2018.
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