Heartburn: What You Should Know
By Phoebe Chi, MD
Heartburn. It’s something that hardly needs an introduction. Most people have experienced it at least once in their lifetime. For some, it’s an occasional annoyance; for others, a serious medical problem. But what discerns one from the other? When and why should it be treated? And what exactly can be done about it? These are the questions that will be addressed today.
Heartburn vs GERD
Picture this: You take a bite of a burger. You swallow, initiating a complex coordination of muscle reflexes that quickly move the food down your esophagus. At the end is a closed valve, a ring of muscle around the stomach entrance called the lower esophageal sphincter (LES).
In a normal situation, the LES opens momentarily to let the food go through and closes as soon as it enters the stomach. However, sometimes the LES fails to close all the way or opens at inappropriate times; when this happens, the acid in your stomach leaks into the esophagus—a state called acid reflux. Since the esophageal lining is more sensitive, this leads to the pain and discomfort commonly known as heartburn.
Some characteristics of heartburn:
Sharp or burning sensation in the center of the chest or the upper abdomen that can move up to the throat which–
- can last up to 2 hours
- is usually worse after eating
- is worsened by lying down or bending over
While it is completely normal to experience heartburn once in a while, when acid reflux starts to occur on a regular basis (more than twice a week for several weeks), this becomes a condition called acid reflux disease, or gastroesophageal reflux disease (GERD).
While the most common symptom of GERD is heartburn, chronic acid reflux can lead to many different symptoms, such as:
- Taste of bitter acid in the throat or mouth while sleeping or bending over
- Hiccups that don’t let up
- Wheezing, dry cough, or chronic sore throat
- Hoarseness (especially in the morning)
- Worsening of asthma after meals, lying down, or at night
- The sensation of food being stuck in your throat
Causes of Acid Reflux
While specific medical conditions (like a hiatal hernia) can cause GERD, lifestyle factors play a large contributory role in acid reflux:
- Heavy meals or eating too fast
- Lying down or exercising right after a meal
- Certain foods:
- Citrus fruits
- Mint flavoring
- Garlic and onions
- Spicy or greasy foods
- Coffee (caffeinated and decaf)
- Carbonated drinks
- Alcohol and Tobacco
- Being overweight or obese
- Poor posture (slouching)
- Clothing that is tight around the waist
- Certain medications:
- Calcium-channel blockers (eg. amlodipine)
- Alpha blockers (eg. doxazosin)
- Anti-inflammatories (eg. ibuprofen, aspirin)
- Tricyclics antidepressants (eg. amitriptyline)
The Importance of Treating GERD
Besides being uncomfortable, when left untreated, GERD can lead to painful inflammation and ulcers of the esophagus. Long term inflammation causes scarring of the mucosal lining and subsequent narrowing of the esophagus called an esophageal stricture, which leads to swallowing difficulties. An even more serious long-term effect of untreated acid reflux disease is the development of a precancerous condition called Barrett’s esophagus, which markedly increases your risk of developing esophageal cancer.
Avoid large meals. Eating a lot of food at one time increases the amount of acid needed to digest it. A full stomach also puts pressure on the LES, leading to leakage of stomach acid into your esophagus. Rather, eat smaller, more frequent meals throughout the day.
- Meal timing: Don’t eat within 3 hours of bedtime. This allows your stomach to empty and acid production to decrease.
- Post-meal activity: Don’t lie down right after eating at any time of day. Also, avoid vigorous exercise for 2 hours after eating. An after-dinner stroll is fine, but a more strenuous workout, especially if it involves bending over, can send acid into your esophagus.
- Avoid food triggers: Although different people have different foods that trigger heartburn, consider avoiding the common ones that are known to relax the LES, such as peppermint, caffeine, sodas, chocolate, citrus fruits and juices, tomatoes, onions, and greasy foods. Also, avoid or limit your alcohol intake.
- Add fiber: Eat more fiber to keep your digestive tract moving and healthy.
- Chew gum after a meal: Chewing non-mint-flavored, sugarless gum after meals promotes salivation, which neutralizes acid, soothes the esophagus, and washes acid back down to the stomach.
Use gravity to keep the acid down at night. Unfortunately, just propping up your head and shoulders with an extra pillow isn’t enough (this can actually worsen reflux). Rather, sleep on an incline:
- Bed tilt method: Place six-inch blocks under the legs at the head of your bed to create a gradual incline.
- Use a specialty pillow: Raise your torso up by sleeping on a large, wedge-shaped pillow (which you can find at medical supply stores). Doing this will decrease the pressure on your LES and improve your nighttime symptoms.
If you smoke tobacco, here is another good reason to quit: smoking not only weakens the muscles of your LES, worsening heartburn symptoms, but tobacco itself significantly increases your risk of developing esophageal cancer.
Increased weight spreads the muscular structure that supports the LES, relaxing it and causing acid reflux. Excess abdominal fat also presses against the stomach, forcing acid up into the esophagus. This also goes for any tight clothing that constricts your waist. Having trouble jumpstarting your weight loss efforts? This article may help.
If you find that lifestyle modifications are simply not enough to eliminate or control your symptoms, heartburn medications may be appropriate for you. As there are numerous available medications on the market, the following is an overview of the three main classes highlighting the important differences you should be aware of.
- Brand Names:
- Milk of Magnesia
- Contains: Calcium carbonate, magnesium hydroxide, aluminum hydroxide
- What they do: Neutralizes stomach acid. Antacids do not reduce the amount of acid produced by the stomach.
- Best for: Occasional, mild heartburn
- How to take: Whenever heartburn symptoms start
- Note: Antacids work immediately but only provide short term relief (a few hours). Liquid forms work faster than chewable tablets. Antacids that contain magnesium can also produce loose stools.
- Ranitidine (Zantac)
- Cimetidine (Tagamet)
- Famotidine (Pepsid)
- What they do: Lower the amount of acid produced by the stomach by acting directly on the stomach’s acid-secreting cells.
- Best for: Occasional, moderate heartburn that does not respond to lifestyle changes or antacids.
- How to take: Before symptoms start (ideally before meals or at bedtime)
- Note: H2 blockers take 1-2 hours to start working but can provide relief for up to 24 hours. They can be taken in combination with antacids if you need immediate but also longer relief (just wait an hour in between meds). H2 blockers should not be taken daily for longer than 2 weeks unless instructed by a doctor.
Proton Pump Inhibitors (PPI)
- Omeprazole (Prilosec)
- Esomeprazole (Nexium)
- Pantoprazole (Protonix)
- Lansoprazole (Prevacid)
- What they do: Lower the amount of acid produced by the stomach by acting directly on the stomach’s acid-secreting cells (by a different mechanism than H2 blockers)
- Best for: Persistent, severe heartburn, GERD, gastric inflammation and ulcers
- How to take: In the morning on an empty stomach
- Notes: Proton pump inhibitors make up the strongest class of heartburn medications (more potent than H2 blockers and antacids). They do not act immediately (takes a few days to start working), therefore they may be taken with antacids in the meantime. Avoid taking PPI’s and H2 blockers at the same time.
Here’s to healthy living and a heartburn-free future!
*All the information here should only be used for general information and not as medical advice. Please, never start a new medication before consulting with your physician in order to discuss potential interactions and side effects.