Heartburn

Lying down after a big meal, you feel a burning pain in the center of your chest. Before long, the fire spreads upward to your neck. The pain eventually dies down, but not before you curse that third helping.

That searing pain you felt was heartburn, also known as acid indigestion -- a symptom experienced at least once a month by more than 60 million adults in the United States. A survey from Simmons Market Research Bureau yields an intriguing portrait of the average American suffering from indigestion: More people who have heartburn live in the South than in other areas of the country, with Virginia at the top of the list. Women suffer from indigestion at higher rates than men, and older people more than younger ones. Interestingly, people in middle-income brackets suffer more indigestion than those who have either higher or lower incomes. Skilled blue-collar and clerical workers have less indigestion than managers, and homeowners suffer more than renters.

Though we know a fair amount about who is most likely to suffer from heartburn, the condition itself is a mystery to many who are plagued by it. Here is some basic information that may help you get relief.

Fuel for the fire

Think of your stomach as a finely crafted container built to hold acid. As long as the container does its job, the acid isn't likely to cause any trouble. But the valve that connects the stomach to the esophagus sometimes leaks, allowing acid to splash upwards.

Normally, everything that's in the stomach is kept from escaping upward by a band of muscle called the lower esophageal sphincter, or LES, located where the bottom of the esophagus intersects with the stomach. The LES valve opens when you're swallowing food, but otherwise is supposed to be clamped tight. If it begins to open too easily, the contents of the stomach -- food or acid -- can back up into the esophagus. The esophagus isn't designed to handle acid, so the leakage usually causes discomfort and a burning pain.

Most people have heartburn every once in awhile. But if acid frequently escapes into your esophagus, the pain can be a regular part of your life. This condition is known as gastroesophageal reflux disease, or GERD. Heartburn is the most important symptom of GERD, but it's not the only one. Instead of a searing pain, some people have a sour taste in their throat (acid regurgitation). Other symptoms include a pain in the chest, as if food was "stuck" there, and abdominal pain. Nausea may also be a symptom of GERD.

Anything that weakens the valve can set the stage for heartburn and GERD. Diet may play a role in some people. Large meals, fatty foods, chocolate and carbonated beverages all make the LES valve open abnormally, although there is little scientific evidence that removing these things from your diet will improve heartburn. Alcohol can irritate the valve as well as the mucous membrane of the esophagus. Smoking relaxes the valve, leading to symptoms of acid reflux; it can also cause the stomach to secrete more acid. Pregnancy and obesity put extra strain on the valve, often causing frequent heartburn.

Some people with severe, chronic heartburn have a hiatal hernia, a condition in which a small portion of the stomach slides up into the chest through the opening that the normal esophagus passes through. This means the stomach joins the esophagus higher in the chest, often leading to a weaker LES. The hernia is an anatomic abnormality, or defect, that may or may not be associated with GERD -- though some studies suggest that it may contribute to the disease. (Many people with heartburn don't have hiatal hernias, and some hiatal hernias cause no symptoms.)

Heartburn -- or a heart attack?

Believe it or not, the symptoms of a heart attack can closely mimic the symptoms of heartburn and indigestion, especially among women. Far too often, people with chest pain reach for an antacid when they should be calling 911.

You can avoid a potentially fatal mixup by paying close attention to your symptoms. Heartburn usually ignites a burning pain that runs from your stomach to your breastbone, and it's often accompanied by a sour taste in your mouth. Heart attacks, on the other hand, may cause a prolonged heavy feeling or squeezing pain in your chest. (Angina, or heart pain, causes similar pain that lasts just a minute or two.) Although pressure chest pain is more commonly associated with heart disease, spasm of the esophagus may cause the same symptoms. It's best to assume the pain is coming from the heart, get emergency help to rule the heart out as a cause, then focus on the esophagus. Other potential symptoms of a heart attack include dizziness, nausea, sweating, shortness of breath, weakness, overwhelming anxiety, and pain that spreads into the jaw, shoulder, or down the arm.

Timing is also important. While heartburn usually flares up after a meal, heart attacks and angina are often triggered by exercise, but may come on at any time.

If you have ANY doubt about whether you're having a heart attack, call 911 immediately.

Trouble down the road

An occasional bout of heartburn isn't anything to worry about. But frequent bouts of pain may be a sign that your esophagus is in danger. Over time, acid can eat away at the lining of the esophagus, causing painful sores and even bleeding and scarring. This condition is called esophagitis.

In some people with acid reflux, the esophagus produces cells that closely resemble cells from the intestines. This condition is called Barrett's esophagus. Barrett's esophagus, in turn, increases the risk of cancer of the esophagus -- the fastest increasing cancer in the Western world. If you have Barrett's esophagus, your doctor will want to follow you regularly for signs of cancer by doing endoscopy on a regular basis.

So if heartburn is causing you pain or discomfort, or if you have trouble swallowing, see a doctor right away.

Controlling the burn

A few simple lifestyle changes -- perhaps combined with a couple of not-so-simple changes -- often bring great relief from heartburn. Even if your case is severe, a little self-help can go a long way.

Here are some important steps to take:

• Lose weight if you're overweight: getting rid of a few pounds can make a big difference.
• If heartburn bothers you at night, try raising the head of the bed four to six inches, perhaps by sliding blocks of wood under the bedposts. (Putting an extra pillow under your head probably won't help and can even make heartburn worse.) Sleeping on your left side has also been shown to be better than lying on the right side or stomach.
• Try to eat at least three or four hours before getting into bed. Don't lie down within three hours of a meal, because lying flat just after eating is likely to result in a bad case of acid reflux.
• Eat smaller meals, and avoid those late-night snacks.
• If you smoke, do whatever it takes to quit. Smoking decreases lower esophageal sphincter pressure. Although there is little scientific evidence that quitting will cure your GERD, it certainly will greatly lower your risk of heart disease, cancer, and many other serious health problems.
• If you are a heavy drinker, cut back on alcohol. Although eliminating alcohol hasn't been proven to reduce heartburn, alcohol does decrease lower esophageal pressure and it is good for your general health to cut back.
• Though a recent review of clinical studies showed little evidence that changing your diet can relieve GERD, it makes sense to avoid food that seems to increase your stomach upset. Foods that have historically been thought to cause symptoms include fatty foods, chocolate, caffeinated food and drinks, citrus fruit or juices, tomato-based products, alcohol, and spicy foods.
• Go for a walk after meals if possible (this may also help with gas and bloating).
• Avoid tight clothing, including restrictive belts and "control-top" underwear.
• Don't bend over from your waist after a big meal.
• Eat more yogurt. Although there is no firm data on this issue, some physicians interested in complementary medicine recommend this food to heartburn patients. Yogurt with live cultures of beneficial bacteria may aid in digestion and help promote a healthy intestinal tract.
• Sucking on an antacid tablet, as necessary, may offer relief by stimulating saliva as well as bathing the esophagus with antacid. Chewing a stick of gum 30 minutes after a meal may also help prevent heartburn by stimulating saliva. Don't chew mint-flavored gum, however, because that can affect the valve between your stomach and esophagus. Because people tend to swallow air when they chew, it's also a good idea to avoid gum if you suffer from gas.

Should I try over-the-counter remedies?

When heartburn does flare up, an antacid usually brings quick relief. It works best when taken at the first sign of symptoms. Over time, however, regular doses of antacids that contain magnesium salts can cause diarrhea, while antacids containing calcium can lead to constipation. (If they're taken for a long period of time, high doses of calcium salts can even cause kidney disease in rare cases.) For these reasons, some specialists, including Gary Gitnick, MD, chief of the division of digestive diseases at University of California at Los Angeles Medical School, recommend that you not take antacids for more than a week at a time three or four times a year unless advised otherwise by your doctor. Antacids help relieve symptoms but don't promote healing of acid-induced damage.

To prevent future attacks -- and break your antacid habit -- you can try an over-the-counter H-2 blocker, which reduce the stomach's production of acid. (Many are also available in prescription strengths.) The possible side effects of acid blockers include diarrhea, rash, dizziness, nausea, and headache.

Ideally, you should talk to your doctor before trying any of these remedies. Besides having side effects, these medications can interact with certain other drugs, particularly heart medications, in harmful ways. If heartburn is still a problem after a few weeks of self-treatment, don't put off that doctor's appointment any longer.

The medical approach

Your doctor may ask you a lot of questions about your diet and make suggestions for lifestyle changes that you can implement one by one. If your pain is severe and your heartburn isn't responding to lifestyle changes, your physician can offer several effective treatments for heartburn. One option is a prescription strength version of an H-2 receptor antagonist or other acid blocker. These medicines provide short-term relief, but should be used in conjunction with long-term lifestyle changes.

More severe cases of GERD may call for a medicine known as a proton pump inhibitor (PPI), which strongly block the production of acid. According to the American College of Gastroenterology, PPIs (like omeprazole) offer the fastest relief of GERD and also help heal sores in the esophagus.

Proton-pump inhibitors rarely cause side effects, but they may cause headache, stomach pain, diarrhea, or an allergic reaction. Even if you feel fine after taking the drugs, don't go on a binge and consume a lot of alcohol and fatty food: they'll irritate your GI tract even if you don't get heartburn.

In the rare event that medications and lifestyle changes fail to control your heartburn, surgery may be an option. Surgery may also be necessary if you have severe damage to your esophagus or other complications. Surgery can be helpful in some cases, though its effectiveness over the long term is uncertain. According to guidelines published in the American Journal of Gastroenterology, the more experience your surgeon has in the procedure, the better your chance for a good outcome.

The most common type of operation strengthens the valve between the stomach and the esophagus. Surgery can also repair severe hiatal hernias. These operations can be performed laparoscopically -- using thin surgical instruments inserted through a small incision. This type of operation keeps pain and recovery time to a minimum.

References

National Digestive Diseases Information Clearinghouse. Heartburn, Gastroesophageal Reflux (GER), and Gastroesophageal Reflux Disease (GERD).

Szarka LA et al. Diagnosing gastroesophageal reflux disease. Mayo Clinic Proceedings. Vol. 76: 97-101.

Kaltenbach T, Crockett S, and Gerson L. Are Lifestyle Measures Effective in Patients with Gastroesophageal Reflux Disease? Archives of Internal Medicine; 166: 965-971.

DeVault KR, et al. Updated Guidelines for the Diagnosis and Treatment of Gastroesophageal Reflux Disease. Am J Gastroenterol, Vol.100:190-200.