When is heartburn more than just heartburn?

The vast majority of Australians (80%) experience heartburn at some stage in their lives, which might imply that heartburn is ‘just heartburn’ and not a serious disease requiring medical treatment. But heartburn is a symptom of a range of diseases, and while most are not particularly serious, prompt medical treatment is often needed to prevent serious complications in the future. So what exactly is heartburn? And when is heartburn ‘just heartburn’ and when does it require medical attention?

This heart’s on fire

Heartburn is a burning feeling in the chest. Not the pleasant, burning-with-love kind of feeling we get sometimes, but a painful, gripping sensation of burning which rises from the stomach, and spreads behind the chest, and sometimes to the neck.^2,3,16 It generally occurs 30–60 minutes after eating and, like the pleasant kind of heartburn, it might just be caused by something you love. Spicy or fatty foods and alcoholic or caffeinated beverages are some of the foods and drinks which might set your heart on fire in this unpleasant kind of way.⁴ 

The old advice to ‘get down low and go, go, go’, won’t do much to prevent a heartburn fire. On the contrary bending, stooping, lying down and straining tend to make heartburn pains worse. But none of these things alone can cause heartburn.^2,3

An open door to this (burning) heart

Heartburn occurs when acid from the stomach escapes into the throat. The stomach sphincter, which is something like a door between your stomach and throat, normally closes once food has passed down the throat and entered the stomach. If the ‘door’ doesn’t close properly, the stomach contents, including the food you’ve eaten along with stomach acids, can escape back up into the throat and cause the burning feeling that characterises heartburn.^5,6

While heartburn attacks are generally brief and occur intermittently, it is a very common experience; 2 in every 5 Australians get heartburn regularly. Of those, 1 in 5 experience heartburn about once a month, which is considered infrequent.⁷ If you’re amongst those Australians who experiences infrequent heartburn, you can rest easy knowing that heartburn, although painful, is not doing any serious damage and can be easily managed.⁸

For more information about the different components of the gastrointestinal system, how they’re connected and what they do, see Gastrointestinal System.

Dousing the fire with lifestyle changes and antacids

Usually, if you experience infrequent symptoms a few simple lifestyle changes and a dose of antacids will be enough to douse the fire in your heart. A good place to start is with dietary changes which should include:

• Reducing fat, alcohol and caffeine intake;⁹
• Quitting smoking;⁹
• Increasing fruit and vegetable intake;¹⁰ 
• If you are overweight or obese, eating a restricted calorie diet until you lose weight;¹⁰
• Eating smaller meals more frequently;⁴
• Avoiding eating for at least 3 hours before you go to bed or lie down.⁴

Another simple change you can make is to raise the head of your bed slightly, so that your head is elevated a little bit when you do lie down.⁹ These measures usually reduce the frequency of heartburn, but most people also occasionally need to use medicines called antacids to stop the burning pain when heartburn occurs.⁸ Antacids are medicines which neutralise the acid produced by your stomach, so when your stomach forgets to close the door on the hell-fire below, there’s no acid there to creep up your throat and set your heart on fire.¹¹ You can purchase antacids over the counter at the chemist and keep them on hand for unexpected flares.⁹

Can’t put out the fire in your heart

However, even if your heartburn is infrequent, it’s a good idea to keep an eye on your symptoms. If they get worse or start to occur more frequently, and especially if they occur more than once a week, heartburn attacks could be the sign of another disease which requires different forms of treatment.⁸ Even in cases of frequent heartburn attacks, there’s usually little to worry about, after all 1 in 5 Australians experience weekly heartburn attacks.^3,6 But when heartburn occurs at least once a week, there’s a risk that something more serious is happening. It’s important to see your doctor promptly and get the right treatment to ensure you don’t have a serious condition and to reduce the likelihood one will occur in the future.⁸

Heartburn is usually a symptom of gastro-oesophageal reflux disease, which is often referred to by its charming acronym, GORD. GORD causes the problems that enable acid to escape the stomach. It is a disease characterised by the sphincter of the stomach failing to close properly and allowing stomach acids and partially digested foods to flow back up. Heartburn is a symptom of GORD, and when it occurs infrequently, it’s nothing to worry about. But frequent hits of acid (> 1 per week) are a concern; in addition to causing symptoms like heartburn, they can also damage the oesophagus and increase the risk of other, more serious conditions.^5,6 So you’ll need more than a simple dose of antacids to treat your heartburn attacks if they occur once a week or more.⁸

                            Figure 1: Inflamed oesophagus due to GORD.

This fire is out of control

When acid enters the oesophagus frequently, a condition called oesophagitis may occur. The oesophagus becomes damaged by the acid and larger quantities of stomach contents are allowed to escape during future episodes of heartburn, damaging the oesophagus further. It’s a vicious cycle which needs to be broken and the best way to do that is by using low doses of medicines called proton pump inhibitors (PPIs).⁸ Low dose formulations (e.g. Somac Heartburn Relief) are available over-the-counter in Australia.¹

Unlike antacids which neutralise acid after it is produced and aim only to stop the immediate symptoms, PPIs reduce the production of acid in the stomach. This in turn reduces the likelihood of acid escaping and causing heartburn and further oesophageal damage in the future.⁸

More than just a fire

Preventing further damage to the oesophagus by reducing acid production in the stomach is not only important for reducing episodes of heartburn. It’s also necessary to prevent serious complications like Barrett’s oesophagus and oesophageal cancer. Heartburn may also be related to comorbid health conditions like asthma. In these cases, getting the right heartburn treatment is an important component of managing the comorbid condition.⁸

If you experience heartburn at least once a week, it is essential to visit a doctor for a thorough examination. This will help to determine the extent of your symptoms, and suggest a course of treatment to prevent symptoms recurring while also stopping more serious complications. It’s also important to seek medical care if you experience any ‘warning’ symptoms of serious disease alongside heartburn.These include:⁸

• Pain in the abdomen;
• Symptoms of the upper throat like a hoarse voice and sore throat;
• Difficulty swallowing;
• Weight loss;
• Feeling of having a lump in your throat;
• Gastrointestinal bleeding;
• Persistent vomiting.

Having these symptoms does not necessarily mean your condition is more serious, but it does mean you need a different type of treatment to someone who only experiences heartburn. When these symptoms are present, it’s unlikely that PPIs will relieve your heartburn pain.⁸

High fire danger

Often the types of symptoms you experience will be enough to alert the doctor that something serious is going on. If you don’t have any ‘warning’ symptoms, the doctor will usually recommend a short course of PPIs at prescription-only doses (e.g. Somac 20 mg or 40 mg). For the majority of people who have GORD, this will relieve heartburn and also heal any damage to the oesophagus which has already occurred.⁸

However, if you fail to respond to prescription PPIs, it’s an indication that GORD is not the problem. The next step is using medicines to eradicate a bacterium called Helicobacter pylori, which is often responsible for heartburn symptoms when GORD is not the cause. If these work, the problem is solved. If not, your doctor will need to delve a bit deeper to work out what’s going wrong.¹⁰

Forensic testing- what starts the fire?

There are several tests the doctor might use to further investigate the cause of your heartburn:

• Oesophageal pH monitoring is a test in which the pH (acidity or alkalinity) of the oesophagus is measured for a period of 24 hours by a probe which is inserted in the oesophagus, near it’s junction with the stomach. This test is used to confirm that acid is actually present in the oesophagus. The absence of acid indicates a condition other than GORD Is causing the problem;^12,13
• Barium swallow and meal is a test in which you’ll need to swallow a dye called barium and then have an x-ray taken.⁹ The dye passes into your stomach and shows up on the x-ray. It is usually used to look for hiatus hernia, or the formation of an abnormal pocket which traps food in the stomach;¹⁴ 
• Manometry is a test which involves inserting a small pipe through your nose and oesophagus, to the vicinity of the stomach sphincter. It measures the pressure of the sphincter, which is an indicator of whether it seals tightly (high pressure), or opens allowing acid to escape (low pressure);¹²
• Upper gastrointestinal endoscopy, also called gastroscopy, is a test which involves viewing the oesophagus with a fibre optic telescope or camera. The camera is inserted through the mouth until it reaches the area of the oesophagus which joins to the stomach. Images from the camera are displayed on a screen so the doctor can literally look inside you. They can also take small cuttings of the oesophageal tissue for later viewing under a microscope (biopsy). This test is used to check for cancer, Barrett’s oesophagus and other serious complications.¹⁴

Fire extinguishers- getting the right treatment

The test results will indicate to your doctor how your heartburn should best be treated. Whatever the result, you should try to make some small dietary and lifestyle changes (discussed above) which can help relieve heartburn. These are important steps for optimising the effects of other treatments, but alone these will not stop your symptoms.⁸

If the tests show you have GORD, the usual treatment is PPIs and they are effective for the majority of people. However, you’ll need a prescription for a high-dose formulation, not the over-the-counter version which contains less of the active ingredient.⁸ There are several types of PPIs available in Australia and all work in the same way (by stopping acid production in the stomach). However, some are more appropriate for certain people than others, depending, for example, on the other medications the person takes.¹⁵ One PPI may work better for you than another so the doctor may switch to another type of PPI if the first does not provide adequate relief.⁸

Sometimes the doctor will prescribe medicines called prokinetic agents to be taken at the same time as PPIs. These are medicines which stimulate the stomach to empty its contents into the bowel more quickly.¹⁶ Medicines called histamine H₂-receptor antagonists, which block the secretion of acid from stomach cells,¹⁷ may also be prescribed to take before bedtime during PPI therapy.⁸

A surgical procedure called Nissen fundoplication is also sometimes used to treat heartburn and GORD in individuals who have hiatus hernia or low sphincter pressure. The surgery involves wrapping the upper stomach lining around the stomach sphincter to increase sphincter pressure.¹⁴

Conclusion

Digestion is an essential process for getting all the things we need out of the food we eat but it should know its place and stay there. When it creeps out into your throat it causes heartburn which is an unpleasant experience but one that is easily treated with a variety of lifestyle changes and medications. Determining the best treatment requires careful consideration of your specific symptoms, particularly how often heartburn occurs but also its triggers and the other symptoms which might accompany it. If you get heartburn less than once a week and it resolves with antacid therapy you most probably have normal run-of-the-mill heartburn which does not require further treatment.

However, if other symptoms like persistent vomiting or weight loss occur, or if heartburn attacks happen at least once a week, it’s time to see a doctor. This will ensure you get appropriate treatment and reduce the risk of serious complications in the future.

References

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