🩺 Heartburn

## Overview Heartburn is a burning sensation felt behind the breastbone (retrosternal area) that often rises toward the throat. Despite its name, heartburn has nothing to do with the heart — it is caused by stomach acid flowing back into the esophagus, a process called gastroesophageal reflux. The term is used both as a standalone symptom and as the hallmark complaint of gastroesophageal reflux disease (GERD). Heartburn is remarkably common. Population-based studies estimate that **20–30 % of adults in Western countries** experience heartburn at least once a week, and up to 44 % report monthly episodes [1]. In the United States alone, GERD-related symptoms account for roughly 8–9 million outpatient visits per year. The high prevalence, discomfort, and overlap with potentially serious conditions (including cardiac chest pain) make heartburn one of the most frequently searched health symptoms online. The ICD-10 code for heartburn is **R12**, classified under symptoms and signs involving the digestive system. --- ## Common Causes Heartburn results when the lower esophageal sphincter (LES) — a ring of muscle at the junction of the esophagus and stomach — relaxes inappropriately or becomes weakened, allowing acidic gastric contents to contact the esophageal mucosa. Below are the most common causes, ranked roughly by frequency. ### 1. Transient Lower Esophageal Sphincter Relaxations (TLESRs) The single most common mechanism behind heartburn in otherwise healthy individuals. TLESRs are brief, reflexive relaxations of the LES unrelated to swallowing, triggered by gastric distension. They account for up to **70 % of reflux episodes** in people without a hiatal hernia [2]. ### 2. Gastroesophageal Reflux Disease (GERD) When reflux becomes chronic — typically defined as troublesome symptoms occurring two or more times per week — the diagnosis shifts to GERD [1]. Mucosal damage (erosive esophagitis) is present in roughly 30–40 % of GERD patients; the remainder have non-erosive reflux disease (NERD). ### 3. Hiatal Hernia A hiatal hernia occurs when the upper part of the stomach protrudes through the diaphragmatic hiatus. This disrupts the LES barrier, promotes acid pooling, and is strongly associated with more severe reflux and esophagitis [3]. ### 4. Dietary and Lifestyle Triggers Certain foods and habits weaken the LES or increase intra-abdominal pressure: - **Fatty or fried foods** — slow gastric emptying, reduce LES tone - **Caffeine, chocolate, peppermint** — relax the LES - **Alcohol** — directly irritates esophageal mucosa and reduces LES pressure - **Citrus, tomatoes, spicy foods** — lower pH of refluxate, irritate mucosa - **Large meals and late-night eating** — gastric distension triggers TLESRs - **Obesity** — increased intra-abdominal pressure is a strong, dose-dependent risk factor [4] ### 5. Medications Several drug classes can provoke or worsen heartburn: - NSAIDs (ibuprofen, naproxen) — direct mucosal injury - Calcium-channel blockers, nitrates — relax the LES - Bisphosphonates (alendronate) — pill esophagitis - Tetracyclines, potassium chloride, iron supplements — esophageal irritation - Anticholinergics — delayed gastric emptying ### 6. Pregnancy Hormonal changes (particularly elevated progesterone) relax the LES, while the enlarging uterus increases intra-abdominal pressure. Up to **80 % of pregnant women** report heartburn, especially in the third trimester [7]. ### 7. Functional Heartburn Some patients have typical heartburn symptoms with normal acid exposure and no reflux–symptom correlation on pH monitoring. This entity, defined by Rome IV criteria, involves esophageal hypersensitivity and central pain processing abnormalities rather than excess acid. --- ## RED FLAGS Most heartburn is benign, but certain features demand **urgent or emergent evaluation**. Seek immediate medical attention (call emergency services) if heartburn is accompanied by: - **Crushing or pressure-like chest pain** radiating to the jaw, left arm, or back — may indicate acute coronary syndrome - **Sudden-onset severe chest or upper abdominal pain** with vomiting — raises concern for esophageal perforation (Boerhaave syndrome) - **Difficulty swallowing (dysphagia)** or **painful swallowing (odynophagia)** — suggests stricture, eosinophilic esophagitis, or malignancy - **Unintentional weight loss** (> 5 % body weight in 6–12 months) - **Vomiting blood (hematemesis)** or **black, tarry stools (melena)** — indicates gastrointestinal bleeding - **Persistent vomiting** preventing any oral intake - **New-onset heartburn after age 55** with any alarm feature — warrants prompt endoscopy per ACG guidelines [2] - **Anemia of unknown origin** with reflux symptoms - **Choking, hoarseness, or recurrent aspiration pneumonia** — suggests laryngopharyngeal reflux complications > **Important:** Heartburn and cardiac chest pain can feel identical. If there is any doubt, especially in patients with cardiovascular risk factors, **treat as a cardiac emergency until proven otherwise.** --- ## Self-Care at Home For mild, infrequent heartburn, the following evidence-based non-pharmacological measures may provide meaningful relief: ### Dietary Modifications - **Avoid known trigger foods** — fatty foods, chocolate, peppermint, caffeine, alcohol, citrus, and tomato-based products. A 2016 systematic review confirmed that dietary intervention generally reduces symptom burden [4]. - **Eat smaller, more frequent meals** rather than large portions. - **Avoid eating within 2–3 hours of bedtime** — allows gastric emptying before lying down. ### Positional Strategies - **Elevate the head of the bed by 15–20 cm (6–8 inches)** using blocks or a wedge pillow. This uses gravity to reduce nocturnal reflux and has been shown in controlled trials to decrease esophageal acid exposure time [4]. - **Avoid lying on the right side** — left-lateral positioning reduces reflux episodes by keeping the gastroesophageal junction above the acid pool. ### Weight Management - **Lose excess weight.** A prospective cohort study found that a BMI reduction of ≥ 3.5 units was associated with a roughly 40 % decrease in reflux symptoms [4]. Even modest weight loss may help. ### Other Measures - **Quit smoking** — nicotine reduces LES pressure and impairs salivary bicarbonate secretion. - **Wear loose-fitting clothing** — avoids increasing intra-abdominal pressure. - **Chewing sugar-free gum** after meals may stimulate saliva production, which neutralizes esophageal acid (small trials suggest benefit). - **Manage stress** — psychological stress can heighten esophageal pain perception even without increased acid reflux. --- ## OTC Medications That Help Over-the-counter (OTC) options are appropriate for mild, intermittent heartburn. They fall into three main classes. | Class | Example(s) | Typical Adult Dose | Mechanism | Notes | |---|---|---|---|---| | **Antacids** | Calcium carbonate (Tums), aluminum/magnesium hydroxide (Maalox, Mylanta) | 500–1000 mg calcium carbonate chewed as needed; max 7500 mg/day | Directly neutralize gastric acid on contact | Fast onset (minutes) but short duration (30–60 min). May cause constipation (aluminum) or diarrhea (magnesium). Avoid in renal impairment. | | **H2-receptor antagonists (H2RAs)** | Famotidine (Pepcid AC) 10–20 mg | 10–20 mg once or twice daily as needed; max 40 mg/day OTC | Block histamine H2 receptors on parietal cells, reducing acid secretion | Onset ~30–60 min; duration 6–12 h. Good for predictable heartburn (e.g., before a trigger meal). Tachyphylaxis may develop with continuous daily use. | | **Proton pump inhibitors (PPIs)** | Omeprazole (Prilosec OTC) 20 mg, esomeprazole (Nexium 24HR) 20 mg, lansoprazole (Prevacid 24HR) 15 mg | One capsule daily, 30 min before breakfast, for up to 14 days | Irreversibly inhibit H⁺/K⁺-ATPase (proton pump) in parietal cells | Most potent acid suppression. Not for immediate relief — peak effect takes 2–3 days. OTC labeling limits use to 14-day courses, no more than 3 times per year. Do not exceed OTC duration without clinician guidance [5]. | | **Alginate-based products** | Sodium alginate + sodium bicarbonate (Gaviscon Advance) | 10–20 mL after meals and at bedtime | Forms a physical "raft" on gastric contents that blocks reflux | Particularly useful for postprandial and nocturnal symptoms. Generally well-tolerated. Sodium content may matter in salt-restricted diets. | > **Tip:** For occasional heartburn, start with an antacid for rapid relief. If symptoms recur several times a week, an H2RA or a short-course PPI is generally more effective [2]. --- ## Prescription Options Prescription therapy is generally indicated when OTC measures fail after 4–8 weeks, alarm features are present, or endoscopy reveals erosive esophagitis or Barrett's esophagus. | Class | Examples | Typical Adult Dose | When Used / Notes | |---|---|---|---| | **Prescription-strength PPIs** | Omeprazole 20–40 mg, esomeprazole 20–40 mg, pantoprazole 40 mg, rabeprazole 20 mg, dexlansoprazole 30–60 mg | Once or twice daily, 30 min before meals, typically 4–8 weeks | First-line Rx for erosive esophagitis and moderate-to-severe GERD. Healing rates of 80–90 % at 8 weeks [2]. Long-term use requires periodic reassessment. | | **Potassium-competitive acid blockers (P-CABs)** | Vonoprazan 10–20 mg | 20 mg once daily for healing; 10 mg for maintenance | Faster onset than PPIs, effective regardless of meal timing. Approved in some markets for erosive esophagitis and GERD [2]. | | **Prokinetics** | Metoclopramide 10 mg, domperidone 10 mg (availability varies by country) | 10 mg up to three times daily before meals | Enhance gastric emptying and LES tone. Limited by side-effect profile (extrapyramidal symptoms with metoclopramide). Generally reserved as adjuncts. | | **Baclofen** | Baclofen 5–20 mg TID | 5 mg TID titrated up | GABA-B agonist that reduces TLESRs. Used off-label for refractory GERD, typically by gastroenterologists. Sedation is dose-limiting. | | **Neuromodulators** | Tricyclic antidepressants (amitriptyline 10–25 mg at bedtime), SSRIs | Low-dose, typically at bedtime | For functional heartburn / esophageal hypersensitivity when acid suppression fails and pH testing is normal. Prescribed by gastroenterologists. | ### Surgical and Endoscopic Options For patients with confirmed GERD who cannot tolerate or wish to discontinue long-term medication: - **Laparoscopic fundoplication (Nissen or Toupet)** — the standard anti-reflux surgery; effective long-term in appropriately selected patients. - **Magnetic sphincter augmentation (LINX device)** — a ring of magnetic beads placed around the LES; FDA-approved, with growing evidence for efficacy. - **Transoral incisionless fundoplication (TIF)** — an endoscopic alternative with shorter recovery but potentially lower durability. Surgical referral is typically managed by a gastroenterologist in collaboration with a foregut surgeon. --- ## Lab Tests Typically Ordered Heartburn itself is a clinical diagnosis, but when symptoms are persistent, atypical, or accompanied by alarm features, clinicians may order the following: | Test | Rationale | |---|---| | **Upper endoscopy (EGD)** | Gold standard for detecting erosive esophagitis, Barrett's esophagus, strictures, and malignancy. Indicated for alarm symptoms, failure of empiric therapy, or screening in high-risk patients [2]. | | **Esophageal pH monitoring (24-hour catheter or wireless Bravo capsule)** | Quantifies acid exposure time. Essential for confirming or excluding pathologic reflux before anti-reflux surgery or in patients with normal endoscopy and refractory symptoms. | | **Esophageal impedance-pH monitoring** | Detects both acidic and non-acidic reflux events. Useful when symptoms persist despite adequate PPI therapy. | | **High-resolution esophageal manometry** | Assesses LES pressure and esophageal motility. Required before anti-reflux surgery to exclude achalasia or severe dysmotility. | | **Complete blood count (CBC)** | To evaluate for [iron-deficiency anemia](/tests/complete-blood-count) if GI bleeding is suspected. | | **Helicobacter pylori testing** (urea breath test, stool antigen, or biopsy-based) | Recommended in patients with concurrent dyspepsia. The relationship between H. pylori and GERD is complex; eradication is recommended for infection but does not reliably improve reflux [6]. See [H. pylori tests](/tests/helicobacter-pylori-test). | | **Serum gastrin level** | Considered if Zollinger-Ellison syndrome is suspected (refractory, severe symptoms with multiple ulcers). | | **Esophageal biopsy** | Performed during EGD to evaluate for Barrett's metaplasia, eosinophilic esophagitis, or dysplasia. | --- ## Special Populations ### Children and Adolescents Gastroesophageal reflux is physiologic in infants ("spitting up") and typically resolves by 12–18 months. Pathologic GERD in children may present with heartburn (in older children), feeding refusal, irritability, or respiratory symptoms. - **Non-pharmacological measures** (thickened feeds, upright positioning after meals) are first-line for infants. - **Pharmacological therapy** in pediatric GERD should be managed by a pediatrician or pediatric gastroenterologist. PPIs and H2RAs are used in children, but doses are **weight-based and age-dependent** — do not extrapolate adult dosing. The NASPGHAN/ESPGHAN guidelines provide evidence-based pediatric recommendations. - Antacids are generally **not recommended for infants** due to aluminum and magnesium accumulation risks. ### Pregnancy Heartburn affects up to 80 % of pregnant women [7]. Management priorities center on safety for the developing fetus. - **First-line:** Lifestyle modifications (small meals, avoid eating before bed, head-of-bed elevation) and antacids (calcium carbonate is preferred — also provides supplemental calcium). Avoid sodium bicarbonate (fluid retention) and magnesium trisilicate in high doses. - **Second-line:** Famotidine is generally considered acceptable in pregnancy when lifestyle measures and antacids are insufficient. - **PPIs:** Omeprazole and other PPIs have been used in pregnancy with reassuring observational safety data. Current guidelines generally consider them acceptable when clearly needed, though shared decision-making with the prescribing clinician is recommended [7]. - **Avoid:** Metoclopramide in the first trimester unless benefits clearly outweigh risks. Misoprostol is **contraindicated** (abortifacient). ### Elderly - Older adults may present with **atypical or milder symptoms** despite more severe esophageal disease (reduced pain perception). - **Higher risk of complications** from GERD: strictures, Barrett's esophagus, and esophageal adenocarcinoma increase with age. - **PPI considerations in the elderly:** Long-term PPI use has been associated in observational studies with small increased risks of *Clostridioides difficile* infection, osteoporotic fractures, hypomagnesemia, and chronic kidney disease. While causality remains debated, clinicians generally recommend using the **lowest effective dose for the shortest duration** [2]. - **Drug interactions:** PPIs (especially omeprazole) may interact with clopidogrel (CYP2C19 inhibition). Pantoprazole is generally preferred in patients on dual antiplatelet therapy. - **Antacid caution:** Aluminum-containing antacids may worsen constipation; magnesium-based products require caution in renal impairment. ### Athletes - Exercise-induced heartburn is common, particularly during **high-impact activities** (running) and exercises that increase intra-abdominal pressure (weightlifting, crunches). - Mechanisms include increased transient LES relaxations during exertion, reduced splanchnic blood flow, and mechanical compression of the stomach. - **Management tips:** - Avoid eating 2–3 hours before exercise - Stay hydrated but avoid carbonated beverages - An antacid or H2RA taken 30–60 minutes before exercise may help - Consider lower-impact alternatives (cycling, swimming) if symptoms are severe --- ## When to Escalate The decision to escalate depends on symptom severity, duration, response to treatment, and the presence of warning signs. ### See a GP or Primary-Care Clinician (Within Days to Weeks) - Heartburn occurring **two or more times per week** for more than 4 weeks - Symptoms **not controlled by 2 weeks of OTC PPI** therapy - Need for OTC acid-suppression medication **more than 3 times per year** (14-day courses) - Chronic throat clearing, hoarseness, or cough suspected to be reflux-related - History of Barrett's esophagus requiring surveillance ### Seek Same-Day or Urgent-Care Evaluation - **New-onset severe heartburn** unresponsive to antacids, especially if accompanied by nausea or vomiting - **Difficulty swallowing solids** (food getting stuck) - **Dehydration from persistent vomiting** - Heartburn combined with **unexplained fever** ### Go to the Emergency Room / Call Emergency Services - **Chest pain that could be cardiac** — especially with shortness of breath, diaphoresis, radiation to the arm or jaw, or exertional onset - **Vomiting blood** or passing **black tarry stools** - **Severe abdominal pain** with rigidity or rebound tenderness - **Complete inability to swallow** (including liquids) - **Signs of anaphylaxis** after taking a new medication for heartburn > **Rule of thumb:** If you are unsure whether your chest pain is heartburn or heart-related, **always err on the side of seeking emergency care.** Time-sensitive cardiac conditions require rapid evaluation. --- ## References [1] Vakil N, van Zanten SV, Kahrilas P, Dent J, Jones R. The Montreal definition and classification of gastroesophageal reflux disease: a global evidence-based consensus. *Am J Gastroenterol*. 2006;101(8):1900-1920. PMID:16928254. [2] Katz PO, Dunbar KB, Schnoll-Sussman FH, Greer KB, Yadlapati R, Spechler SJ. ACG Clinical Guideline for the Diagnosis and Management of Gastroesophageal Reflux Disease. *Am J Gastroenterol*. 2022;117(1):27-56. PMID:34807007. [3] Richter JE, Rubenstein JH. Presentation and Epidemiology of Gastroesophageal Reflux Disease. *Gastroenterology*. 2018;154(2):267-276. PMID:29289524. [4] Ness-Jensen E, Hveem K, El-Serag H, Lagergren J. Lifestyle Intervention in Gastroesophageal Reflux Disease. *Clin Gastroenterol Hepatol*. 2016;14(2):175-182.e3. PMID:26091849. [5] Kahrilas PJ. Gastroesophageal Reflux Disease. *N Engl J Med*. 2008;359(16):1700-1707. PMID:18923172. [6] Moayyedi PM, Lacy BE, Andrews CN, Enns RA, Howden CW, Vakil N. ACG and CAG Clinical Guideline: Management of Dyspepsia. *Am J Gastroenterol*. 2017;112(7):988-1013. PMID:28631728. [7] Body C, Christie JA. Gastrointestinal Diseases in Pregnancy: Nausea, Vomiting, Hyperemesis Gravidarum, Gastroesophageal Reflux Disease, Constipation, and Diarrhea. *Gastroenterol Clin North Am*. 2016;45(2):267-283. PMID:27261898. [8] National Institute for Health and Care Excellence (NICE). Gastro-oesophageal reflux disease and dyspepsia in adults: investigation and management. Clinical guideline [CG184]. Published September 2014, updated October 2019. Available at: https://www.nice.org.uk/guidance/cg184. [9] U.S. Food and Drug Administration. FDA Drug Safety Communication: Possible increased risk of fractures of the hip, wrist, and spine with the use of proton pump inhibitors. Updated March 2011. Available at: https://www.fda.gov/drugs/drug-safety-and-availability. --- *This article is for informational purposes only and does not constitute medical advice. Always consult a qualified healthcare professional for diagnosis and treatment decisions.*