Heartburn is a common complaint characterised by a burning sensation in the chest, behind the breastbone. This sensation often radiates towards the neck and throat as well. Although the name may be misleading, heartburn has nothing to do with the heart. The symptom is caused by the backflow of stomach acid into the oesophagus. Many people experience this unpleasant sensation from time to time, for example after a heavy, fatty meal. However, if heartburn occurs regularly, at least twice a week, it may be a sign of a more serious condition, gastro-oesophageal reflux disease (GERD), which requires medical treatment. In this article, we provide a detailed overview of the underlying causes of heartburn, the diagnostic options and effective treatment methods, including lifestyle changes and medication.
The physiological processes underlying heartburn
The underlying cause of heartburn is the malfunctioning of the lower oesophageal sphincter (LES). This ring-shaped muscle is situated at the junction of the oesophagus and the stomach. Normally, it relaxes when food is swallowed to allow the food to pass into the stomach, and then closes tightly to prevent the contents of the stomach – including stomach acid – from flowing back into the oesophagus.
If this sphincter muscle weakens or relaxes unnecessarily, acidic stomach contents can flow back into the oesophagus. Whilst the stomach lining has a special protective layer that resists the corrosive effects of acid, the tissues of the oesophagus are sensitive to it. The acid irritates the wall of the oesophagus, causing inflammation and the characteristic burning pain known as heartburn.
Several mechanisms may contribute to sphincter dysfunction:
- Transient sphincter relaxations (TLESR): This is the most common cause. Short, temporary episodes of relaxation do occur under normal circumstances, but in people with reflux disease they are more frequent and last longer. Stomach distension, for example after a large meal, can trigger this reflex.
- Sphincter muscle with reduced contractile strength: In some cases, the resting pressure of the sphincter is persistently low, meaning it is unable to prevent reflux effectively.
- A hernia (hiatus hernia): This condition occurs when the upper part of the stomach slips into the chest cavity through the opening in the diaphragm. This alters the position and anatomy of the sphincter, which impairs its closing function and makes it difficult to clear acid that has refluxed into the oesophagus.
What factors can trigger heartburn?
A number of lifestyle and dietary factors, as well as certain medical conditions, can contribute to the development of heartburn or to the worsening of its symptoms.
Lifestyle and dietary factors
Certain foods and drinks are known to trigger heartburn by reducing the pressure of the lower oesophageal sphincter, increasing stomach acid production, or irritating the lining of the oesophagus.
- Fatty and spicy foods: High-fat meals slow down gastric emptying, which increases pressure in the stomach and the likelihood of reflux. Hot and spicy foods can also directly irritate the oesophagus.
- Certain foods: Chocolate, mint, onions and garlic can relax the sphincter muscle. Tomato-based products (e.g. sauces) and citrus fruits (oranges, lemons) can make the burning sensation worse due to their high acid content.
- Drinks: Coffee (both caffeinated and decaffeinated), alcoholic drinks and fizzy soft drinks can all increase acid production and impair the function of the sphincter muscle.
- Large portions and late meals: Large meals stretch the stomach, increasing pressure and the likelihood of TLESR. Eating before going to bed is also problematic, as when lying down, gravity does not help to keep the stomach contents in place.
- Overweight and obesity: Fat tissue that accumulates in the abdominal area increases intra-abdominal pressure, which constantly puts pressure on the stomach and promotes acid reflux. Losing weight is one of the most effective ways of alleviating the symptoms.
- Smoking: Nicotine relaxes the lower oesophageal sphincter, reduces the acid-neutralising effect of saliva and damages the oesophageal mucosa.
Other health factors and medicines
- Pregnancy: Hormonal changes (e.g. a rise in progesterone levels) cause the sphincter muscle to relax, whilst the growing uterus puts pressure on the stomach. This is why heartburn is extremely common amongst pregnant women.
- Certain medicines: Heartburn can occur as a side effect of many medicines. These include, for example, certain blood pressure-lowering medicines (calcium channel blockers), asthma medicines (beta-agonists), anxiolytics (benzodiazepines), and non-steroidal anti-inflammatory drugs (NSAIDs), such as aspirin or ibuprofen, which can also directly damage the lining of the stomach and oesophagus.
- Stress: Although stress does not in itself cause reflux, it can make the symptoms feel more pronounced. When under stress, people become more sensitive to pain, so even a mild episode of reflux can feel like more severe heartburn.
When should we see a doctor?
Occasional heartburn is not usually a cause for concern and can be treated with over-the-counter antacids or lifestyle changes. However, if symptoms persist or worsen, it is strongly recommended that you consult a gastroenterologist.
Visit the Endomedix one of our gastroenterology centres if you experience any of the following:
- He suffers from heartburn two or more times a week.
- Over-the-counter medicines do not relieve your symptoms.
- You notice difficulty swallowing (dysphagia) or painful swallowing (odynophagia).
- Frequent nausea or vomiting may occur.
- You are experiencing unexplained weight loss.
- Their stools are black, tar-like or contain blood, which may indicate internal bleeding.
These symptoms may indicate complications of GERD or other, more serious conditions, which is why it is essential to establish an accurate diagnosis.
Diagnosing heartburn
From Endomedix At these centres, specialists decide on the necessary tests after taking a medical history and discussing the symptoms in detail.
- Upper endoscopy (gastroscopy): This is the most common and most accurate diagnostic procedure. During the examination, a thin, flexible tube fitted with a camera (an endoscope) is passed through the mouth into the oesophagus, the stomach and the upper part of the small intestine. This allows direct examination of the lining of the oesophagus and enables the detection of acid-related changes, such as inflammation (oesophagitis), ulcers or Barrett’s oesophagus (a precancerous condition). A tissue sample (biopsy) may also be taken during the examination. The EndomedixWe offer the option of carrying out the examination under anaesthesia, thereby minimising any discomfort for the patient.
- Oesophageal pH and impedance monitoring: This test is carried out when an endoscopy shows no abnormalities but the symptoms persist. A thin probe is passed through the nose into the oesophagus, where it measures acidity (pH) levels and the reflux of fluid and gas over a 24-hour period. This helps to establish a link between the symptoms and episodes of reflux.
- Oesophageal manometry: This procedure measures the function and pressure of the oesophageal muscles, particularly the lower oesophageal sphincter. It is recommended if a motility disorder of the oesophagus is suspected.
Treatment options
The treatment of heartburn is based on several key elements: lifestyle changes, medication and, in severe cases, surgery.
1. Lifestyle and dietary changes
This forms the basis of the treatment, which in many cases can bring about a significant improvement on its own.
- Avoid trigger foods: Keep a food diary to identify which foods and drinks are causing your symptoms, and avoid them.
- Eat smaller portions, but more frequently: Instead of three large meals a day, try eating five or six smaller portions.
- Do not eat before going to bed: Your last meal should be at least 2–3 hours before going to bed.
- Raise the head of the bed: Place a raised support 15–20 cm high under the legs at the head end of the bed. This uses gravity to prevent acid reflux whilst you sleep. It is important not to simply raise your head with several pillows, as this can increase abdominal pressure.
- Lose weight if you are overweight: Even losing just a few kilograms can reduce intra-abdominal pressure and alleviate the symptoms.
- Stop smoking: This is one of the most important steps in restoring the proper functioning of the sphincter muscle.
- Wear loose-fitting clothing: Tight belts and clothes put pressure on the stomach.
2. Medication
If lifestyle changes are not enough, your doctor may recommend medication.
- Antacids (acid-neutralising agents): These over-the-counter medicines provide rapid but only temporary relief by neutralising stomach acid. They are mainly recommended for occasional heartburn.
- H2 receptor blockers: These medicines (e.g. famotidine) reduce the production of stomach acid. They take longer to take effect but last longer than antacids. They are available both over the counter and on prescription.
- Proton pump inhibitors (PPIs): These are the most effective acid-reducing medicines (e.g. omeprazole, pantoprazole, esomeprazole). They significantly and sustainably inhibit the production of stomach acid, allowing inflammation of the oesophagus to heal. They are usually taken once a day, before a meal. Long-term use requires medical supervision.
3. Surgical and endoscopic procedures
In severe cases that do not respond to medication, or if the patient does not wish to take medication for the rest of their life, surgery may be an option. The most common procedure is Nissen fundoplication, in which a sleeve is formed from the upper part of the stomach and wrapped around the lower part of the oesophagus, thereby strengthening the function of the lower oesophageal sphincter.
Summary
Heartburn is an extremely unpleasant symptom, but one that can be well managed with the right care and treatment. Identifying the underlying causes and making lifestyle changes are key to treatment. However, it is important to understand that persistent heartburn may be a sign of gastro-oesophageal reflux disease (GERD), which can lead to serious complications in the long term. If your symptoms are regular, do not hesitate to consult a specialist! The Endomedix Our highly qualified gastroenterologists and state-of-the-art diagnostic equipment help us to make an accurate diagnosis and find the most effective, personalised treatment, so that you can enjoy your everyday life again without heartburn.
