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Heartburn, also known as pyrosis, cardialgia or acid indigestion, is a burning sensation in the central chest or upper central abdomen. Heartburn is usually due to regurgitation of gastric acid (gastric reflux) into the
esophagus The esophagus (American English) or oesophagus (British English; both ), non-technically known also as the food pipe or gullet, is an organ in vertebrates through which food passes, aided by peristaltic contractions, from the pharynx to t ...
. It is the major symptom of gastroesophageal reflux disease (GERD). Other common descriptors for heartburn (besides burning) are belching, nausea, squeezing, stabbing, or a sensation of pressure on the chest. The pain often rises in the chest (directly behind the breastbone) and may radiate to the neck, throat, or angle of the arm. Because the chest houses other important organs besides the esophagus (including the heart and lungs), not all symptoms related to heartburn are esophageal in nature. The cause will vary depending on one's family and medical history, genetics, if a person is pregnant or lactating, and age. As a result, the diagnosis will vary depending on the suspected organ and the inciting disease process. Work-up will vary depending on the clinical suspicion of the provider seeing the patient, but generally includes endoscopy and a trial of antacids to assess for relief. Treatment for heartburn may include medications and dietary changes. Medication include antacids. Dietary changes may require avoiding foods that are high in fats, spicy, high in
artificial flavors A flavoring (or flavouring), also known as flavor (or flavour) or flavorant, is a food additive used to improve the taste or smell of food. It changes the perceptual impression of food as determined primarily by the chemoreceptors of the gustato ...
, heavily reducing NSAID use, heavy alcohol consumption, and decreasing
peppermint Peppermint (''Mentha'' × ''piperita'') is a hybrid species of mint, a cross between watermint and spearmint. Indigenous to Europe and the Middle East, the plant is now widely spread and cultivated in many regions of the world.Euro+Med Plantb ...
consumption. Lifestyle changes may help such as reducing weight.


Definition

The term
indigestion Indigestion, also known as dyspepsia or upset stomach, is a condition of impaired digestion. Symptoms may include upper abdominal fullness, heartburn, nausea, belching, or upper abdominal pain. People may also experience feeling full earlier t ...
includes heartburn along with a number of other symptoms. Indigestion is sometimes defined as a combination of epigastric pain and heartburn. Heartburn is commonly used interchangeably with gastroesophageal reflux disease (GERD) rather than just to describe a symptom of burning in one's chest.


Differential diagnosis

Heartburn-like symptoms and/or lower chest or upper abdomen may be indicative of much more sinister and/or deadly disease. Of greatest concern is to confuse heartburn (generally related to the esophagus) with a heart attack as these organs share a common nerve supply. Numerous abdominal and thoracic organs are present in that region of the body. Many different organ systems might explain the discomfort called heartburn.


Heart

The most common symptom for a heart attack is chest pain. However, as many as 30% of chest pain patients undergoing cardiac catheterization have findings that do not account for their chest discomfort. These are often defined as having "atypical chest pain" or chest pain of undetermined origin. Women experiencing heart attacks may also deny classic signs and symptoms and instead complain of GI symptoms. One article estimates that ischemic heart disease may appear to be GERD in 0.6% of people.


Esophagus

* GERD (most common cause of heartburn) occurs when acid refluxes from the stomach and inflames the esophagus. * Esophageal spasms typically occur after eating or drinking and may be combined with difficulty swallowing. *
Esophageal stricture A benign esophageal stricture, or peptic stricture, is a narrowing or tightening of the esophagus that causes swallowing difficulties. Signs and symptoms Symptoms of esophageal strictures include heartburn, bitter or acid taste in the mouth, chok ...
s * Esophageal cancers


Esophagitis

* GERD * Eosinophilic esophagitis – a disease commonly associated with other atopic diseases such as asthma, food allergies, seasonal allergies, and atopic skin disease * Mallory-Weis tears – tears of the superficial mucosa of the esophagus that are subsequently exposed to gastric acid commonly due to vomiting and/or retching * Chemical esophagitis – related to the intake of caustic substances, excessive amounts of hot liquids, alcohol, or tobacco smoke * Infections may explain heartburn symptoms. These especially include CMV and certain fungal infections, most common in immunocompromised persons


Stomach

* Peptic ulcer disease – can be secondary to H. Pylori infection or heavy NSAID use that weakens stomach mucosal layer. Pain often worsens with eating. * Stomach cancer


Intestines

* Intestinal ulcers – generally secondary to other conditions such as H. Pylori infection or cancers of the GI tract. Pain often improves with eating. * Duodenitis – inflammation of the small intestine. May be the result of several conditions


Gallbladder

* Gallstones


Pancreas

* Pancreatitis – can be autoimmune, due to a gallstone obstructing the lumen, related to alcohol consumption.


Hematology

* Pernicious anemia – can be autoimmune, due to atrophic gastritis.


Pregnancy

Heartburn is common during pregnancy having been reported in as high as 80% of pregnancies. It is most often due to GERD and results from relaxation of the lower esophageal sphincter (LES), changes in gastric motility, and/or increasing intra-abdominal pressure. The onset of symptoms can be during any trimester of pregnancy. * Hormonal – related to the increasing amounts of estrogen and progesterone and their effect on the LES * Mechanical – the enlarging uterus increasing intra-abdominal pressure, inducing reflux of gastric acid * Behavioral – as with other instances of heartburn, behavioral modifications can exacerbate or alleviate symptoms


Unknown origin

Functional heartburn is heartburn of unknown cause. It is commonly associated with psychiatric conditions like depression, anxiety, and panic attacks. It is also seen with other
functional gastrointestinal disorders Functional gastrointestinal disorders (FGID), also known as disorders of gut–brain interaction, include a number of separate idiopathic disorders which affect different parts of the gastrointestinal tract and involve visceral hypersensitivity a ...
like irritable bowel syndrome and is the primary cause of lack of improvement post treatment with proton pump inhibitors (PPIs). Despite this, PPIs are still the primary treatment with response rates in about 50% of people. The diagnosis is one of elimination, based upon the Rome III criteria. It was found to be present in 22.3% of Canadians in one survey.


Diagnostic approach

Heartburn can be caused by several conditions and a preliminary diagnosis of GERD is based on additional signs and symptoms. The chest pain caused by GERD has a distinct 'burning' sensation, occurs after eating or at night, and worsens when a person lies down or bends over.The Mayo Clinic Heartburn page
.Accessed May 18, 2010.
It also is common in pregnant women, and may be triggered by consuming food in large quantities, or specific foods containing certain spices, high fat content, or high acid content.
Accessed May 18, 2010.
In young persons (typically <40 years) who present with heartburn symptoms consistent with GERD (onset after eating, when laying down, when pregnant), a physician may begin a course of PPIs to assess clinical improvement before additional testing is undergone. Resolution or improvement of symptoms on this course may result in a diagnosis of GERD. Other tests or symptoms suggesting acid reflux is causing heartburn include: * Onset of symptoms after eating or drinking, at night, and/or with pregnancy, and improvement with PPIs * Endoscopy looking for erosive changes of the esophagus consistent with prolonged acid exposure (e.g. -
Barrett's esophagus Barrett's esophagus is a condition in which there is an abnormal ( metaplastic) change in the mucosal cells lining the lower portion of the esophagus, from stratified squamous epithelium to simple columnar epithelium with interspersed goblet cells ...
) *
Upper GI series An upper gastrointestinal series, also called a barium swallow, barium study, or barium meal, is a series of radiographs used to examine the gastrointestinal tract for abnormalities. A contrast medium, usually a radiocontrast agent such as barium ...
looking for the presence of acid reflux


GI cocktail

Relief of symptoms 5 to 10 minutes after the administration of viscous lidocaine and an antacid increases the suspicion that the pain is esophageal in origin. This however does not rule out a potential cardiac cause as 10% of cases of discomfort due to cardiac causes are improved with antacids.


Biochemical

Esophageal pH monitoring: a probe can be placed via the nose into the esophagus to record the level of acidity in the lower esophagus. Because some degree of variation in acidity is normal, and small reflux events are relatively common, esophageal pH monitoring can be used to document reflux in real-time. Patients are able to record symptom onset to correlate lower esophageal pH with time of symptom onset.


Mechanical

Manometry: in this test, a pressure sensor ( manometer) is passed via the mouth into the esophagus and measures the pressure of the LES directly. Endoscopy: the esophageal mucosa can be visualized directly by passing a thin, lighted tube with a tiny camera known as an endoscope attached through the mouth to examine the oesophagus and stomach. In this way, evidence of esophageal inflammation can be detected, and biopsies taken if necessary. Since an endoscopy allows a doctor to visually inspect the upper digestive tract the procedure may help identify any additional damage to the tract that may not have been detected otherwise.
Biopsy A biopsy is a medical test commonly performed by a surgeon, interventional radiologist, or an interventional cardiologist. The process involves extraction of sample cells or tissues for examination to determine the presence or extent of a dise ...
: a small sample of tissue from the oesophagus is removed. It is then studied to check for inflammation, cancer, or other problems.


Treatment

Treatment plans are tailored to the specific diagnosis and etiology of the heartburn. Management of heartburn can be sorted into various categories.


Pharmacologic management

* Antacids (i.e. calcium carbonate) are often taken to treat the immediate problem * H2 receptor antagonists or proton pump inhibitors are effective for the two most common causes of heartburn (e.g. gastritis and GERD) * Antibiotics are used if H. pylori is present.


Behavioral management

* Taking medications 30–45 minutes before eating suppresses the stomach's acid generating response to food * Avoiding spicy foods, foods high in fats, peppermint, and chocolate * Avoiding reclining 2.5–3.5 hours after a meal to prevent the reflux of stomach's contents


Lifestyle modifications

* Early studies show that diets that are high in fiber may show evidence in decreasing symptoms of dyspepsia. * Weight loss can decrease abdominal pressure that both delays gastric emptying and increases gastric acid reflux into the esophagus


Alternative and complementary therapies

Symptoms of heartburn may not always be the result of an organic cause. Patients may respond better to therapies targeting anxiety and symptoms of hyper-vigilance, through medications aimed towards a psychiatric etiology, osteopathic manipulation and acupuncture. * Psychotherapy may show a positive role in treatment of heartburn and the reduction of distress experienced during symptoms. * Acupuncture - in cases of functional heartburn (e.g. heartburn of unknown origin) acupuncture may be as effective if not more than PPIs alone.


Surgical management

In the case of GERD causing heartburn symptoms,
surgery Surgery ''cheirourgikē'' (composed of χείρ, "hand", and ἔργον, "work"), via la, chirurgiae, meaning "hand work". is a medical specialty that uses operative manual and instrumental techniques on a person to investigate or treat a pa ...
may be required if PPI is not effective. Surgery is not undergone if functional heartburn is the leading diagnosis.


Epidemiology

About 42% of the United States population has had heartburn at some point.


References

{{Digestive system and abdomen symptoms and signs Symptoms and signs: Digestive system and abdomen