acid indigestion
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Heartburn, also known as pyrosis, cardialgia or acid indigestion, is a burning sensation in the central
chest The thorax or chest is a part of the anatomy of humans, mammals, and other tetrapod animals located between the neck and the abdomen. In insects, crustaceans, and the extinct trilobites, the thorax is one of the three main divisions of the crea ...
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 ...
. It is the major symptom of
gastroesophageal reflux disease Gastroesophageal reflux disease (GERD) or gastro-oesophageal reflux disease (GORD) is one of the upper gastrointestinal chronic diseases where stomach content persistently and regularly flows up into the esophagus, resulting in symptoms and/ ...
(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
medication A medication (also called medicament, medicine, pharmaceutical drug, medicinal drug or simply drug) is a drug used to diagnose, cure, treat, or prevent disease. Drug therapy ( pharmacotherapy) is an important part of the medical field and ...
s and dietary changes. Medication include
antacids An antacid is a substance which neutralizes stomach acidity and is used to relieve heartburn, indigestion or an upset stomach. Some antacids have been used in the treatment of constipation and diarrhea. Marketed antacids contain salts of alu ...
. Dietary changes may require avoiding foods that are high in fats,
spicy Pungency () refers to the taste of food commonly referred to as spiciness, hotness or heat, found in foods such as chili peppers. Highly pungent tastes may be experienced as unpleasant. The term piquancy () is sometimes applied to foods with a l ...
, high in artificial flavors, heavily reducing
NSAID Non-steroidal anti-inflammatory drugs (NSAID) are members of a therapeutic drug class which reduces pain, decreases inflammation, decreases fever, and prevents blood clots. Side effects depend on the specific drug, its dose and duration of ...
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 Plantba ...
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 Abdominal pain, also known as a stomach ache, is a symptom associated with both non-serious and serious medical issues. Common causes of pain in the abdomen include gastroenteritis and irritable bowel syndrome. About 15% of people have a more ...
and heartburn. Heartburn is commonly used interchangeably with
gastroesophageal reflux disease Gastroesophageal reflux disease (GERD) or gastro-oesophageal reflux disease (GORD) is one of the upper gastrointestinal chronic diseases where stomach content persistently and regularly flows up into the esophagus, resulting in symptoms and/ ...
(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 A myocardial infarction (MI), commonly known as a heart attack, occurs when blood flow decreases or stops to the coronary artery of the heart, causing damage to the heart muscle. The most common symptom is chest pain or discomfort which ma ...
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 Gerd or GERD may refer to: * Gerd (given name), a list of people with the given name or nickname * Gerd (moon), a moon of Saturn * Gerd Island, South Orkney Islands, Antarctica * Gastroesophageal reflux disease, a chronic symptom of mucosal damage ...
(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 Eosinophilic esophagitis (EoE) is an allergic inflammatory condition of the esophagus that involves eosinophils, a type of white blood cell. In healthy individuals, the esophagus is typically devoid of eosinophils. In EoE, eosinophils migrate ...
– 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 Peptic ulcer disease (PUD) is a break in the inner lining of the stomach, the first part of the small intestine, or sometimes the lower esophagus. An ulcer in the stomach is called a gastric ulcer, while one in the first part of the intestines ...
– 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 Duodenitis is inflammation of the duodenum. It may persist acutely or chronically. Symptoms Known symptoms of duodenitis include: * Abdominal pain * vomiting * nausea * discomfort in stomach Causes Known causes of duodenitis include: * ''He ...
– inflammation of the small intestine. May be the result of several conditions


Gallbladder

*
Gallstone A gallstone is a stone formed within the gallbladder from precipitated bile components. The term cholelithiasis may refer to the presence of gallstones or to any disease caused by gallstones, and choledocholithiasis refers to the presence of mi ...
s


Pancreas

*
Pancreatitis Pancreatitis is a condition characterized by inflammation of the pancreas. The pancreas is a large organ behind the stomach that produces digestive enzymes and a number of hormones. There are two main types: acute pancreatitis, and chronic pancr ...
– can be autoimmune, due to a gallstone obstructing the lumen, related to alcohol consumption.


Hematology

*
Pernicious anemia Pernicious anemia is a type of vitamin B12 deficiency anemia, a disease in which not enough red blood cells are produced due to the malabsorption of vitamin B12. Malabsorption in pernicious anemia results from the lack or loss of intrinsic fa ...
– can be autoimmune, due to
atrophic gastritis Atrophic gastritis is a process of chronic inflammation of the gastric mucosa of the stomach, leading to a loss of gastric glandular cells and their eventual replacement by intestinal and fibrous tissues. As a result, the stomach's secretion o ...
.


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 like
irritable bowel syndrome Irritable bowel syndrome (IBS) is a "disorder of gut-brain interaction" characterized by a group of symptoms that commonly include abdominal pain and or abdominal bloating and changes in the consistency of bowel movements. These symptoms may ...
and is the primary cause of lack of improvement post treatment with
proton pump inhibitor Proton-pump inhibitors (PPIs) are a class of medications that cause a profound and prolonged reduction of stomach acid production. They do so by irreversibly inhibiting the stomach's H+/K+ ATPase proton pump. They are the most potent inhibitor ...
s (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 ce ...
) * Upper GI series 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 An antacid is a substance which neutralizes stomach acidity and is used to relieve heartburn, indigestion or an upset stomach. Some antacids have been used in the treatment of constipation and diarrhea. Marketed antacids contain salts of alu ...
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 Esophageal pH monitoring is the current gold standard for diagnosis of gastroesophageal reflux disease (GERD). It provides direct physiologic measurement of acid in the esophagus and is the most objective method to document reflux disease, assess t ...
: a probe can be placed via the nose into the esophagus to record the level of
acidity In computer science, ACID ( atomicity, consistency, isolation, durability) is a set of properties of database transactions intended to guarantee data validity despite errors, power failures, and other mishaps. In the context of databases, a ...
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 Pressure measurement is the measurement of an applied force by a fluid (liquid or gas) on a surface. Pressure is typically measured in units of force per unit of surface area. Many techniques have been developed for the measurement of pressu ...
) is passed via the mouth into the esophagus and measures the pressure of the LES directly.
Endoscopy An endoscopy is a procedure used in medicine to look inside the body. The endoscopy procedure uses an endoscope to examine the interior of a hollow organ or cavity of the body. Unlike many other medical imaging techniques, endoscopes are inse ...
: 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

*
Antacid An antacid is a substance which neutralizes stomach acidity and is used to relieve heartburn, indigestion or an upset stomach. Some antacids have been used in the treatment of constipation and diarrhea. Marketed antacids contain salts of alu ...
s (i.e. calcium carbonate) are often taken to treat the immediate problem *
H2 receptor antagonist H2 antagonists, sometimes referred to as H2RAs and also called H2 blockers, are a class of medications that block the action of histamine at the histamine H2 receptors of the parietal cells in the stomach. This decreases the production of stom ...
s or
proton pump inhibitors Proton-pump inhibitors (PPIs) are a class of medications that cause a profound and prolonged reduction of stomach acid production. They do so by irreversibly inhibiting the stomach's H+/K+ ATPase proton pump. They are the most potent inhibitor ...
are effective for the two most common causes of heartburn (e.g.
gastritis Gastritis is inflammation of the lining of the stomach. It may occur as a short episode or may be of a long duration. There may be no symptoms but, when symptoms are present, the most common is upper abdominal pain (see dyspepsia). Other possi ...
and
GERD Gerd or GERD may refer to: * Gerd (given name), a list of people with the given name or nickname * Gerd (moon), a moon of Saturn * Gerd Island, South Orkney Islands, Antarctica * Gastroesophageal reflux disease, a chronic symptom of mucosal damage ...
) * Antibiotics are used if
H. pylori ''Helicobacter pylori'', previously known as ''Campylobacter pylori'', is a gram-negative, microaerophilic, spiral (helical) bacterium usually found in the stomach. Its helical shape (from which the genus name, helicobacter, derives) is thoug ...
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 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