Heartburn in Adults

Heartburn in AdultsHeartburn is a very common symptom experienced by adults. It is the sensation one gets when acid from the stomach refluxes and comes in contact with the esophagus. Often mistaken as chest pain or abdominal pain but mainly described as a burning sensation in the chest. It is so common that the majority of American adults have taken medication at least once in their lifetime. Heartburn may be a symptom of gastro esophageal reflux disease, commonly referred to as GERD, which is the result of ongoing reflux of acid from the stomach. If left untreated, it can lead to complications over time. It is estimated that heartburn/reflux, and its complications, at one time or another will affect approximately 33% of American adults.

If you have heartburn, it is important to prevent its progression to GERD. The earlier it is identified, the easier it is to treat and therefore prevent more severe complications. These complications include: severe inflammation and ulceration of the esophagus, esophageal rings or strictures (which are essentially scarring resulting from chronic reflux) and Barrett’s esophagus (which is when the cells in the bottom part of the esophagus start to change after years of reflux). If cells continue to become damaged, they can eventually turn into cancer. These symptoms can and should be treated in a timely manner before they get worse.

Some people with mild heartburn actually have severe findings discovered on an endoscopic evaluation, or an EGD, which is the procedure where a thin tube with a camera on the end of it is passed, under gentle sedation, through the esophagus (swallowing tube), stomach and into a small part of the small intestine called the duodenum. Patients are asleep during the procedure and don’t experience any discomfort. Conversely, some patients have severe heartburn and have a completely normal endoscopy. Because of this uncertainty and inability to predict damage related to acid reflux, anybody having two to three heartburn related episodes a week should seek a medical consultation with a gastroenterologist. Those with warning signs are encouraged to undergo an endoscopy. Some warning signs that your heartburn/reflux may have progressed and become complicated are difficulty or painful swallowing, chest pain, weight loss, anemia and black stools. Less common and sometimes more subtle signs to be aware of are hoarseness, globus (a ball like sensation in throat), nighttime cough, sour taste, whitish coating on tongue and chronic or recurrent sinusitis.

An endoscopy may identify and even treat complications of GERD. A stricture, which is usually a narrowing at the bottom of the esophagus near the connection with the stomach, can be dilated at the time of endoscopy. Routine biopsies are taken to check for a bacteria called H. pylori, which is a common bacteria and treatable with a course of antibiotics. Ulcers can be biopsied and polyps are sometimes removed. The patient will not feel this during the procedure, as there are no sensory nerves affected by the biopsies. Additionally, other conditions associated with similar warning signs as with GERD may be identified during the study, such as gastric ulcers and gastric cancer. Partially digested food may also be seen during endoscopy, which may be related to gastro paresis, which is a condition where the stomach does not move properly. This may occur without any reason or may be related to diabetes. This condition may contribute to the symptoms of GERD by increasing the contact time of acid from the stomach with the esophagus. In addition, a frequently talked about “condition” called a hiatal hernia is also commonly identified during endoscopy. Normally the esophagus is protected from the refluxing acid by an intimate connection between a circular muscle called the lower esophageal sphincter (LES) and diaphragm (muscle instrumental in breathing). They both usually act together to squeeze the bottom of the esophagus closed. When the esophagus sphincter muscle separates and slides into the chest along with the upper part of the stomach, the protective pressure barrier weakens and acid is more likely to enter the esophagus. One may also experience chest pressure.

Initially, treatment is focused on symptoms. With mild heartburn, prevention with diet and lifestyle modifications is effective. One should avoid tight fitting clothes, quit smoking, cut down or eliminate alcohol intake. Avoid foods that may relax the LES such as tomatoes, chocolate, peppermints/gum, onions and spicy foods. Eating your last meal no sooner then three hours before bed is helpful and dinner should be a smaller meal compared to lunch. Certain medications such as asthma inhalers and heart/blood pressure medications may worsen symptoms by relaxing the LES muscle as well. If possible, place bricks or cinder blocks under the legs at the head of the bed, which creates a decline to help acid drain out of the stomach. A large foam wedge is also available to achieve that same goal and saves your bed partner from experiencing this angulation of the bed. Avoid elevating yourself with pillows, as this worsens heartburn and reflux by bending you and increasing pressure at your stomach.

At your first office visit, a histamine or H2 blocker may be prescribed such as Zantac or Pepcid. By the time you come to the office, you have most likely take many over-the-counter (OTC) antacids such as Gaviscon, Tums, Maalox, etc. All the above medications can be taken in situations where heartburn is mild and infrequent (< 1-2 times a week) and when experienced with certain foods. When heartburn occurs unprovoked >2-3 times a week, and when the warning signs are present, it is time for an endoscopic evaluation especially if you are older than 50 years. Personally,  I don’t make any medication changes prior to the endoscopy as this helps to identify whether the medications you are taking prior to the study are working, or if you need to change or add another medication based on the endoscopic findings. Frequently, a stronger medication called a Proton Pump Inhibitor (PPI) is prescribed after the procedure due to the findings of inflammation, strictures, or ulcers. This medication will inactivate the pumps that produce acid. It is paramount that PPIs be taken 30 minutes before a meal, usually at breakfast because otherwise they are not effective.

So take care of yourself, eat well, exercise and listen to your body. Heartburn is very manageable and by seeking an evaluation, you can prevent its avoidable complications. You will be glad you did!