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Heartburn

From Wikipedia, the free encyclopedia
This article is about the medical condition. For other uses, seeHeartburn (disambiguation).
"Cardialgia" redirects here. For the meaning "pain in or near the heart", seeHeart painandChest pain.
Heartburn
Other namesPyrosis,[1]cardialgia
SpecialtyGastroenterology,family medicine,emergency medicine
SymptomsBurning, stabbing, or squeezing sensation in the chest,nausea,belching
CausesGastroesophageal reflux disease
Risk factorsSmoking, obesity
Diagnostic methodPhysical examination, medical history, antacid response, imaging,manometry
Differential diagnosisChest pain,heart attack,gastritis,peptic ulcer disease,esophageal spasms,esophageal strictures,duodenitis,cancer,Crohn's disease
PreventionAvoid foods that are high in fats, spicy, high in artificial flavors. Avoid reclining 3–4 hours after a meal, heavyNSAIDuse, heavyalcoholconsumption. Decrease peppermint consumption. Chew foods thoroughly between bites, consume meals with plenty of liquid, and ensure adequate time to eat meals in a non-hurried fashion
TreatmentAntacids,weight loss, surgery
MedicationAntacids

Heartburn,also known aspyrosis,cardialgiaoracid indigestion,[2]is a burning sensation in the centralchestorupper central abdomen.[3][4][5]Heartburn is usually due to regurgitation ofgastric acid(gastric reflux) into theesophagus.It is the major symptom ofgastroesophageal reflux disease(GERD).[6]

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.[7]

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.[citation needed]

Treatment for heartburn may includemedicationsand dietary changes.[3]Medication includeantacids.Dietary changes may require avoiding foods that are high in fats,spicy,high inartificial flavors,heavily reducingNSAIDuse, avoiding heavyalcoholconsumption, and decreasingpeppermintconsumption.[3]Lifestyle changes may help such as reducing weight.

Definition[edit]

The termindigestionincludes heartburn along with a number of other symptoms.[8]Indigestion is sometimes defined as a combination ofepigastric painand heartburn.[9]Heartburn is commonly used interchangeably withgastroesophageal reflux disease(GERD) rather than just to describe a symptom of burning in one's chest.[10]

Differential diagnosis[edit]

Heartburn-like symptoms and/or lower chest or upper abdomen may be indicative of much more sinister and/or deadly disease.[11]Of greatest concern is to confuse heartburn (generally related to the esophagus) with a heart attack as these organs share a commonnervesupply.[12]Numerous abdominal and thoracic organs are present in that region of the body. Many different organ systems might explain the discomfort called heartburn.[7]

Heart[edit]

The most common symptom for aheart attackischest pain.[13]However, as many as 30% of people who receivecardiac catheterizationfor chest pain 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.[14]Women experiencing heart attacks may also deny classic signs and symptoms[15]and instead complain of GI symptoms.[13][16][17]One article estimates thatischemic heart diseasemay appear to be GERD in 0.6% of people.[12]

Esophagus[edit]

Stomach[edit]

Intestines[edit]

Gallbladder[edit]

Pancreas[edit]

Hematology[edit]

Pregnancy[edit]

Heartburn is common duringpregnancyhaving been reported in as many as 80% of pregnancies.[22]It is most often due to GERD and results from relaxation of thelower esophageal sphincter (LES),changes ingastric motility,and/or increasing intra-abdominal pressure.[23][22]The onset of symptoms can be during any trimester of pregnancy.

  • Hormonal – related to the increasing amounts ofestrogenandprogesteroneand 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[edit]

Functional heartburn is heartburn of unknown cause.[24]It is commonly associated with psychiatric conditions like depression, anxiety, and panic attacks. It is also seen with otherfunctional gastrointestinal disorderslikeirritable bowel syndromeand is the primary cause of lack of improvement post treatment withproton pump inhibitors(PPIs).[24]Despite this, PPIs are still the primary treatment with response rates in about 50% of people.[24]The diagnosis is one of elimination, based upon theRome III criteria.It was found to be present in 22.3% of Canadians in one survey.[24]

Rome III Criteria
1 Burning retrosternal discomfort
2 Elimination of heart attack and GERD as the cause
3 Noesophageal motility disorders[24]

Diagnostic approach[edit]

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.[25]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.[25][26]In young persons (typically <40 years) who present with heartburn symptoms consistent with GERD (onset after eating, when lying down, when pregnant), a physician may begin a course of PPIs to assess clinical improvement before additional testing is undergone.[27]Resolution or improvement of symptoms on this course may result in a diagnosis of GERD.[citation needed]

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)[27]
  • Upper GI serieslooking for the presence of acid reflux[26][28]

GI cocktail[edit]

Main article:GI cocktail

Relief of symptoms 5 to 10 minutes after the administration of viscouslidocaineand anantacidincreases the suspicion that the pain is esophageal in origin.[29]This however does not rule out a potential cardiac cause[30]as 10% of cases of discomfort due to cardiac causes are improved with antacids.[31]

Biochemical[edit]

Esophageal pH monitoring:a probe can be placed via the nose into the esophagus to record the level ofacidityin 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.[32]Patients are able to record symptom onset to correlate lower esophageal pH with time of symptom onset.

Mechanical[edit]

Manometry:in this test, a pressure sensor (manometer) is passed via the mouth into the esophagus and measures the pressure of the LES directly.[33]

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.[34]

Biopsy:a small sample of tissue from the oesophagus is removed. It is then studied to check for inflammation, cancer, or other problems.[33]

Treatment[edit]

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

Pharmacologic management[edit]

Behavioral management[edit]

  • Taking medications 30–45 minutes before eating suppresses thestomach's acid generatingresponse to food
  • Avoiding chocolate, peppermint, caffeine intake, and foods high in fats[36]
  • Limiting big meals, instead consuming smaller, more frequent meals[36]
  • Avoiding reclining 2.5–3.5 hours after a meal to prevent the reflux of stomach contents

Lifestyle modifications[edit]

  • Early studies show that diets that are high in fiber may show evidence in decreasing symptoms of dyspepsia.[37]
  • Weight loss can decrease abdominal pressure that both delays gastric emptying and increases gastric acid reflux into the esophagus
  • Smoking cessation[36]

Alternative and complementary therapies[edit]

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.[24]

  • Psychotherapy may show a positive role in treatment of heartburn and the reduction of distress experienced during symptoms.[24]
  • Acupuncture– in cases ofidiopathicheartburn, acupuncture may be as effective if not more than PPIs alone.[38]

Surgical management[edit]

In the case of GERD causing heartburn symptoms,surgerymay be required if PPI is not effective.[39]Surgery is not undergone if functional heartburn is the leading diagnosis.[40]

Epidemiology[edit]

About 42% of the United States population has had heartburn at some point.[41]

References[edit]

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  2. ^"Gastroesophageal Reflux (GER) and Gastroesophageal Reflux Disease (GERD) in Adults".The National Institute of Diabetes and Digestive and Kidney Diseases.Archivedfrom the original on 2015-07-25.Retrieved2015-07-24.
  3. ^abc"heartburn"atDorland's Medical Dictionary
  4. ^abDifferential diagnosis in primary care.Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins. 2008. p. 211.ISBN978-0-7817-6812-2.
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  39. ^Spechler SJ, Hunter JG, Jones KM, Lee R, Smith BR, Mashimo H, et al. (October 2019)."Randomized Trial of Medical versus Surgical Treatment for Refractory Heartburn".The New England Journal of Medicine.381(16): 1513–1523.doi:10.1056/NEJMoa1811424.PMID31618539.S2CID204757299.
  40. ^Fass R, Zerbib F, Gyawali CP (June 2020). "AGA Clinical Practice Update on Functional Heartburn: Expert Review".Gastroenterology.158(8): 2286–2293.doi:10.1053/j.gastro.2020.01.034.PMID32017911.S2CID211036316.
  41. ^Kushner PR (April 2010). "Role of the primary care provider in the diagnosis and management of heartburn".Current Medical Research and Opinion.26(4): 759–765.doi:10.1185/03007990903553812.PMID20095795.S2CID206964899.
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