What Causes Heartburn? How to Beat the Burn (podcast)

There are a variety of triggers. First let’s talk about dietary triggers. They are acidic foods, such as spicy foods, fatty foods, fried foods, caffeinated beverages and carbonated beverages. Cigarette smoking can make it worse. Alcohol relaxes the lower esophageal sphincter and can make reflux worse.

Anatomic things can trigger heartburn. For example, if you eat a large meal, it distends the stomach, especially if you lay down. Reflux happens more commonly at night.

Other things would be obesity, even pregnancy. Certain medications, aspirin, non-steroidal anti-inflammatants, ibuprofen, Motrin, Advil and Aleve. Different medications used to treat osteoporosis, such as Fosamax, Actonel and other bisphosphonates. Chemotherapeutic drugs. There are a variety of exacerbating factors.

Citrus, tomatoes, tomato-based foods or sauces, spicy foods. Jalapenos and salsa are good examples of spicy foods. For citrus, it’s oranges, lemons, that family of fruit.

The classic symptoms would be the upper abdominal burning that radiates up. People often complain of regurgitation, when you get some stomach contents into your mouth. Often patients may even vomit small amounts of undigested food. Other symptoms are hyper-salivation, meaning they produce more saliva, a globus sensation, which is a feeling that something is in their throat. Patients complain of a foreign body in there. It feels like there is something in the throat. There is also painful swallowing, difficulty swallowing. They can have extra esophageal symptoms. These would be symptoms outside of the gastrointestinal track, such as cough, a chronic cough. It can even trigger asthma.

Everyone is susceptible. But you certainly have risk factors that predispose and increase your risk. Obesity is one. It causes some compression and increases the pressure there. Pregnancy is another issue. Cigarette smoking, medications and alcohol are other risk factors.

Also, there is an anatomic reason. People can have a hiatal hernia, which is fairly common. In a hiatal hernia, you have your esophagus, and then you have your diaphragm, and then underneath that is your stomach. You have a muscle right here called your lower esophageal sphincter that relaxes when you eat food and then contracts so that stomach contents don’t reflux back up. Your diaphragm helps pinch that lower esophageal sphincter. What happens with a hiatal hernia is the stomach actually leaks up into the chest cavity and reflux happens more easily.

Two main reasons. One is anatomic. As the pregnancy advances, the uterus enlarges and the abdomen distends. That puts pressure on the stomach, and reflux happens more easily. The other is actually hormonal. Progesterone relaxes the lower esophageal sphincter, so as the pregnancy advances, progesterone rises, and that contributes to reflux. Fortunately, the heartburn typically resolves after delivery.

That’s a very important differentiation to make. Sometimes, it’s not as easy as it sounds. Cardiac chest pain classically is a diffuse squeezing, pressure pain, often accompanied by shortness of breath, nausea, vomiting, sometimes light-headedness. Patients will complain of getting sweaty. It’s often related to exertion as well. A classic story is “Hey I walk up a couple flight of stairs and then boom I get this diffuse chest pain along with those other symptoms.” Heartburn tends to be more focal, not diffused, fairly localized. The nature of the pain is different. It’s a burning pain, and it typically has those exacerbating factors.

Alcohol makes it worse. Large meals make it worse. Certain treatments make it feel better, such as antacids, Tums, Prilosec, those types of medications. But it’s in two types of patients that you have to be very careful. Women often present differently from a cardiac standpoint and so do diabetics. I had one patient come in and say “Hey, doc, I'm having heartburn,” but his symptoms were pretty classic. It was a localized burning pain. But it wasn’t better with the normal treatments and it was worse with exertion, and he was diabetic. I did an EKG, which was fine, but then proceeded with a stress test and he had cardiac disease and had to be stented or have a stent put in.

Think of heartburn as the symptom and GERD as the disease or the condition. GERD stands for gastroesophageal reflux disease. People with GERD have heartburn symptoms that occur in mild degree twice a week or more, or more severe weekly. Patients may have complications from their GERD, which could be ulcers, strictures. Chronic reflux can even cause two different types of cancers, adenocarcinoma of the esophagus and lymphoma.

The first thing I would recommend is try to eliminate the triggers. If alcohol or cigarette smoking or spicy foods are triggers, you have to eliminate those triggers.

Weight loss has proven to be helpful. Elevating the height of your bed is helpful, six to eight inches. You can put blocks under the top of the bed or wedges that elevate the bed. Eat at least three hours or more prior to bedtime. If you eat right before bedtime and then you lay down, your stomach gets distended and then reflux is more likely. Then of course, there are a variety of medications.

A lot of the medications that used to be prescription are fairly safe and are now over the counter. But the most commonly used ones that have been out there forever are your antacids, things like Tums and Mylanta. They just neutralize the stomach acid. The next step up would be H2 blockers, which are Pepcid, Zantac, [which are famotidine and ranitidine respectively]. Those bind to cells in the stomach.

The strongest medication would be Proton pump inhibitors, such as Prilosec, Nexium, Capadex and Protonix. There is a variety of them. They’re the strongest medications to reduce acid. There is another class of medication. Carafate is a common one that helps coat the stomach. Those are the mainstays of medical treatment. [As for how often you should you take this medication], in years past we thought proton pump inhibitors were really benign and patients could use them for the long term. We still use them long-term in certain high risk patients, but we don’t like to use them for too long if we can get away with that because of potential side effects.

There is a list of side effects. One thing that Prilosec, or PPIs as a class, can do is increase a patient’s risk for osteoporosis. It does that by two main mechanisms. One is reducing the absorption of insoluble calcium. It does not effect the absorption of soluble calcium, such as milk and dairy products. But it will block the absorption of calcium carbonate, which is a common supplement. The other mechanism linked to osteoporosis is its effect on osteoclast [bone activity]. For bone remodeling, there are two types of cells, osteoblast, which causes bone deposition, and osteoclast, which takes bone away. Proton pump inhibitors seem to augment osteoclast activity and cause a net reduction or bone loss, and increase the patient’s risk of osteoporosis. It can also lower magnesium levels, which is equally, if not more important. Magnesium is involved with muscle contraction and heart rhythms. If somebody is on a proton pump inhibitor chronically, I would recommend they get that screened periodically, especially if they’re at risk for arrhythmia. It may increase some men’s risk of pneumonia and clostridium difficile, which is a type of colon infection, but these risks are fairly low. I don’t want people to be turned away from these medications if they need them, but they should be aware of some of the risks.

First would be avoiding the triggers. Second, we wouldn’t want them to lose weight. Hopefully, they’re not smoking or drinking. Watch the caffeine, watch the carbonated beverages, acidic foods and the citrus foods. The other thing that really can be helpful is elevating the height of the bed.

Indigestion is more of a layman’s term, not so much of a medical term. But it’s used to describe an upper abdominal pain often associated with food. Think of that as a symptom. Obviously heartburn, reflux would fall under that category. But other things can cause upper abdominal pain with food, such as gallstones, food intolerances, lactose intolerances and celiac sprue, which is a gluten sensitivity or wheat allergy. There is a variety of causes of indigestion. It’s not just one entity.

You treat the cause. Basically if it’s heartburn, you treat it as we talked about earlier. If it is due to gallstones, the treatment there is primarily surgical. There are some medications for gallstones, but they don’t work very well and you have to take them for an extended period of time. For indigestion, think of that as a symptom, find a cause and then treat the cause.

Let’s say you’ve tried some of these remedies, you’re still having ongoing symptoms, and none of these remedies have helped. You should see a physician. But there are also some earlier danger signs. If you’re a patient over 60 and you haven’t had heartburn before and you’re having new onset heartburn you should see your doctor.

Other danger signs are painful swallowing, difficulty swallowing, any signs of blood loss, vomiting blood, vomiting something that looks like coffee grounds because that’s what digested or partially digested blood looks like, black tarry stools because black stools are what digested blood looks like. Other things can turn your stool black, like Pepto-Bismol or iron, things like that. Difficulty swallowing. Unexplained weight loss. If you have a first-degree family member with a gastrointestinal cancer, meaning parent, sibling or child, that increases your risk.