What is heartburn

Heartburn also called acid reflux, acid indigestion, acid regurgitation or gastroesophageal reflux (GER) is a painful burning feeling in your chest or throat that occurs when stomach acid backs up into the tube called the esophagus that carries food from your mouth to your stomach  ¹, ², ³. Typically, when food is swallowed, a band of muscle around the bottom of your esophagus called the lower esophageal sphincter (LES) relaxes to allow food and liquid to flow down into your stomach. Then the lower esophageal sphincter muscle tightens again. If the lower esophageal sphincter (LES) isn’t working as it should, stomach acid can flow back up into your esophagus (acid reflux) and you might feel a burning sensation in your chest, commonly called heartburn. The acid backup may be worse when you’re bent over, lying down, after eating a big meal or drinking coffee or alcohol. Pregnancy, certain foods, and some medications can bring on heartburn. Treating heartburn is important because over time as acid reflux can damage your esophagus.

Many people experience heartburn and reflux at some point in their lives. In a survey of more than 70,000 people living in the United States, nearly a third had experienced heartburn and reflux in the past week ⁴.

Typical signs and symptoms of heartburn include:

• A burning sensation in the chest that may also involve the upper abdomen
• Usually occurs after eating or while lying down or bending over
• May awaken you from sleep, especially if you have eaten within two hours of going to bed
• Is usually relieved by antacids
• May be accompanied by a sour taste in your mouth — especially when you’re lying down
• May be accompanied by a small amount of stomach contents rising up into the back of your throat (regurgitation)

Sometimes acid reflux progresses to gastroesophageal reflux disease (GERD), a more severe form of acid reflux ⁵, ⁶, ⁷, ⁸, ⁹. If you have heartburn more than twice a week, you may have gastroesophageal reflux disease (GERD). But you can have gastroesophageal reflux disease (GERD) without having heartburn. Gastroesophageal reflux disease (GERD) can present as non-erosive reflux disease or erosive esophagitis. Gastroesophageal reflux disease (GERD) can seriously damage your esophagus or lead to precancerous changes in the esophagus called Barrett’s esophagus. Gastroesophageal reflux disease (GERD) can occur at any age, even in babies. Many times, you or your doctor can determine the triggers for your reflux. Gastroesophageal reflux disease (GERD) treatment may require prescription medications and, occasionally, surgery or other procedures.

There are many lifestyle changes you can make to reduce or eliminate acid reflux, including:

• Not drinking alcohol
• Don’t smoke or use tobacco. Smoking decreases the lower esophageal sphincter’s ability to function properly.
• Don’t eat within 3 or 4 hours before bed. Wait at least three hours after eating before lying down or going to bed.
• Lose weight if you’re overweight. Excess weight put pressure on your abdomen, pushing up your stomach and causing acid to reflux into your esophagus.
• Avoid tight-fitting clothing that are tight around your waist or abdomen. Clothes that fit tightly around your waist put pressure on your abdomen and the lower esophageal sphincter.
• Avoid foods or drinks that trigger your heartburn, such as chocolate, caffeine, peppermints, fried or fatty foods, spicy, and acidic foods
• Eating smaller meals or avoiding overeating
• Eat food slowly and chew thoroughly. Put down your fork after every bite and pick it up again once you have chewed and swallowed that bite.
• Try to find ways to relax.

Don’t stop taking any prescribed medicine without speaking to a doctor first

Many nonprescription medications can help relieve heartburn. The options include:

• Antacids, such as Alka-Seltzer, Maalox, Mylanta, Rolaids, and Riopan, which help neutralize stomach acid, are usually the first drugs recommended to relieve symptoms of heartburn. Antacids may provide quick relief. But they can’t heal an esophagus damaged by stomach acid. Many brands on the market use different combinations of three basic salts—magnesium, calcium, and aluminum—with hydroxide or bicarbonate ions to neutralize the acid in the stomach. Antacids, however, can have side effects. Magnesium salt can lead to diarrhea, and aluminum salt may cause constipation. Aluminum and magnesium salts are often combined in a single product to balance these effects. Calcium carbonate antacids, such as Tums, Titralac, and Alka-2, can also be a supplemental source of calcium, though they may cause constipation.
• H2-receptor blockers (Histamine Type-2 Receptor Antagonists) include ranitidine (Zantac), cimetidine (Tagamet HB), famotidine (Pepcid AC), and nizatidine (Axid AR) and are available both by prescription and over-the-counter. H2-receptor blockers treat symptoms of indigestion by reducing the amount of stomach acid released into your digestive tract, which relieves ulcer pain and encourages healing. Stronger versions of these medicines also are available by prescription. They work longer than but not as quickly as antacids. Side effects of H2-receptor blockers may include headache, nausea, vomiting, constipation, diarrhea, and unusual bleeding or bruising.
• Proton pump inhibitors (PPIs) reduce stomach acid by blocking the action of the parts of cells that produce acid. Proton pump inhibitors (PPIs), which are stronger than H2-receptor blockers, also treat indigestion symptoms by reducing stomach acid. Proton pump inhibitors (PPIs) are most effective in treating symptoms of indigestion in people who also have GERD. Proton pump inhibitors (PPIs) include the prescription and over-the-counter medications omeprazole (Prilosec, Zegerid), lansoprazole (Prevacid), rabeprazole (Aciphex), esomeprazole (Nexium), dexlansoprazole (Dexilant) and pantoprazole (Protonix). There are very few medical differences between these drugs. However, long-term use of proton pump inhibitors (PPIs), particularly at high doses, may increase your risk of hip, wrist and spine fracture. Ask your doctor whether a calcium supplement may reduce this risk. In patients whose symptoms improve with proton pump inhibitors (PPIs), PPI (proton pump inhibitor) therapy should be discontinued every 6 to 12 months to reduce the long-term risk of therapy. Side effects of PPIs may include back pain, aching, cough, headache, dizziness, abdominal pain, gas, nausea, vomiting, constipation, and diarrhea. The standard dosages of orally administered proton pump inhibitors are as follows:
  • Lansoprazole 30 mg daily
  • Omeprazole 20 mg daily
  • Pantoprazole 40 mg daily
  • Rabeprazole 20 mg daily
  • Esomeprazole 20 mg daily
• Proton pump inhibitors (PPIs) require a meal to activate them. You should eat a meal within 30 minutes to 1 hour after taking this medication for the acid suppression therapy to work most effectively. Waiting later than this time can decrease the positive effect of this medication. This might delay healing or even result in the failure of the ulcer to heal.

The World Gastroenterology Organization’s guidelines for treating frequent heartburn (heartburn symptoms two or more days/week) recommend a two-week course of treatment with an over-the-counter PPI (proton pump inhibitor) along with lifestyle and dietary modifications ¹⁰. In the US, over-the-counter esomeprazole 20 mg is approved for 14 days of treatment for frequent heartburn, a treatment course that can be repeated once every four months; however, if symptoms persist or recur within this time frame the individual should consult a physician ¹⁰, ¹¹.

If nonprescription treatments don’t work or you rely on them often, see your doctor. You may need prescription medication and further testing. Additional tests might include:

• pH test. This test checks for acid in the esophagus.
• Upper endoscopy or gastroscopy. This procedure checks for other conditions. During it, your doctor looks into your stomach through a long, thin tube that is inserted down your esophagus. You are sedated for this procedure, so you don’t feel it. Your doctor may also check for Helicobacter pylori, bacteria that can cause ulcers.

Figure 1. Digestive system

Footnotes: Your digestive system processes nutrients in foods that you have eaten and helps pass waste material out of your body. Food moves from your throat to your stomach through a tube called the esophagus. After food enters your stomach, it is broken down by stomach acid and muscles that mix the food and liquid with digestive juices. After leaving your stomach, partly digested food passes into your small intestine and then into your large intestine. The end of the large intestine, called the rectum, stores the waste from the digested food until it is pushed out of the anus during a bowel movement.

Figure 2. Gastroesophageal reflux disease (GERD)

Figure 3. Gastroesophageal reflux disease diagnostic algorithm

[Source ¹ ]

How can I tell the difference between a heartburn and heart attack?

Heartburn, angina and heart attack may feel very much alike. Even experienced doctors can’t always tell the difference from your medical history and a physical exam. That’s why, if you go to the emergency room because of chest pain, you’ll immediately have tests to rule out a heart attack.

The “textbook” heart attack involves sudden, crushing chest pain and difficulty breathing, often brought on by exertion. Many heart attacks don’t happen that way, though. The signs and symptoms of a heart attack vary greatly from person to person. Heartburn itself can accompany other symptoms of heart attack.

Typical heart attack signs and symptoms include:

• Pressure, tightness, pain, or a squeezing or aching sensation in your chest or arms that may spread to your neck, jaw or back
• Nausea, indigestion, heartburn or abdominal pain
• Shortness of breath
• Cold sweat
• Fatigue
• Lightheadedness or sudden dizziness

The most common symptom of heart attack for both men and women is chest pain or discomfort. But women are more likely than men to experience some of the other symptoms, such as jaw or back pain, shortness of breath, and nausea or vomiting. Heart problems are more common among people who have high blood pressure, diabetes or high cholesterol. Smoking and being overweight are other risk factors.

What’s the best thing to do if you have chest pain and you’re not sure what’s causing it?

If you have persistent chest pain and you aren’t sure it’s heartburn, call your local emergency services number for emergency medical help.

See your doctor if you had an episode of unexplained chest pain that went away within a few hours and you did not seek medical attention. Both heartburn and a developing heart attack can cause symptoms that subside after a while. The pain doesn’t have to last a long time to be a warning sign.

Heartburn causes

Heartburn occurs when stomach acid backs up into the tube (esophagus) that carries food from your mouth to your stomach. Typically, when food is swallowed, a band of muscle around the bottom of the esophagus called lower esophageal sphincter (LES) relaxes to allow food and liquid to flow down into your stomach. Then the muscle tightens again. If the lower esophageal sphincter (LES) isn’t working as it should, stomach acid can flow back up into the esophagus (acid reflux) and cause heartburn. The acid backup may be worse when you’re bent over or lying down.

Hiatus hernia, a condition in which part of your stomach is pushed up through the diaphragm (the muscle wall between the stomach and chest) and into your chest, can also compromise lower esophageal sphincter (LES) function and cause heartburn

Risk factors for heartburn

Certain foods and drinks can trigger heartburn in some people, including:

• Spicy foods
• Onions
• Citrus products
• Tomato products, such as ketchup
• Fatty or fried foods
• Peppermint
• Chocolate
• Alcohol, carbonated beverages, coffee or other caffeinated beverages
• Large or fatty meals

Being overweight or pregnant also can increase your risk of experiencing heartburn.

Heartburn during pregnancy

Heartburn is one of the most common gastrointestinal symptoms in pregnant women ¹², ¹³. Heartburn can occur in all trimesters of pregnancy and occurs in approximately two-thirds of all pregnancies reaching 80% in some populations ¹⁴, ¹⁵, ¹⁶, ¹⁷, ¹⁴, ¹⁸. Most women begin their symptoms late in the first trimester or in the second trimester and these symptoms become more frequent and severe in the final months of pregnancy ¹⁹, ¹³. The symptoms of heartburn in pregnancy may be frequent, severe and distressing, but serious complications are rare, symptoms are generally limited to the pregnancy period without long-term effects ¹⁹, ²⁰.

Pregnancy hormones appear to weaken the lower esophageal sphincter (LES) muscle and your uterus pressing up against your stomach as your baby grows encourages acid reflux. You’re more likely to get heartburn during pregnancy if you’ve had a baby before or if you get heartburn when you’re not pregnant ¹³. Generally, if there has not been too much weight gain during the pregnancy, a woman’s heartburn improves after delivery.

The diagnosis of heartburn is based on clinical history. Upper endoscopy and other diagnostic tests are infrequently performed ²¹, ¹³, ²².

What might help for heartburn during pregnancy:

• Eat several small meals instead of three large meals — eat slowly.
• Drink fluids between meals — not with meals.
• Don’t eat greasy and fried foods.
• Avoid citrus fruits or juices and spicy foods.
• Do not eat or drink within a few hours of bedtime.
• Do not lie down right after meals.

See your doctor if symptoms don’t improve after trying these suggestions. Ask your doctor about using an antacid.

If your heartburn doesn’t improve by changing how you eat, your doctor may suggest that you take medicine for it. Antacids are the first type of medicine to try. They can relieve your symptoms quickly. Antacids are safe in pregnancy as long as you don’t take more than the recommended dose. There are many different types — talk to your pharmacist to find one that’s most suitable for you.

If antacids don’t control your symptoms, speak to your doctor about other medicines you can take.

Figure 4. Heartburn during pregnancy treatment algorithm

Footnote: Step-up approach towards management of gastroesophageal reflux disease (GERD) during pregnancy.

Abbreviations: GERD = gastroesophageal reflux disease, H2RA = histamine-2 receptor antagonist, PPI = proton pump inhibitor.

[Source ¹² ]

Can heartburn hurt my baby?

Heartburn usually won’t cause any problems for your baby, but it’s uncomfortable for you.

A healthy diet is important for both your and your baby’s health. If heartburn is making it hard to eat healthy food, it’s best to treat it.

Heartburn during pregnancy causes

The cause of heartburn during pregnancy is multifactorial, involving both hormonal and mechanical factors. Pregnancy hormones called estrogen and progesterone, can relax the the lower esophageal sphincter (LES) muscle that usually holds your esophagus closed where it meets your stomach ¹⁸, ²³, ²⁴. The lowest lower esophageal sphincter pressure occurs at 36 weeks gestation ²⁴. This allows food and acid from your stomach to go back up your esophagus. Pregnancy hormones also slow down the muscles of your digestive tract. So food tends to move more slowly and digestion is sluggish. This causes many pregnant women to feel bloated.

Other factors that may also play a part in heartburn during pregnancy are increased intragastric pressure secondary to the enlarging uterus and changes in gastrointestinal motility through ineffective esophageal motility, with prolonged clearance time ¹⁸, ²⁵.

Abnormal gastric emptying or delayed small bowel transit might also contribute to heartburn in pregnancy ¹³.

Heartburn becomes more common as your pregnancy progresses. This can happen when your uterus (womb) pushes up against your stomach as your baby grows. This also pushes the contents of your stomach up into your esophagus.

Risk factors for heartburn in pregnancy include advancing gestational age, heartburn symptom before getting pregnant and women who have previously had one or more babies ¹³.

Heartburn can also be triggered by what you eat and drink, such as:

• a big meal
• high-fat foods
• spicy foods
• chocolate
• citrus fruit juices
• drinks containing caffeine, including coffee, tea and cola
• alcohol (which is not recommended in pregnancy)

Other things that may trigger heartburn include:

• doing exercise soon after eating
• lying down after eating
• feeling anxious

Because mothers are different, it’s a good idea to take note of the particular foods, drinks or activities that give you heartburn while you are pregnant.

Heartburn during pregnancy prevention

If your symptoms are mild, changing how you eat may help prevent heartburn. You could try:

• eating smaller meals more often and eating slowly
• avoiding eating for 2 or 3 hours before exercise or going to bed
• avoiding foods and drinks that give you heartburn
• avoiding eating and drinking at the same time, which can make your stomach more full
• sitting up straight while eating and not lying down after a meal
• raising the head of your bed or sleeping on at least 2 pillows
• sleeping on your left side

You might find it helpful to chew gum, which makes you produce more saliva to help neutralize the acid from your stomach. Drinking milk can also help neutralize acid.

Heartburn during pregnancy treatment

If your heartburn doesn’t improve by changing how you eat, your doctor may suggest that you take medicine for it. Antacids are the first type of medicine to try. They can relieve your symptoms quickly. Antacids are safe in pregnancy as long as you don’t take more than the recommended dose. There are many different types — talk to your pharmacist to find one that’s most suitable for you.

If antacids don’t control your symptoms, speak to your doctor about other medicines you can take.

The common drugs used for the treatment of heartburn in pregnancy include antacids, sucralfate, H2 receptor blockers (histamine-2 receptor antagonists), prokinetic drugs (drugs that stimulate the muscles of the gastrointestinal tract to prevent acids from staying in the stomach too long), proton pump inhibitors (PPIs), and alginate-based reflux suppressants such as Liquid Gaviscon and Gaviscon Advance ²⁶, ²⁷, ¹³. Traditional Chinese Medicine such as acupuncture has been used in treatment of heartburn in pregnancy in one study ²⁸. There are insufficient data to assess acupuncture versus no treatment ²⁹. More research is needed on acupuncture and other complimentary therapies as treatments for heartburn in pregnancy ²⁹.

Heartburn prevention

There are ways to prevent gastroesophageal reflux disease and acid reflux. To start, you need to know your body and how it reacts to different food and drinks. Spicy and acidic foods and carbonated drinks can trigger acid reflux. Try to avoid those things when possible. Eat smaller meals throughout the day, and don’t eat too late at night. Don’t lie down too soon after eating. Limit the use of alcohol. If you use tobacco, try to quit. Stress and lack of sleep also can worsen symptoms.

There are many dietary and lifestyle changes you can make to reduce or eliminate acid reflux, including:

• Not drinking alcohol
• Not smoking
• Avoid these foods and drinks that are commonly known to be heartburn triggers
  • Fried foods
  • Fast foods
  • Pizzas
  • Potato chips and other processed snacks
  • Chili powder and pepper (white, black, cayenne)
  • Fatty meats such as bacon and sausage
  • Cheese
  • Alcohol
  • Carbonated beverages
  • Caffeine
  • Acidic foods
  • Peppermints
• Not eating too close to bedtime
• Losing weight
• Not wearing tight clothing
• Eating smaller meals or avoiding overeating

Foods that help prevent acid reflux

Ginger is one of the best digestive aids because of its medicinal properties. Ginger is alkaline in nature and anti-inflammatory, which eases irritation in the digestive tract. Try sipping ginger tea when you feel heartburn coming on.

High-fiber foods

Fibrous foods make you feel full so you’re less likely to overeat, which may contribute to heartburn. So, load up on healthy fiber from these foods:

• Whole grains such as oatmeal, couscous and brown rice.
• Root vegetables such as sweet potatoes, carrots and beets.
• Green vegetables such as asparagus, broccoli and green beans.

Alkaline foods

Foods that have a low pH are acidic and more likely to cause reflux. Those with higher pH are alkaline and can help offset strong stomach acid. Alkaline foods include:

• Bananas
• Melons
• Cauliflower
• Fennel
• Nuts

Watery foods

Eating foods that contain a lot of water can dilute and weaken stomach acid. Choose foods such as:

• Celery
• Cucumber
• Lettuce
• Watermelon
• Broth-based soups
• Herbal tea

Heartburn symptoms

Symptoms of heartburn include:

• A burning pain in your chest that usually occurs after eating and may occur at night
• Pain that worsens when lying down or bending over
• A bitter or acidic taste in your mouth

Symptoms are often worse after eating, when lying down or when bending over.

You may also have:

• Non-burning chest pain, which is usually located in the middle of the chest and radiates to the back
• Difficulty swallowing (dysphagia)
• Atypical reflux symptoms relating to the throat, larynx or lungs:
  • Sore throat
  • Coughing or hiccups that keep coming back
  • Increased salivation
  • Shortness of breath
  • A hoarse voice
  • Bad breath
• Bloating and feeling sick

Heartburn complications

Heartburn that occurs frequently and interferes with your routine is considered gastroesophageal reflux disease (GERD). Gastroesophageal reflux disease (GERD) can seriously damage your esophagus or lead to precancerous changes in the esophagus called Barrett’s esophagus.

Gastroesophageal reflux disease (GERD) can sometimes lead to the following complications:

• Swelling of the vocal cords, also known as reflux laryngitis
• Inflammation of the tissue in the esophagus (esophagitis). Stomach acid can break down tissue in the esophagus, causing inflammation, bleeding, and sometimes an open sore (ulcer). Esophagitis can cause pain and make swallowing difficult.
• Narrowing of the esophagus (esophageal stricture), caused by scar tissues that develop due to repeated ulcerations. Damage to the lower esophagus from stomach acid causes scar tissue to form. The scar tissue narrows the food pathway, leading to problems with swallowing. American College of Gastroenterology guidelines recommend esophageal dilation and continue proton pump inhibitor (PPI) therapy to prevent the need for repeated dilations ³⁰.
• Barrett’s esophagus, a precancerous changes to the esophagus tissue caused by long-lasting gastroesophageal reflux disease which increases the risk of esophageal cancer. Current guidelines recommend the performance of periodic surveillance endoscopy in patients with a diagnosis of Barrett’s esophagus ³¹.
• Lung damage which may include pulmonary fibrosis and bronchiectasis
• Ulcers in the esophagus, caused by burning from stomach acid.

Heartburn diagnosis

To determine if your heartburn is a symptom of gastroesophageal reflux disease (GERD) starts with a thorough medical history during which you describe your signs and symptoms and physical examination. If the typical symptoms of acid reflux disease are present, including heartburn and regurgitation, your doctor may begin treatment without performing specific diagnostic tests.

However, tests may be performed if:

• Your symptoms are atypical
• The severity of acid reflux raises concerns about esophageal damage
• Symptoms do not respond to initial treatment
• Your doctor is considering anti-reflux surgery

To confirm a diagnosis of gastroesophageal reflux disease (GERD) or to check for complications, your doctor might recommend:

• Upper endoscopy or gastroscopy. Your doctor inserts a thin, flexible tube equipped with a light and camera (endoscope) down your throat. The endoscope helps your provider see inside your esophagus and stomach. Test results may not show problems when reflux is present, but an endoscopy may detect inflammation of the esophagus (esophagitis) or other complications. An endoscopy can also be used to collect a sample of tissue (biopsy) to be tested for complications such as Barrett esophagus. In some instances, if a narrowing is seen in the esophagus, it can be stretched or dilated during this procedure. This is done to improve trouble swallowing (dysphagia).
• Transnasal esophagoscopy. This test is done to look for any damage in your esophagus. A thin, flexible tube with a video camera is put through your nose and moved down your throat into the esophagus. The camera sends pictures to a video screen.
• Reflux testing (wireless pH/pH impedance). Ambulatory acid (pH) probe is placed in your esophagus to identify when, and for how long, stomach acid regurgitates there. The monitor connects to a small computer that you wear around your waist or with a strap over your shoulder. The monitor might be a thin, flexible tube (catheter) that’s threaded through your nose into your esophagus. Or it might be a clip that’s placed in your esophagus during an endoscopy. The clip passes into your stool after about two days.
  • Wireless pH Testing. Wireless pH testing allows your doctor to evaluate your reflux activity over a 48-hour period while you continue your normal activities. To perform wireless pH testing:
    • Your doctor performs an endoscopy and places a small chip in your lower esophagus
    • The chip records the acid level in your esophagus for 48 hours.
    • The chip transmits your acid level to a wireless recording device that you wear around your belt.
    • The data from the recording device can gauge your reflux severity.
  • 24-Hour pH Impedance. Your doctor may order this procedure to evaluate your reflux. This procedure monitors your pH level (level of acidity) for a prolonged period. During pH impedance:
    • Your doctor places a thin, flexible catheter with an acid-sensitive tip through your nose into your esophagus. The catheter is placed in separate recording spots to evaluate the flow of liquid from your stomach into your esophagus.
    • The catheter stays in your nose for a period of 24 hours.
    • Your doctor is able to evaluate whether you have GERD, the severity of your reflux, the presence of non-acid reflux and the correlation between your reflux and symptoms. This procedure helps in the design of a course of treatment for you.
• X-ray of the upper digestive system. X-rays are taken after you drink a chalky liquid that coats and fills the inside lining of your digestive tract. The coating allows your doctor to see a silhouette of your esophagus and stomach. This is particularly useful for people who are having trouble swallowing. You may also be asked to swallow a barium pill that can help diagnose a narrowing of the esophagus that may interfere with swallowing.
• Esophageal manometry also known as esophageal motility (movement) studies. This test measures the rhythmic muscle contractions in your esophagus when you swallow. Esophageal manometry also measures the coordination and force exerted by the muscles of your esophagus. This is typically done in people who have trouble swallowing. An esophageal manometry is an essential part of the assessment process prior to anti-reflux surgery.
  • During an esophageal manometry your doctor places a pressure-sensitive catheter into the esophagus. This may be performed right before esophageal pH impedance studies, as it determines where your doctor should place the catheter. The catheter evaluates the strength and coordination of your muscle contractions. It also tests the strength and relaxation function of the lower esophageal sphincter.
• Barium esophagram also called barium swallow,  is an imaging test that checks for problems in your upper gastrointestinal tract. Your upper gastrointestinal tract includes your mouth, back of the throat, esophagus, stomach, and first part of your small intestine. The test uses a special type of x-ray called fluoroscopy. Fluoroscopy is a kind of X-ray “movie.” A barium esophagram also evaluates the coordination of your esophageal motor function. While it does not test for the presence of reflux, it is useful for evaluating injury to your esophagus.
  • During barium contrast radiography:
    • You swallow a contrast solution called barium.
    • The barium coats your esophagus and gastrointestinal tract, making it easier for the doctor to detect abnormalities.
    • An X-ray is taken.
    • During the X-ray, your doctor looks for a narrowing in the esophagus called a stricture.

Heartburn differential diagnosis

Heartburn differential diagnosis include:

• Coronary artery disease
• Achalasia
• Eosinophilic esophagitis (EoE)
• Non-ulcer dyspepsia
• Rumination syndrome
• Esophageal diverticula
• Gastroparesis
• Esophageal and gastric neoplasm
• Peptic ulcer disease (PUD)

Heartburn treatment

If your symptoms are mild, treatment may not be necessary. Your doctor is likely to recommend that you first try lifestyle changes and nonprescription medications. If you don’t experience relief within a few weeks, your doctor might recommend prescription medication and additional testing.

Over-the-counter medicine is effective for treating mild cases of acid reflux. These medicines include:

• Antacids: This is a quick-acting medicine that reduces stomach acid. Unfortunately, antacids alone won’t heal the damage stomach acid causes in your esophagus. Sometimes, overusing antacids can cause diarrhea or constipation.
• H-2 receptor blockers (Histamine-2 Receptor Antagonists): These medicines reduce acid production. They don’t work as quickly as antacids. However, they provide longer relief (up to 12 hours). Stronger versions of these medications are available by prescription from your doctor.
• Proton pump inhibitors (PPIs): These medicines block acid production and heal the damage in your throat. They are stronger than H2-receptor blockers.

If these medicines are not providing relief after a few weeks, contact your doctor. Your doctor may give you a prescription version of H2 receptor blockers or proton pump inhibitors. Additionally, your doctor may prescribe medicine to strengthen the lower esophageal sphincter. The medicine may decrease the number of times your muscle relaxes. It is often used for severe reflux. Side effects include fatigue or confusion. Another medicine your doctor may prescribe helps your stomach empty faster. This will cause the food to move along the digestive tract and not back up into your throat. Your doctor may combine more than one medicine, depending upon the severity of your reflux.

In some cases, surgery may be required to treat acid reflux. This is when medicine doesn’t help, or if you want a long-term solution. Types of surgery may include:

• Nissen fundoplication: This surgery reinforces the lower muscle in the esophagus. A surgeon will wrap the very top of the stomach around the outside of the lower esophagus. This reduces reflux by putting pressure on your esophagus. This is a laparoscopic surgery. This means the surgeon makes three or four small cuts in the abdomen (stomach region). He or she will insert instruments, including a flexible tube with a tiny camera, through the cuts.
• Linx surgery: This surgery strengthens the muscle in the esophagus. The Linx device is a ring of tiny beads made of titanium. The surgery wraps the ring around the area between the stomach and esophagus. The magnetic attraction of the beads keeps the opening between the two closed. This helps keep acid from backing up into your throat. However, it’s weak enough to allow food to pass. The surgery is minimally invasive.
• Transoral incisionless fundoplication (TIF). This new procedure involves tightening the lower esophageal sphincter by creating a partial wrap around the lower esophagus using polypropylene fasteners. Transoral incisionless fundoplication (TIF) is performed through the mouth by using an endoscope and requires no surgical incision. Its advantages include quick recovery time and high tolerance. If you have a large hiatal hernia, transoral incisionless fundoplication (TIF) alone is not an option. However, transoral incisionless fundoplication (TIF) may be possible if it is combined with laparoscopic hiatal hernia repair.

Home remedies for heartburn

You can ease, stop or reduce heartburn and acid reflux yourself by doing the following:

• Eat smaller, more frequent meals.
• Eat food slowly and chew thoroughly. Put down your fork after every bite and pick it up again once you have chewed and swallowed that bite.
• Lose weight if you’re overweight. Excess weight put pressure on your abdomen, pushing up your stomach and causing acid to reflux into your esophagus.
• Try to find ways to relax
• Avoid foods or drinks that trigger your heartburn — such as alcohol, fried or fatty foods, chocolate, and peppermint.
• Don’t eat within 3 or 4 hours before bed. Wait at least three hours after eating before lying down or going to bed.
• Avoid tight-fitting clothing that are tight around your waist or abdomen. Clothes that fit tightly around your waist put pressure on your abdomen and the lower esophageal sphincter.
• Don’t smoke or use tobacco. Smoking decreases the lower esophageal sphincter’s ability to function properly.
• Don’t drink alcohol
• Don’t stop taking any prescribed medicine without speaking to a doctor first

Elevate the head of your bed. You may find that using wood, bricks or books under the feet at the head end of your bed to raise the head of your bed by around 10 to 20 cm, so your chest and head are above your waist, helps relieve symptoms. This can help stop stomach acid traveling up towards your throat. If you can’t elevate your bed, you can insert a wedge between your mattress and box spring to elevate your body from the waist up. Raising your head with additional pillows isn’t effective as this can increase pressure on your abdomen and make your symptoms worse. When you go to bed, start by lying on your left side to help make it less likely that you will have reflux.

Alternative medicine

Some complementary and alternative therapies, such as ginger, chamomile and slippery elm, may be recommended to treat gastroesophageal reflux disease. However, none have been proved to treat gastroesophageal reflux disease or reverse damage to the esophagus. Talk to your doctor if you’re considering taking alternative therapies to treat GERD.

Nonprescription medications

If necessary, occasional acid reflux can be treated with nonprescription medication, options include:

• Antacids that neutralize stomach. Antacids containing calcium carbonate such as Mylanta, Rolaids and Tums, may provide quick relief. But antacids alone won’t heal an inflamed esophagus damaged by stomach acid. Overuse of some antacids can cause side effects, such as diarrhea or sometimes kidney problems.
• H-2 receptor blockers (Histamine-2 Receptor Antagonists) to reduce acid production, such as cimetidine (Tagamet HB), famotidine (Pepcid AC) or nizatidine (Axid AR). H-2 blockers don’t act as quickly as antacids, but they provide longer relief and may decrease acid production from the stomach for up to 12 hours. Stronger versions are available by prescription.
• Proton pump inhibitors (PPIs) block acid production and heal the esophagus. Proton pump inhibitors are stronger acid blockers than H-2 blockers and allow time for damaged esophageal tissue to heal. Nonprescription proton pump inhibitors include lansoprazole (Prevacid 24 HR), omeprazole (Prilosec OTC) and esomeprazole (Nexium 24 HR).

If you suspect that you have gastroesophageal reflux disease (GERD), your symptoms worsen, or you have nausea, vomiting or difficulty swallowing, talk to your doctor. Prescription medications might help. In a few cases, gastroesophageal reflux disease (GERD) might be treated with surgery or other procedures.

Prescription medications

Prescription-strength treatments for gastroesophageal reflux disease (GERD) include:

• Prescription-strength proton pump inhibitors. Prescription-strength proton pump inhibitors include esomeprazole (Nexium), lansoprazole (Prevacid), omeprazole (Prilosec), pantoprazole (Protonix), rabeprazole (Aciphex) and dexlansoprazole (Dexilant). Although generally well tolerated, prescription-strength proton pump inhibitors might cause diarrhea, headaches, nausea, or in rare instances, low vitamin B-12 or magnesium levels.
• Prescription-strength H-2 blockers. Prescription-strength H-2 blockers include prescription-strength famotidine and nizatidine. Side effects from these medications are generally mild and well tolerated.

Multiple studies have demonstrated that proton-pump inhibitors (PPIs) provide superior therapeutic efficacy in the management of GERD than other antireflux medications such as H-2 receptor antagonists ³². Overall, proton-pump inhibitors (PPIs) demonstrate an unsurpassed rates of symptomatic relief and healing of esophageal inflammation as well as significant improvement in health-related quality of life in patients with erosive esophagitis ³³, ³⁴.

Surgery and other procedures

Gastroesophageal reflux disease (GERD) can usually be controlled with medication. But if medications don’t help or you wish to avoid long-term medication use, your doctor might recommend:

• Fundoplication. The surgeon wraps the top of your stomach around the lower esophageal sphincter, to tighten the muscle and prevent reflux. Fundoplication is usually done with a minimally invasive (laparoscopic) procedure. The wrapping of the top part of the stomach can be complete (Nissen fundoplication) or partial. The most common partial procedure is the Toupet fundoplication. Your surgeon will recommend the type that is best for you.
• LINX device. A ring of tiny magnetic beads is wrapped around the junction of the stomach and esophagus. The magnetic attraction between the beads is strong enough to keep the junction closed to refluxing acid, but weak enough to allow food to pass through. The LINX device can be implanted using minimally invasive surgery. The magnetic beads do not have an effect on airport security or magnetic resonance imaging.
• Transoral incisionless fundoplication (TIF). This new procedure involves tightening the lower esophageal sphincter by creating a partial wrap around the lower esophagus using polypropylene fasteners. Transoral incisionless fundoplication (TIF) is performed through the mouth by using an endoscope and requires no surgical incision. Its advantages include quick recovery time and high tolerance. If you have a large hiatal hernia, transoral incisionless fundoplication (TIF) alone is not an option. However, transoral incisionless fundoplication (TIF) may be possible if it is combined with laparoscopic hiatal hernia repair.

Because obesity can be a risk factor for gastroesophageal reflux disease (GERD), your doctor may suggest weight-loss surgery as an option for treatment. Talk with your doctor to find out if you’re a candidate for weight-loss surgery.

Acid reflux diet

Diet plays a major role in controlling acid reflux symptoms and is the first line of therapy used for people with gastroesophageal reflux disease (GERD).

Foods that help prevent acid reflux

Ginger is one of the best digestive aids because of its medicinal properties. Ginger is alkaline in nature and anti-inflammatory, which eases irritation in the digestive tract. Try sipping ginger tea when you feel heartburn coming on.

High-fiber foods

Fibrous foods make you feel full so you’re less likely to overeat, which may contribute to heartburn. So, load up on healthy fiber from these foods:

• Whole grains such as oatmeal, couscous and brown rice.
• Root vegetables such as sweet potatoes, carrots and beets.
• Green vegetables such as asparagus, broccoli and green beans.

Alkaline foods

Foods that have a low pH are acidic and more likely to cause reflux. Those with higher pH are alkaline and can help offset strong stomach acid. Alkaline foods include:

• Bananas
• Melons
• Cauliflower
• Fennel
• Nuts

Watery foods

Eating foods that contain a lot of water can dilute and weaken stomach acid. Choose foods such as:

• Celery
• Cucumber
• Lettuce
• Watermelon
• Broth-based soups
• Herbal tea.

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