Heartburn, also called acid indigestion, is a burning sensation in the chest (nothing to do with the heart). It is caused by acid backup, or reflux, from the stomach into the esophagus and throat, and can be accompanied by nausea, belching, bloating, and other unpleasant symptoms. Nearly everybody has had heartburn at some time, especially after eating too much. Smoking and obesity make you especially susceptible.
When does simple heartburn become gastroesophageal reflux disease (GERD)? Heartburn is a symptom, while GERD is a disease, characterized by chronic acid reflux (regurgitation) that can damage the lining of the esophagus (the tube connecting the throat to the stomach). Still, the line between heartburn and GERD is hard to draw. But if you have at least two episodes of heartburn a week, that’s a sign you need medical advice to find out what is going on and what your treatment options are. It’s estimated that about 20 percent of American adults have GERD, and the incidence is increasing, probably as a result of increasing obesity rates and longevity.
What causes GERD? Apart from smoking and obesity, your genes may predispose you. Pregnancy, perimenopause (the transition towards menopause), and menopause are other factors. Some medications and illnesses can cause or worsen GERD. Sleep apnea (also associated with obesity) increases the risk. Older people are at higher risk for potentially serious complications resulting from GERD, as discussed below.
Drugs for heartburn and GERD are huge best-sellers. Old-fashioned antacids have largely given way to stronger medications known as H-2 blockers and proton pump inhibitors (PPIs), which are now sold over the counter as well as by prescription. Many people pop these newer drugs without a second thought, taking them sometimes for months or even years. Researchers are increasingly concerned that overuse of PPIs, in particular, is causing a slew of adverse effects, some only recently identified (see inset below, PPIs for GERD: With Benefits Come Risks).
What's going on
The sphincter (a specialized segment of the circular muscle layer) at the lower end of the esophagus just above the entrance to the stomach normally prevents the stomach’s contents from backing up. But if this sphincter weakens, acidic digestive juices, along with bits of food and bile, can go back up into the esophagus, producing a burning sensation. In addition, there is an upper sphincter at the top of the esophagus, and if this also opens at the wrong time or is weak, reflux can back up into the throat and even the rear of the nasal airway; this is called laryngopharyngeal reflux, or LPR. Other gastrointestinal factors, such as slow stomach emptying and a hiatal hernia, can also play roles in reflux disease.
Simple heartburn usually goes away on its own, or with the help of an occasional antacid. But if heartburn becomes frequent or chronic and becomes GERD, it can cause a host of problems, some serious.
GERD can interrupt your sleep, leaving you tired during the day. It can cause hoarseness, laryngitis, painful swallowing, chronic cough, wheezing, postnasal drip, sinusitis, and chest, ear, or jaw pain. About half of people with such GERD-related problems have no reflux symptoms or heartburn, which can make the condition hard to diagnose. In fact, about one-third of unexplained asthma may actually be the result of GERD—possibly because the acid causes spasms in the larynx or airway. Damage to tooth enamel can also result from GERD.
In some people with GERD, acid reflux damages the lining of the esophagus. In 5 to 10 percent of them, this leads to a condition called Barrett’s esophagus, in which abnormal cellular changes develop in the lower esophagus, often without any reflux symptoms. Men are twice as likely as women to develop Barrett’s esophagus, which is more common after age 50. In a small percentage of cases, Barrett’s esophagus develops into cancer (esophageal adenocarcinoma) that can be aggressive and hard to treat. More rarely, GERD can even lead to a life-threatening perforation or hemorrhage of the esophagus.
Interestingly, you can have GERD without increased acid reflux and no esophageal damage—a condition dubbed non-erosive reflux disease, or NERD. This may sound simply like a less severe version of GERD, but in fact it is a distinct form of the disorder, which may involve hypersensitivity of the esophagus. People who have NERD may not respond as well to standard medications for GERD, though these are still the first line of treatment.
Best advice: If you have persistent heartburn or unexplained symptoms such as poor sleep, chronic cough, hoarseness, or difficulty swallowing, see a doctor. If it turns out you have GERD (or NERD), there’s a lot you can do to relieve your symptoms and prevent esophageal damage—or heal the damage if it has occurred.
When That Burning Sensation Isn't Heartburn
If you think you have heartburn but the chest pain keeps worsening, or you feel pressure instead of just burning, you may be having a heart attack. Here are other warning signs.
First line of defense:
- Lose weight if you are overweight. Extra pounds, especially abdominal obesity, can contribute to heartburn or GERD, notably by putting pressure on the stomach, which can push its contents up into the esophagus. All it takes is a little weight gain to increase the risk of reflux, according to a large study of female nurses in the New England Journal of Medicine back in 2006. It found that even for women in the “normal” weight range, a gain of 10 pounds increased the risk by 40 percent. And once they got into the overweight or obese category, the risk of GERD symptoms doubled or tripled. When women lost weight, the symptoms decreased.
- Don’t eat for two to three hours before going to bed. That will leave time for your stomach to empty. Don’t lie down after eating. Also avoid exercise shortly after eating.
- Eat small meals, and cut back on fluids with meals. If you eat large meals, the contents of your stomach will put more pressure on the lower sphincter and are more likely to back up into the esophagus.
- If you smoke, quit. Smokers are at increased risk for chronic acid reflux, possibly because smoking may relax the sphincter muscle. In addition, smoking decreases production of saliva, which normally helps neutralize acid in the esophagus.
- Avoid foods and beverages that you think bring on symptoms. Some people find that spicy, fatty, or fried foods as well as alcohol, chocolate, milk, peppermint, coffee, tea, and carbonated beverages make matters worse. Citrus fruit and juices may worsen heartburn. Avoid mints and limit fatty foods, since these can relax the sphincter. Milk is often recommended as soothing, but it can promote acid production in some people.
- Don’t count on special “low-acid” orange juice, coffee, and other “stomach friendly” products that are often touted for people with heartburn or GERD. No published research supports the idea that such foods and beverages help, but if you like them, there’s no harm in trying them.
- Elevate the head of your bed, if you have symptoms at night or in the early morning. Put wooden blocks under the headboard to raise it four to eight inches. The idea is to use gravity to prevent reflux. Another good option is a special foam bed wedge for acid reflux, which elevates your upper body. (In contrast, using large pillows to raise just your head and shoulders is not effective and may even worsen matters since that can put more pressure on your stomach.)
- Sleep on your left side, not your right side or on your back. Your stomach bends to the left, so when you lie on this side, a portion of it remains lower than your esophagus, which can help reduce the backup of food and acid into the esophagus.
- Chew sugarless gum after meals. This stimulates production of saliva, which helps neutralize stomach acid and soothe the esophagus.
- Make sure medications you are taking aren’t causing or contributing to heartburn or acid reflux. Ask your doctor or pharmacist. Common culprits include certain antibiotics, bisphosphonates (for osteoporosis), pain relievers (such as aspirin and ibuprofen), benzodiazepines (for anxiety and sleep), opioid narcotics, calcium channel blockers (for hypertension), potassium supplements, progesterone, and anticholinergic drugs (a large group that includes certain antihistamines, antidepressants, and antispasmodics). But don’t stop taking these drugs without consulting your doctor.
- Avoid tight-fitting clothes. Tight pants, pantyhose, girdles, and belts put pressure on the stomach and can worsen reflux.
- When picking up or reaching for something on the floor, bend at the knees, not at the waist. This is particularly important for people whose occupation involves a lot of bending.
Next step: medication
For occasional heartburn, over-the-counter antacids provide short-term relief by neutralizing stomach acid. They come in a variety of forms and combinations of ingredients. Many brands (such as Mylanta, Maalox, Rolaids, and Tums) offer different formulations and flavors; generics are also available. Liquids tend to work better than tablets. You may have to experiment to find something that works for you. The following compounds are used in most antacids, singly or combined:
- Calcium carbonate works well and is inexpensive (it also provides calcium for your bones).
- Aluminum compounds are slower acting and may cause constipation or, at high doses, calcium depletion.
- Magnesium compounds may have a laxative effect. Overuse can bring on low blood pressure and irregular heart rhythms, especially in older people.
- Simethicone, an anti-foaming agent, reduces the size of gas bubbles and is often used to reduce belching. But there’s little evidence showing it’s effective for GERD.
- Alginate (or alginic acid), derived from seaweed, is listed as an inactive ingredient in Gaviscon in the U.S., but as an active ingredient in Gaviscon sold in Canada and Europe. Versions of Gaviscon in the U.S. also contain aluminum and magnesium compounds, sometimes along with sodium bicarbonate. Alginate is supposed to form a foam barrier in the stomach that reduces acid reflux. Some studies have found it more effective than a placebo for relieving mild to moderate GERD symptoms.
- Sodium bicarbonate (baking soda) is the active ingredient in fizzy antacids like Alka-Seltzer and its generics. Such products are high in sodium and often contain aspirin, which can contribute to heartburn as well as gastrointestinal bleeding, so we don’t recommend them.
- Pepto-Bismol (bismuth subsalicylate) is sometimes taken for heartburn, but we don’t recommend this since its salicylates (also in aspirin) can be irritating. And it can be constipating when taken frequently.
Like any acid-reducing medication, antacids can cause acid rebound if you use them regularly and then abruptly stop.
As with any over-the-counter medication, read the label, and talk with your doctor or pharmacist if you have questions. In particular, ask your pharmacist if ant-acids could interfere with other medications you are taking. You may be advised not to take antacids within an hour or two of your other drug. People with impaired kidney function should consult a health care provider if they take antacids on a regular basis.
A type of histamine antagonist, H-2 blockers reduce the production of stomach acid (which is stimulated by?histamine), instead of simply neutralizing it. Originally available only by prescription, most are now also sold over the counter in lower doses and in generic form. The H-2 blockers are ranitidine (such as Zantac), famotidine (such as Pepcid), nizatidine (such as Axid), and cimetidine (such as Tagamet).
It takes about 30 to 60 minutes for the drugs to start working, so take them just before or with a meal or before you think you are likely to get an attack (for instance, at bedtime). You should not take them regularly for more than 14 days; if symptoms persist or recur, check with your doctor for further treatment plans. If you are taking other medications, there may be interactions. Be sure to read the labels carefully, or ask your doctor or pharmacist.
PPIs for GERD: With Benefits Come Risks
In recent years researchers have uncovered a growing list of potentially serious adverse effects that can result from prolonged use of proton pump inhibitors (PPIs), drugs commonly taken for heartburn and gastroesophageal reflux disease (GERD).
Stepping up to PPIs
Proton pump inhibitors (PPIs) go further than H-2 blockers; they actually turn off almost all acid production. PPIs not only alleviate symptoms of GERD, but also allow the esophagus time to heal if it has been damaged (more so than H-2 blockers).
These drugs work best when taken 30 to 60 minutes before eating. If symptoms occur mostly at night, the drugs should be taken before dinner.
PPIs have become the second biggest selling drugs in the world. You’ve undoubtedly seen ads for brand-name PPIs—such as Prilosec (omeprazole), Prevacid (lansoprazole), and Nexium (esomeprazole). All have been found to be equally effective. Most are now sold over the counter, usually at half the prescription dose and often in less expensive generic form.
What you may not have noticed in the ads are the warnings, usually in small type, that the over-the-counter drugs should not be taken for more than 14 days and not more often than every four months, unless directed by a doctor. The FDA requires those directions in order to encourage people to seek medical attention if they need to take the OTC drugs longer than that. Moreover, studies have found that 14 days of use is sufficient to resolve chronic heartburn in most people, with the therapeutic effect often persisting for two to three months afterwards.
But many health care providers prescribe longer-term use of PPIs for chronic conditions (such as peptic ulcers or esophagitis) or advise taking the lower-dose over-the-counter versions longer or intermittently—often for good reason, but sometimes not. And many people who self-prescribe PPIs don’t read or else ignore the labels’ directions and warnings and take the drugs longer than recommended, without consulting a health care provider. Once they start taking the drugs, they may get used to doing so and worry that they’ll suffer if they stop. Such PPI overuse is a bad idea, since it has many potential risks.
Whether you take a PPI or H-2 blocker: If over-the-counter products don’t help enough, your doctor may prescribe stronger formulas. But depending on how severe your GERD is, it is best to gradually reduce the dose so you use the lowest dose that works for you, and try to taper off it to see if it’s still needed. This is especially true for people at highest risk for serious side effects from PPIs. If you’ve been on the drugs for longer than recommended, work with your doctor to determine a plan for getting off them gradually. Do not just stop taking them, since that can worsen symptoms.
Heartburn and GERD During Pregnancy
About one-third to one-half of pregnant women experience heartburn. Which heartburn drugs are safe for them?
“Pro-kinetic” drugs such as metoclopramide (Reglan) speed stomach emptying and may benefit certain people with GERD. But they can have serious side effects, such as tremors, seizures, and other uncontrollable body movements (notably on the face), and are usually ineffective in the long term. Sucralfate (Carafate) and baclofen (Lioresal) may be useful under some circumstances.
There are also surgical procedures to correct GERD, but generally they should be done only when all else fails or medications are not tolerated. Most long-term studies show that surgery and medical treatment are equally beneficial. There are potential complications from all types of surgery; some people need to resume medication after surgery.
Don’t count on dietary supplements
Countless dietary supplements—containing enzymes (such as pepsin and pancreatin), aloe vera juice, anise, chamomile, ginger, licorice, slippery elm, and other herbals—are sold to treat heartburn and GERD symptoms. Some of these may be soothing, but there is no credible evidence that any of them are as effective as medication. And like the over-the-counter drugs, they can be harmful if they prevent or delay you from getting proper medical advice.
7 Tips About Endoscopy
When do people need to undergo an endoscopy if gastroesophageal reflux disease (GERD) is suspected? Less often than is commonly done. Here are 7 things you need to know.
Published November 18, 2016