Heartburn

Heartburn, also known as pyrosis or acid indigestion is a burning sensation in the chest, in the epigastrium. The pain often rises in the chest may radiate to the neck, throat, or angle of the jaw. Heartburn is usually associated with regurgitation of gastric acid reflux which is the major symptom of gastro esophageal reflux disease. (GERD). It however may also be a symptom of ischemic heart disease, though this is true for only 0.6% of those experiencing heartburn. Differential diagnosis Cardiac and esophageal causes may share similar symptoms as these two structures have the same nerve supply. y Cardiac disease is one of the first conditions that must be excluded in patients with unexplained chest pain given that patients with chest pain related to GERD cannot be distinguished from those with chest pain due to cardiac conditions y GERD (Gastroesophageal Reflux Disease) is the most common cause of heartburn. In this condition acid reflux has led to inflammation of the esophagus. y Functional heartburn. It is associated with other functional gastrointestinal disorder like irritable bowel syndrome and is the primary cause of lack of improvement post treatment with proton pump inhibitors (PPIs). PPIs are however still the primary treatment with response rates in about 50% of people. The diagnosis is based upon the Rome III criteria of o o o y 1) burning retrosternal discomfort 2) absence of GERD as the cause 3) No esophageal motility disorders

Cardiac. Heartburn is recognized as a symptom of an acute myocardial infarction and angina. A description of burning or indigestion-like pain increases the risk of acute coronary syndrome, but not to a statistically significant level. In a group of people presenting to a hospital with GERD symptoms, 0.6% may be due to ischemic heart disease.

Diagnostic approach 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. 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. If the chest pain is suspected to be heartburn, patients may undergo an upper GI series to confirm the presence of acid reflux. Heartburn or chest pain after eating or drinking and combined with difficulty swallowing may indicate esophageal spasms. y GI cocktail. Relief of symptoms 5 to 10 minutes after the administration of viscous Lidocaine and an antacid increases the suspicion that the pain is esophageal in origin. This however does not rule out a

potential cardiac cause as 10% of cases of discomfort due to cardiac causes are improved with antacids. y Biochemical. Esophageal pH monitoring : A probe can be placed via the nose into the esophagus to record the level of acidity in 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. y Mechanical. Manometry : In this test, a pressure sensor (manometer) is passed through the mouth into the esophagus and measures the pressure of the lower esophageal sphincter directly. 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 esophagus and stomach. In this way, evidence of esophageal inflammation can be detected, and biopsies taken if necessary. Biopsy : A small sample of tissue from the esophagus is removed. It is then studied to check for inflammation, cancer, or other problems. Symptoms: y Burning feeling in the chest, often the sensation may spread up into the throat, jaw, arms, or back. Heartburn (acid indigestion) typically occurs 30-60 minutes after meals. y y Regurgitation it is common after meals, when lying down, bending over, or straining. Stomach acid can also affect the respiratory tract, causing asthma, hoarseness, chronic cough, sore throat, or tooth damage (acid eats the enamel on teeth). y If the acid exposure continues for long periods of time, the esophagus becomes damaged. You may then have difficulty swallowing. y Very rarely, the esophagus may bleed or tear (haematemesis)

Exams and Tests: y y y y esophagogastroduodenoscopy or EGD upper GI series esophageal manometry 24-hour pH monitoring

Treatment: The treatment of heartburn depends on the underlying cause. Medicines such as H2 receptor antagonists or proton pump inhibitors are effective for gastritis and GERD, the two most common causes of heartburn. Antibiotics are used if H. pylori is present. Antacid tablets are slow to act. Tablets are less powerful in neutralizing stomach acid than liquid antacids. o Antacids are useful because they provide rapid relief of heartburn, especially if it is caused by foods or certain activity. But relief is only temporary. Over-the-counter antacids do not prevent heartburn from returning or allow an injured esophagus to heal o Aluminum and magnesium hydroxide (may produce unwanted diarrhea or constipation)

Antacids containing calcium carbonate are the most potent in neutralizing stomach acid.

Medication: o histamine-2 blockers. ranitidine (Zantac), cimetidine (Tagamet), famotidine (Pepcid), and nizatidine (Axid). They provide relief of symptoms within 30 minutes and are taken twice a day. o as metoclopramide (Reglan). This type of drug empties food and acid quickly from the stomach so less can travel back into the esophagus. Metoclopramide also helps tighten the LES muscle. o Proton pump inhibitors: omeprazole (Prilosec), lansoprazole (Prevacid), esomeprazole (Nexium), and pantoprazole (Protonix). These compounds prevent the stomach from secreting acid. They are very effective and are typically taken only once a day. These drugs are usually only prescribed if other drugs have not helped

Surgery: If prescription drugs are not relieving heartburn, or in serious complications of heartburn, surgery may be required (fundoplication). The surgery is relatively simple and is. Its purpose is to tighten the lower esophageal sphincter muscle. The stomach is tied in such a way as to prevent acid from flowing backward into the esophagus.

Self-Care advice: y    lifestyle modifications: Avoid large meals. Avoid caffeine (coffee, teas, soft drinks). Avoid foods or drinks that reduce pressure on the lower esophageal sphincter such as chocolate, peppermint, caffeine-containing beverages, and fatty or fried foods.  Avoid foods that damage the esophagus such as spicy foods, citrus fruits and juices, tomatoes and tomato sauces.  After eating, beware of activities that force acid back into your esophagus. Such activities include lifting, straining, coughing, and wearing tight clothing.    Lose weight if you are overweight. Stop smoking. Limit alcohol intake.