Heartburn
Encyclopedia
Heartburn, also known as pyrosis or acid indigestion is a burning sensation in the chest, just behind the breastbone or in the epigastrium
. The pain often rises in the chest
and may radiate to the neck, throat, or angle of the jaw.
Heartburn is usually associated with regurgitation of gastric acid
(gastric reflux) which is the major symptom of gastroesophageal reflux disease
(GERD). It however may also be a symptom of ischemic heart disease so concluding that it is gastroesophageal reflux disease prematurely may lead to misdiagnosis.
and indigestion are often used interchangeably with heartburn, though some sources emphasize a distinction. Dyspepsia is defined as a combination of epigastric pain and heartburn. Heartburn is commonly used interchangeably with gastroesophageal reflux disease
rather than just to describe a symptom of burning in one's chest.
supply.
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. As many as 30% of chest pain patients undergoing cardiac catheterization have findings which do not account for their chest discomfort, and are often defined as having "atypical chest pain" or chest pain of undetermined origin. According to data recorded in several studies based on ambulatory pH and pressure monitoring, it is estimated that 25% to 50% of these patients have evidence of abnormal GERD.
is the most common cause of heartburn. In this condition acid reflux has led to inflammation of the esophagus
.
like irritable bowel syndrome
and is the primary cause of lack of improvement post treatment with proton pump inhibitor
s (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 1) burning retrosternal discomfort 2) absence of GERD as the cause 3) no esophageal motility disorders. It was found to be present in 22.3% of Canadians in one survey.
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.
Heartburn or chest pain after eating or drinking and combined with difficulty swallowing may indicate esophageal spasms.
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.
: 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.
: 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. 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.
Biopsy
: A small sample of tissue from the esophagus is removed. It is then studied to check for inflammation, cancer, or other problems.
and GERD
, the two most common causes of heartburn. Antibiotics are used if H. pylori is present.
Epigastrium
The epigastrium is the upper central region of the abdomen. It is located between the costal margins and the subcostal plane....
. The pain often rises in the chest
Chest
The chest is a part of the anatomy of humans and various other animals. It is sometimes referred to as the thorax or the bosom.-Chest anatomy - Humans and other hominids:...
and may radiate to the neck, throat, or angle of the jaw.
Heartburn is usually associated with regurgitation of gastric acid
Gastric acid
Gastric acid is a digestive fluid, formed in the stomach. It has a pH of 1 to 2 and is composed of hydrochloric acid , and large quantities of potassium chloride and sodium chloride...
(gastric reflux) which is the major symptom of gastroesophageal reflux disease
Gastroesophageal reflux disease
Gastroesophageal reflux disease , gastro-oesophageal reflux disease , gastric reflux disease, or acid reflux disease is chronic symptoms or mucosal damage caused by stomach acid coming up from the stomach into the esophagus...
(GERD). It however may also be a symptom of ischemic heart disease so concluding that it is gastroesophageal reflux disease prematurely may lead to misdiagnosis.
Definition
The terms dyspepsiaDyspepsia
Dyspepsia , also known as upset stomach or indigestion, refers to a condition of impaired digestion. It is a medical condition characterized by chronic or recurrent pain in the upper abdomen, upper abdominal fullness and feeling full earlier than expected when eating...
and indigestion are often used interchangeably with heartburn, though some sources emphasize a distinction. Dyspepsia is defined as a combination of epigastric pain and heartburn. Heartburn is commonly used interchangeably with gastroesophageal reflux disease
Gastroesophageal reflux disease
Gastroesophageal reflux disease , gastro-oesophageal reflux disease , gastric reflux disease, or acid reflux disease is chronic symptoms or mucosal damage caused by stomach acid coming up from the stomach into the esophagus...
rather than just to describe a symptom of burning in one's chest.
Differential diagnosis
Cardiac and esophageal causes may share similar symptoms as these two structures have the same nerveNerve
A peripheral nerve, or simply nerve, is an enclosed, cable-like bundle of peripheral axons . A nerve provides a common pathway for the electrochemical nerve impulses that are transmitted along each of the axons. Nerves are found only in the peripheral nervous system...
supply.
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. As many as 30% of chest pain patients undergoing cardiac catheterization have findings which do not account for their chest discomfort, and are often defined as having "atypical chest pain" or chest pain of undetermined origin. According to data recorded in several studies based on ambulatory pH and pressure monitoring, it is estimated that 25% to 50% of these patients have evidence of abnormal GERD.
GERD
Gastroesophageal reflux diseaseGastroesophageal reflux disease
Gastroesophageal reflux disease , gastro-oesophageal reflux disease , gastric reflux disease, or acid reflux disease is chronic symptoms or mucosal damage caused by stomach acid coming up from the stomach into the esophagus...
is the most common cause of heartburn. In this condition acid reflux has led to inflammation of the esophagus
Esophagitis
Esophagitis is inflammation of the esophagus. It may be acute or chronic. The acute esophagitis can be catarrhal or phlegmonous, whereas the chronic esophagitis may be hypertrophic or atrophic.-Infectious:...
.
Functional heartburn
Functional heartburn is heartburn of unknown cause. It is associated with other functional gastrointestinal disorderFunctional gastrointestinal disorder
Functional gastrointestinal disorder include a number of separate idiopathic disorders which affect different part of the gastrointestinal tract.-Classification:*Functional esophageal disorders**Functional heartburn...
like irritable bowel syndrome
Irritable bowel syndrome
Irritable bowel syndrome is a diagnosis of exclusion. It is a functional bowel disorder characterized by chronic abdominal pain, discomfort, bloating, and alteration of bowel habits in the absence of any detectable organic cause. In some cases, the symptoms are relieved by bowel movements...
and is the primary cause of lack of improvement post treatment with proton pump inhibitor
Proton pump inhibitor
Proton-pump inhibitors are a group of drugs whose main action is a pronounced and long-lasting reduction of gastric acid production. They are the most potent inhibitors of acid secretion available today. The group followed and has largely superseded another group of pharmaceuticals with similar...
s (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
Rome process
The "Rome process" is an international effort to create scientific data to help in the diagnosis and treatment of functional gastrointestinal disorders, , such as irritable bowel syndrome, functional dyspepsia and rumination syndrome...
of 1) burning retrosternal discomfort 2) absence of GERD as the cause 3) no esophageal motility disorders. It was found to be present in 22.3% of Canadians in one survey.
Cardiac
Heartburn is recognized as a symptom of an acute myocardial infarctionMyocardial infarction
Myocardial infarction or acute myocardial infarction , commonly known as a heart attack, results from the interruption of blood supply to a part of the heart, causing heart cells to die...
and angina
Angina
Angina pectoris, commonly known as angina, is chest pain due to ischemia of the heart muscle, generally due to obstruction or spasm of the coronary arteries . Coronary artery disease, the main cause of angina, is due to atherosclerosis of the cardiac arteries...
. A description of burning or indigestion-like pain increases the risk of acute coronary syndrome
Acute coronary syndrome
Acute coronary syndrome is usually one of three diseases involving the coronary arteries: ST elevation myocardial infarction , non ST elevation myocardial infarction , or unstable angina ....
, 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.
GI cocktail
Relief of symptoms 5 to 10 minutes after the administration of viscous lidocaineLidocaine
Lidocaine , Xylocaine, or lignocaine is a common local anesthetic and antiarrhythmic drug. Lidocaine is used topically to relieve itching, burning and pain from skin inflammations, injected as a dental anesthetic or as a local anesthetic for minor surgery.- History :Lidocaine, the first amino...
and an antacid
Antacid
An antacid is a substance which neutralizes stomach acidity.-Mechanism of action:Antacids perform a neutralization reaction, increasing the pH to reduce acidity in the stomach. When gastric hydrochloric acid reaches the nerves in the gastrointestinal mucosa, they signal pain to the central nervous...
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.
Biochemical
Esophageal pH monitoringEsophageal pH Monitoring
Esophageal pH monitoring is the current gold standard for diagnosis of gastroesophageal reflux disease . It provides direct physiologic measurement of acid in the esophagus and is the most objective method to document reflux disease, assess the severity of the disease and monitor the response of...
: 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.
Mechanical
ManometryManometry
Manometry refers to the evaluation of pressure .Forms include:* Esophageal motility study* Anorectal manometry* Rhinomanometry...
: 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
Endoscopy
Endoscopy means looking inside and typically refers to looking inside the body for medical reasons using an endoscope , an instrument used to examine the interior of a hollow organ or cavity of the body. Unlike most other medical imaging devices, endoscopes are inserted directly into the organ...
: 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. 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.
Biopsy
Biopsy
A biopsy is a medical test involving sampling of cells or tissues for examination. It is the medical removal of tissue from a living subject to determine the presence or extent of a disease. The tissue is generally examined under a microscope by a pathologist, and can also be analyzed chemically...
: A small sample of tissue from the esophagus is removed. It is then studied to check for inflammation, cancer, or other problems.
Treatment
The treatment of heartburn depends on the underlying cause. Medicines such as H2 receptor antagonists or proton pump inhibitors are effective for gastritisGastritis
Gastritis is an inflammation of the lining of the stomach, and has many possible causes. The main acute causes are excessive alcohol consumption or prolonged use of nonsteroidal anti-inflammatory drugs such as aspirin or ibuprofen. Sometimes gastritis develops after major surgery, traumatic...
and GERD
Gerd
In Norse mythology, Gerðr is a jötunn, goddess, and the wife of the god Freyr. Gerðr is attested in the Poetic Edda, compiled in the 13th century from earlier traditional sources; the Prose Edda and Heimskringla, written in the 13th century by Snorri Sturluson; and in the poetry of skalds...
, the two most common causes of heartburn. Antibiotics are used if H. pylori is present.