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In this learning opportunity, you’ll discover the causes of heartburn, gain an understanding of gastroesophageal reflux disease (GERD) and how it can be differentiated from other conditions, explore the benefits of a diet in alleviating heartburn, and learn about the potential use of antidepressants for treatment. Additionally, you’ll explore whether everyone requires a gastroscopy for heartburn.
What will you learn?
- Why does heartburn occur? What is gastroesophageal reflux disease (GERD)?
- Why does gastroesophageal reflux disease occur?
- What other diseases besides GERD can manifest as heartburn?
- Are there other symptoms of GERD besides heartburn?
- Can GERD be confused with ENT diseases?
- Can GERD occur without symptoms?
- How is the diagnosis made for GERD and laryngopharyngeal reflux? For example, how to understand what causes a sore throat?
- Why is gastroscopy not necessary for everyone with heartburn?
- How is heartburn treated and are medications always prescribed?
- What can help reduce heartburn symptoms besides medication?
- How does diet affect heartburn? Are there foods that should be excluded from the diet?
- What are the features of the diagnosis and treatment of functional heartburn and hypersensitive esophagus?
- Can heartburn be treated with baking soda or other home remedies?
- Does heartburn increase the risk of esophageal cancer and to what extent?
Why does heartburn occur? What is gastroesophageal reflux disease?
To begin, it is important to understand what heartburn actually is. Although some people use this term to describe unpleasant burning sensations in the stomach, heartburn is actually felt behind the sternum and is a burning sensation that spreads from the solar plexus to the throat.
This sensation is a typical symptom of gastroesophageal reflux disease, or GERD, which is a chronic condition where the contents of the stomach are regularly thrown back into the esophagus, causing irritation and discomfort. This reflux is called regurgitation, and it happens normally throughout the day in everyone, up to 50 times a day, and is called physiological reflux. This reflux does not harm us and we do not feel it.
However, if the reflux occurs more often and the contents of the stomach stay in the esophagus for longer periods of time, this is considered pathological reflux, which is GERD. The stomach contains acid and some bile, which irritate the esophagus, causing heartburn.
While feeling burning behind the sternum once a year is not typically considered a disease, experiencing heartburn regularly and at least several times a week is considered a disease. It is also important to note that there are other conditions that can cause a similar sensation behind the sternum, but they occur less frequently.
Why does gastroesophageal reflux disease occur?
GERD can be caused by several mechanisms, but the most significant factor is the weakened muscle tone of the lower esophageal sphincter. In normal circumstances, this muscular ring between the esophagus and stomach should close tightly, but in GERD, it remains weak and partially open, making it easier for stomach contents to reflux into the esophagus.
Other mechanisms can also cause GERD, such as disruption of esophageal motility or the ability to move food down and a decrease in the esophagus’ ability to clear reflux due to reduced mucus secretion.
The exact cause of these processes being disrupted in an individual is not always clear, although certain risk factors can increase the likelihood of developing GERD, such as hiatal hernia, obesity, pregnancy, and specific eating habits or lifestyle factors.
However, pathological reflux can occur without any apparent cause, as even a young and slender individual may develop GERD without any predisposing factors.
What other conditions besides GERD can cause heartburn?
Heartburn can be caused by conditions such as functional heartburn and hypersensitive esophagus, which do not involve pathological reflux.
Hypersensitive esophagus
The condition known as hypersensitive esophagus involves the esophagus receptors becoming more sensitive to normal reflux, which can lead to the perception of heartburn even in the absence of pathological reflux. In some cases, the esophagus receptors may send incorrect signals to the brain, even when normal physiological reflux occurs only rarely.
Functional heartburn
Functional heartburn is a condition where heartburn occurs without any connection to reflux. In this case, the esophagus receptors function in an unclear manner, leading to heartburn even when there is no reflux. Both in functional heartburn and hypersensitive esophagus, the issue is not with reflux, but with the disruption of communication between the esophagus nervous system and the central nervous system (the brain).
Eosinophilic esophagitis
Eosinophilic esophagitis is a rare condition characterized by chronic immune-mediated inflammation in the esophagus. The development of eosinophilic esophagitis can be influenced by several factors, including exposure to airborne and food allergens, genetic predisposition, and activation of certain immune cells.
The diagnosis of eosinophilic esophagitis is based on the biopsy results from the esophagus, which can show an increased number of eosinophils, a type of immune cell. This disease typically manifests as dysphagia, or difficulty swallowing food, but heartburn can also occur.
Infectious diseases
Heartburn can also be caused by rare infectious diseases such as fungal or herpes virus-induced inflammatory processes.
Are there other symptoms of gastroesophageal reflux disease besides heartburn?
Esophageal symptoms associated with pathological reflux are not limited to heartburn alone. Pain behind the sternum may also occur, which can be confused with heart pain, especially in the elderly, and may require an ECG and consultation with a cardiologist.
Regurgitation of stomach contents, difficulty swallowing, and the sensation of food sticking in the esophagus can also occur. Nausea is a rare symptom but may occur.
Pathological reflux can also cause extra-esophageal symptoms, although these occur less frequently. Stomach contents can reflux into the larynx and oral cavity, causing a range of symptoms collectively known as “laryngopharyngeal reflux.”
This can cause symptoms typically associated with ENT diseases, such as sore throat, cough, hoarseness, and the sensation of mucus flowing down the back of the throat.
Reflux can also cause burning, an unpleasant taste in the mouth, and dental problems, including cavities.
Can GERD be confused with ENT diseases?
Extra-esophageal symptoms of reflux can be challenging to diagnose and treat. This issue can be related to the fact that patients often see an ear, nose, and throat (ENT) doctor who must determine whether the symptoms are related to GERD or something else.
Laryngopharyngeal reflux is a distinct condition that can occur separately or together with GERD. In these cases, symptoms may only involve the throat, and the esophagus may be functioning correctly, or vice versa.
A distinguishing feature of laryngopharyngeal reflux is that even normal reflux can trigger symptoms in these patients. The larynx’s mucous membrane is more sensitive than the esophageal mucosa, and minor normal refluxes can cause symptoms in this area.
Laryngopharyngeal reflux is caused by a malfunction of both the lower esophageal sphincter, which separates the esophagus and stomach, and the upper esophageal sphincter, which is closer to the throat. Weakness of this sphincter allows even minor physiological refluxes to exit the esophagus and cause persistent symptoms in the larynx.
There is still no consensus among medical professionals about which doctor should manage laryngopharyngeal reflux, an ENT specialist or a gastroenterologist. If symptoms affect both the throat and the esophagus, a gastroenterologist is the right doctor to consult. However, if symptoms are only related to the throat, the choice of specialist may be less clear.
Does GERD occur without symptoms?
While rare, it is possible to have significant inflammation in the esophagus without experiencing any symptoms. I and my colleagues have seen cases like this during gastroscopy, where there was no explanation for the inflammation other than pathological reflux. However, these cases are exceptions rather than the rule, as gastroesophageal reflux disease typically presents with various symptoms.
How is the diagnosis made for GERD and laryngopharyngeal reflux? For example, how do you determine what is causing a sore throat?
Classic GERD with reflux only into the esophagus
The doctor typically diagnoses GERD (gastroesophageal reflux disease) based on a person’s symptoms and expected response to therapy. When a person presents with typical symptoms of GERD, such as heartburn and chest pain, the doctor usually considers GERD as the diagnosis. In some cases, the doctor may order a gastroscopy, especially if the symptoms are persistent. However, not everyone requires this test. Regardless of whether a gastroscopy is needed or not, the doctor typically prescribes proton pump inhibitors, which are medications that can relieve heartburn in about 99% of cases. These medications suppress stomach acid, reduce reflux volume, and alleviate reflux symptoms.
To confirm a diagnosis of GERD, the doctor typically assesses whether the person experiences relief from medication and whether they maintain a period of well-being after a course of therapy. During this period, the person should not experience any significant heartburn symptoms or feel unwell. The period of well-being should last for several months. If a person only complains of a sore throat without any typical GERD symptoms, the doctor may consider a diagnosis of laryngopharyngeal reflux. In this case, further examination and testing may be necessary to confirm the diagnosis.
If there are doubts about whether it’s GERD, functional heartburn, or hypersensitive esophagus
A diagnostic technique known as 24-hour esophageal and gastric pH-impedance monitoring may be utilized to aid in diagnosis. This test involves inserting a thin probe through the nose, down the esophagus, and into the stomach. The probe is then connected to a specialized device that the person wears for 24 hours. Although the procedure can be unpleasant, it does not interfere with breathing or eating.
The probe is equipped with sensors that record various parameters of the esophagus and stomach, including the frequency of reflux and its acidity. Additionally, the test allows for the correlation of symptoms with reflux, as the person keeps a diary during the procedure noting their eating and symptom occurrences. The doctor will compare the reported symptoms with the data collected by the probe during interpretation of the results.
The most informative way to diagnose GERD, functional heartburn, and hypersensitive esophagus is through 24-hour esophageal and gastric pH-impedance monitoring. This method is helpful in identifying pathological refluxes and differentiating between these conditions.
However, not all medical facilities offer this specific and unpleasant examination, and it is not recommended for everyone. It is typically reserved for challenging cases where the doctor is unable to determine whether it is GERD or functional heartburn, such as when reflux medication is ineffective, or symptoms rapidly reappear after treatment discontinuation.
Diagnosis of laryngopharyngeal reflux
In situations where upper reflux needs to be detected, 24-hour pH-impedance monitoring can be helpful, provided that there is an upper sensor at the level of the larynx. This is the only reliable way to diagnose laryngopharyngeal reflux. While an examination by an ear, nose, and throat (ENT) specialist is necessary when there are throat problems, the external appearance of the organ cannot determine the presence of reflux. Redness in the area of the vocal cords and larynx can also occur with other conditions.
As pH-impedance monitoring of the esophagus is a less accessible examination, it is generally more practical to prescribe empirical treatment, which involves using the same medications as those for classic GERD, but at twice the dosage. After taking the medication, reflux symptoms should subside.
Why is gastroscopy not needed for everyone with heartburn?
Gastroscopy, although helpful in diagnosing GERD, may not always be required. The issue is that not all reflux cases will cause esophageal inflammation. The probability of esophageal damage increases with the frequency of reflux, leading to inflammatory changes such as erosion of the lining.
If a gastroscopy reveals significant erosions, this is a convincing indication of GERD. In other words, esophageal damage from reflux confirms the diagnosis. If a gastroscopy shows no alterations or only minor redness in the esophagus, it does not confirm the existence of reflux, but it also does not eliminate it.
Doctors will advise a gastroscopy when risk factors are present. For example, if a woman has been experiencing heartburn for only a month, inflammation in the esophagus is unlikely to have developed, so gastroscopy is not necessary. However, if a man has been self-treating heartburn with baking soda for 20 years, has numerous unhealthy habits, is overweight, and is experiencing heartburn, there is a high risk that his esophagus has been severely affected.
How is heartburn treated and are medications always prescribed?
At the initial consultation for heartburn symptoms, therapy is always prescribed to assess its effectiveness and confirm the diagnosis. For pharmacological treatment, only a few medication groups are used, since it is not possible to increase the tone of the sphincter between the esophagus and stomach. Proton pump inhibitors are the most effective and safe drugs, prescribed in courses of one to six months. The dosage and regimen depend on the individual’s clinical situation, as determined by the doctor.
Antacids are also available and work as a first-aid remedy for quick relief of reflux. However, they cannot achieve remission or eliminate symptoms for an extended period. Antacids are useful for rare heartburn, where the individual experiences occasional discomfort once a week or less.
Occasionally, doctors may use other drugs, such as prokinetics, which regulate the motility of the esophagus and stomach. However, these are considered secondary options. In cases of GERD or laryngopharyngeal reflux, proton pump inhibitors work in 99% of cases, leading to symptom resolution.
What can help reduce the symptoms of heartburn besides medication?
There exist a set of measures known as “anti-reflux rules” that can prevent the provocation of symptoms associated with GERD.
Don’t lie down immediately after eating.
It is recommended to avoid lying down for at least an hour after eating and instead sit or stand. When the stomach expands after a meal, the esophageal sphincter can open wider, leading to increased reflux when in a horizontal position.
Don’t eat heavily before bedtime.
Due to the same reasons, it is recommended to have dinner at least three hours prior to bedtime.
Raise the head of the bed
If you experience reflux symptoms at night, you can alleviate them by elevating the head of the bed by around 15 centimeters. This means that the upper part of the bed should be inclined at a 45° angle, with the upper part of the torso slightly higher than the head.
There are also specially designed pillows available for purchase, which can be found easily by searching for “GERD pillow” or “wedge pillow” on online marketplaces.
Limit some physical exercises that can provoke reflux
Typically, these movements require engaging the abdominal muscles, tilting, or lifting heavy objects. I recommend against completely avoiding physical activities, including strength training, as they are generally beneficial for overall health.
However, if a person experiences a direct link between certain exercises and reflux symptoms, it’s advisable to limit or replace such exercises with alternatives. For example, if lifting weights triggers heartburn, a different type of exercise can be tried.
Ultimately, it’s essential to listen to your body and make adjustments accordingly based on how you feel.
Do not wear tight clothing, such as belts, corsets, and so on, that compress the abdominal area.
Taking medication to treat GERD can alleviate heartburn symptoms, regardless of a person’s activities or position. However, it is not advisable to rely solely on medication for an extended period. During symptom-free periods, it is recommended to implement lifestyle adjustments to prevent heartburn from recurring.
In contrast, for laryngopharyngeal reflux, there is no conclusive evidence that lifestyle changes significantly impact symptoms. Although implementing “anti-reflux rules” can be effective, it may not have the same significant impact as with classic GERD since the condition is usually normal reflux. In such cases, long-term medication prescribed by a doctor is typically the most effective treatment.
How does diet affect heartburn? Are there any foods that should be excluded from the diet?
The course of reflux disease can be influenced by the characteristics of one’s diet.
Eating patterns
Reflux can be triggered by overeating, or even by consuming a normal amount of food while simultaneously drinking a large quantity of liquid.
Food products
It is common practice for gastroenterologists to provide their patients with a list of permissible and forbidden foods, but scientifically speaking, there is no definitive evidence to support such dietary restrictions. There is no clear connection between specific foods and reflux, although some studies have been conducted on certain products. For example, it is often said that citrus fruits, tomatoes, chocolate, mint, and fried or fatty foods can trigger reflux, but there is no clear and understandable connection in research.
In practice, we do not see a direct link in every person, so it is not necessary to strictly forbid certain foods. Instead, it is more reasonable to limit the intake of foods that a patient associates with heartburn. For instance, if a patient experiences symptoms every time after drinking coffee or eating a pastry, then it is worth avoiding these products. The recommendation is to rely on personal sensations, identify patterns, and only exclude those products that cause heartburn.
What are the features of diagnosis and treatment of functional heartburn and hypersensitive esophagus?
How to recognize functional heartburn
Symptoms that do not stem from reflux are unresponsive to standard medications. In cases where a person has taken various proton pump inhibitors without relief, functional heartburn may be suspected by a skilled gastroenterologist. The understanding of the existence of functional heartburn leads the physician to consider the possibility that the condition is not GERD.
How to recognize hypersensitive esophagus
When it comes to physiological reflux, proton pump inhibitors typically have some effect, but it’s often only partial, meaning that heartburn doesn’t completely disappear, or short-lived, with symptoms returning once the medication is stopped. Normally, after a course of therapy, remission should last at least several months, but in this case, the patient experiences heartburn again the very next day.
How to treat functional heartburn and hypersensitive esophagus
The recommended treatment for both conditions involves taking certain antidepressants, as not all antidepressants are effective. These drugs directly target the receptors of the esophagus and can reduce their sensitivity, even if the individual does not have a mental disorder. This neuromodulatory effect restores the connection between the esophagus and the brain. A gastroenterologist is typically responsible for prescribing these medications, while a psychiatrist may also be involved in cases where the person has accompanying anxiety or depressive disorders, which are common triggers for functional esophageal disorders.
Anxiety can trigger and intensify heartburn, while heartburn can further amplify anxiety, creating a harmful cycle. When something triggers anxiety in a person, it can cause heartburn symptoms to arise. Even after the initial trigger has passed, the symptoms may persist, leading the individual to seek medical attention. Doctors may misdiagnose the condition as GERD and prescribe different medications, but the symptoms continue for months or even years. This can cause the individual to become increasingly worried and anxious, leading to heightened heartburn symptoms. They may even start worrying about developing esophageal cancer, further exacerbating their symptoms.
Apart from antidepressants, psychotherapy can also be a useful treatment option in such cases.
Can heartburn be treated with baking soda or other folk remedies?
It is not safe to consume baking soda for heartburn treatment due to potential dangers. Although a one-time use may not cause harm, it is not recommended to use it regularly when there are effective medical treatments available.
When baking soda reacts with stomach acid, it produces carbon dioxide, which stretches the stomach walls and increases acid production. This can result in the “rebound syndrome,” where heartburn initially improves, but then returns stronger. The positive effects of baking soda are also short-lived compared to standard antacids.
Furthermore, using baking soda can worsen stomach conditions like ulcers and increase pain and inflammation. Although rare, there have been cases of stomach rupture caused by baking soda consumption.
Another important consideration is that sodium in baking soda is absorbed into the bloodstream and can impact the body’s acid-base balance and potentially harm kidney function, particularly for individuals with certain chronic conditions. Antacids are a safer option, as some drugs are absorbed to a lesser extent, and others are not absorbed into the bloodstream at all.
Thus, drinking baking soda is not only ineffective, but also harmful. It is strongly advised to avoid consuming other specific substances such as vinegar, hydrogen peroxide, herbs, and tinctures.
There are, however, some safe alternatives: for instance, some people find relief by consuming milk, while others chew mint gum to help clear their esophagus of reflux. These methods may work for specific individuals.
It seems peculiar to rely on traditional remedies when there are now more effective medical treatments available for various ailments.
Does heartburn increase the risk of esophageal cancer and by how much?
Heartburn can cause precancerous cellular changes in the esophagus, a condition known as “Barrett’s esophagus.” Normally, the esophagus has a flat epithelium, but with this condition, it transforms into a cylindrical shape as a protective response to constant inflammation.
During gastroscopy, the changes in Barrett’s esophagus can be observed at the point where the esophagus meets the stomach, as the mucous membrane undergoes alterations. A biopsy can also be taken to examine a piece of tissue under a microscope, which would reveal cells that are characteristic of the intestine, rather than the esophagus, a condition known as “intestinal metaplasia.
A final diagnosis of Barrett’s esophagus can only be confirmed through a biopsy, as it is not possible to diagnose it solely through visual inspection. Additionally, the height of the affected part of the esophagus must be at least one centimeter for it to be considered Barrett’s esophagus; anything smaller would not meet the criteria for this diagnosis.
It is important to note that precancerous changes in the esophagus are not a definitive diagnosis of cancer, and the development of cancer is not certain. According to a large study, the annual risk of Barrett’s esophagus transitioning to cancer was found to be 0.4%, whereas other studies suggest a range of 0.5% to 2.1% risk of developing adenocarcinoma of the esophagus per year. However, the risk varies depending on how promptly the problem is identified and treatment is initiated.
In cases of Barrett’s esophagus, it is recommended to take proton pump inhibitors for life. In this scenario, the benefits of continuous medication outweigh the risks of long-term use. Additionally, regular monitoring is required, including gastroscopy and biopsy at a specific frequency.
Barrett’s esophagus is twice as likely to occur in men compared to women, and the average age of diagnosis is 55 years. Other factors that increase the risk of precancerous changes in the esophagus include smoking, obesity, long-term untreated GERD, a family history of Barrett’s esophagus or esophageal cancer.
In addition, GERD can lead to narrowing of the esophagus, particularly when there is severe inflammation. Mucous membrane damage can heal by forming scars, which ultimately reduces the lumen of the organ.
Remember
- The main cause of heartburn is gastroesophageal reflux disease (GERD). GERD occurs when stomach contents are thrown back into the esophagus and stay there longer
- The reasons for GERD in a particular person may not be identifiable, but excess weight, pregnancy, and other factors may predispose to the disease
- Heartburn can also occur due to functional reasons or increased sensitivity of organ receptors, but these are rare causes
- GERD can cause not only heartburn but also pain behind the sternum, belching, and other symptoms. Reflux may occasionally reach the throat, larynx, and oral cavity, causing symptoms similar to pharyngitis or laryngitis. This is called laryngopharyngeal reflux.
- Laryngopharyngeal reflux is often confused with laryngeal diseases
- A gastroscopy is not necessary for the diagnosis of GERD, as the doctor typically relies on symptoms and the effects of medication. To detect laryngopharyngeal reflux, a pH-impedance test of the esophagus and stomach may be required
- Treatment for GERD involves medications that reduce stomach acidity, such as proton pump inhibitors for long-term use and antacids for immediate relief
- When not taking medication, lifestyle changes can help prevent heartburn, such as not lying down immediately after eating, not eating at night, and not wearing tight clothing
- A strict diet is not necessary for GERD, but it is recommended to identify trigger foods that cause heartburn and avoid them
- For the treatment of functional heartburn and hypersensitive esophagus, certain antidepressants may be prescribed
- Baking soda should not be used for heartburn, as it is ineffective and even dangerous
- Prolonged heartburn in the esophagus can lead to precancerous changes, which do not necessarily mean cancer but do increase the risks. Lifelong treatment and regular check-ups are necessary in such cases.
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