heartburn

Definition heartburn

Heartburn (reflux disease) causes excessive reflux of acidic gastric contents (gastric acid) into the esophagus. Persistent chemical irritation from gastric acid causes inflammation of the oesophageal mucosa (reflux oesophagitis).

Synonyms

Reflux esophagitis, reflux disease, reflux, gastro-esophageal disease

Gastro-esophageal reflux disease (abbr .: GERD)

Epidemiology

In gastroenterological practice (gastrointestinal disorders), heartburn is the most common condition.
6-20% of the population suffer from reflux disease (heartburn). 10% of patients with heartburn develop reflux oesophagitis over time.

10% of these patients with reflux oesophagitis develop a severe esophageal ulcer (beret ulcer)
10% of the ulcers develop into an esophageal tumor (esophageal carcinoma).

Cause of heartburn

Heartburn is a common symptom. In some cases, it occurs chronically - that is, recurring - and rarely in others.
Heartburn occurs because stomach acid runs from the stomach back into the esophagus. This is done either by an excess of stomach acid from overproduction or by an insufficient occlusion of the lower esophageal muscle that normally seals the esophagus to the stomach.
Typical causes of heartburn are alcohol and nicotine abuse, ingestion of greasy, spicy, very sweet meals, excessive coffee consumption, overweight and stress. These stimulate the gastric acid production, it produces more stomach acid than is actually necessary and it comes to a reflux of the excess acid into the esophagus.
The stomach is - unlike the esophagus - designed to come in regular contact with the acid, since the mucosa is constructed differently than that of the esophagus. This means that if gastric acid gets into the esophagus, this leads to a significant irritation of the mucous membrane. If this happens more often, it leads to an inflammation of the esophageal mucosa, one speaks of a reflux oesophagitis.

Heartburn due to stress

Stress is a common cause of heartburn. The exact connections are unclear. So far, two correlations have been observed in studies: on the one hand, stress causes the lower sphincter of the esophagus to relax. The way for the gastric acid in the neck is thus opened. On the other hand, stress leads to increased gastric acid production.

The neuronal connections (ie based on the nerve tracts) have not been conclusively clarified. More and more, however, the focus is on the fact that the vegetative (autonomous) nervous system that controls the digestive system was probably underestimated in all previous medical considerations. Because a similar mechanism in stress-induced diarrhea has long been known, but the scientific justification is missing.

If stress can be identified in a patient as a trigger, a therapeutic approach may be considered here. The person in question can identify stress relievers together with their family doctor, a psychotherapist or a physiotherapist and remove them in order to find relief. If this does not lead to a complaint, physical (somatic) causes should be considered again.

Heartburn during sport

Changes in position such as stooping and lying often lead to an exacerbation of heartburn, because then more pressure is exerted by the abdominal contents on the lower sphincter of the esophagus. If such body positions are taken during exercise, these also aggravate the heartburn. Even strong abdominal breathing or tense abdominal muscles provide increased pressure.

At the same time the gastric juice "spills" by repeated up and down movements increasingly to the upper part of the stomach, so it can also trigger a heartburn with inadequate sphincter muscles. To avoid this, two to three hours after ingestion and any heartburn should be avoided, sporting activities in the form mentioned, as well as gentler movements are used (walk, cycling).

Heartburn after alcohol

Alcohol consumption can worsen the symptoms of gastritis because it involves many simple sugars that stimulate gastric acid production and secondly, because it is a drink with an acidic pH. It therefore potentiates the acidic environment of the stomach. Particularly high-percentage, sharp alcoholic beverages (booze) should therefore be avoided.

Heartburn through coffee

Coffee is an acidic drink that, like alcohol, usually worsens heartburn. The remedy is a shot of milk in the coffee and preferably no sugar. If symptoms such as heartburn and nausea occur immediately after coffee consumption, this food should be avoided altogether until the symptoms have improved sustainably. A more stomach-friendly alternative would be black or green tea with low-fat milk.

Symptoms of heartburn

The leading signs of disease (symptom) of the reflux disease are heartburn (acid reflux), feeling of fullness, puffing and possibly also irregularities of the stool. The sour or bitter taste in the throat usually occurs about 30-60 minutes after the meal.
Patients with heartburn typically complain of laxative and / or sweet meals, lying flat or lifting heavy loads. Significant reflux can cause chest pain, coughing, chronic bronchitis and bronchial asthma.

  • Symptoms of heartburn
  • Burning in the esophagus
  • Burning in the upper abdomen

Heartburn and nausea

Nausea is common with heartburn as a symptom of gastritis (gastritis). Often, it occurs after the period of nagging hunger and is only mitigated by taking basic gels or basic food. Rarely, nausea occurs even without heartburn in a gastritis.

Heartburn and chest pain

Heartburn is felt as a biting or burning pain in the middle of the upper thorax, behind the sternum. The stronger the heartburn, the higher it pulls into the throat and may even lead to a visibly reddened throat and a sour taste in the mouth. If it is chest pain that is sudden, persistent and associated with chest tightness, a heart attack should also be considered. If the pain comes in waves that become stronger, after a stressful situation or when eating food, and can be eased with a glass of milk, a heart attack is unlikely.

Heartburn and flatulence

Flatulence usually does not occur with heartburn as a sign of gastritis. They are therefore to be assigned to another causal complex. Cause can be an unhealthy diet or a food intolerance (eg against lactose). A conversation with the GP helps here.

Discomfort heartburn

  1. Esophagus
  2. stomach

The excerpt image shows the leaky stomach entrance, which allows a backflow of sour chyme the esophagus.

Heartburn at night

Patients suffering from heartburn often complain that the symptoms occur especially at night. This may be because, for example, eating large oily meals in the evening. Another reason is lying flat in bed, which makes gravity more likely to return from the stomach to the esophagus. Accordingly, it is recommended for patients with heartburn to sleep with a slightly elevated upper body.

Cough with heartburn

Not infrequently, cough is a symptom that occurs in the context of mucosal esophagitis and heartburn. This is presumably because the gastric acid flowing back into the esophagus irritates the mucous membrane, which in turn leads to a coughing sensation.

Heartburn and back pain

Back pain is not a typical heartburn symptom, but it can be a concomitant symptom. Heartburn is caused by a transfer of gastric acid from the stomach into the esophagus, the acid then leads to irritation of the mucous membrane, thereby causing a burning pain. This can occasionally also radiate in the back.

Heartburn with nausea and diarrhea

A combination of heartburn with nausea and diarrhea is rare. Heartburn can occasionally cause nausea because the gastric acid that has entered the esophagus from the stomach irritates the mucosa and can cause nausea. Diarrhea usually has nothing to do with heartburn.

Likelihood of confusion with heart trouble / heart attack

A reflux oesophagitis, ie an inflammation of the esophagus, can manifest itself by several symptoms. Typical is acid eructation (heartburn) and a burning sensation behind the breastbone that radiates partially up to the upper abdomen and the left half of the breast. Coughing is not a rare symptom of reflux disease.
Due to burning in the area of ​​the breast, which may be partially localized in the area of ​​the left half of the breast, the symptoms may also be confused with the symptoms of a heart attack. In a heart attack many patients describe a pressure or a burning pain in the area of ​​the heart, which often radiates into the arm, the neck or the upper abdomen, not infrequently there occurs also a shortage of air.
If it can not be ruled out that the symptoms indicate a heart attack, a doctor should be contacted, who can differentiate between the two possible diagnoses by means of blood collection and ECG (electrocardiogram).

Therapy of heartburn

The first step in the treatment of heartburn should be the consideration of the risk factors for the occurrence of heartburn. These include, but are not limited to, consumption of alcohol, nicotine, coffee, greasy, pungent, sweet foods, overweight, and excessive stress. First of all, the person affected should try to eliminate possible risk factors as much as possible. This is not always easy, for example, in stress, but also in addictions such as nicotine consumption and obesity, but if the risk factor persists, the likelihood of heartburn recurring over and over again is very high.
Many sufferers who complain of heartburn, especially at night, sleep with a slightly raised upper body helps. In addition, large meals should be avoided shortly before going to bed.
There are numerous home remedies to help against heartburn. However, there is no proven benefit, so you should try it out individually, which will help you. There are numerous tips from stomach-friendly teas to chewing gum chewing to eating a handful of nuts, milk or soda.
If the heartburn can not be adequately controlled with the above measures, effective treatment of heartburn can be achieved with the use of so-called proton pump inhibitors. These are drugs that significantly inhibit acid production in the stomach. Typical representatives are, for example, pantoprazole and omeprazole. In heartburn without actual inflammation of the gastric mucosa, it is often sufficient to take a tablet if necessary. If there is already an inflamed mucosa of the esophagus, regular intake over several weeks can provide relief.
In case of recurrent heartburn, it may be necessary to have a gastroscopy done. However, this is far from the case with every heartburn patient. Prolonged or worsening complaints, vomiting blood, black stool and the presence of unclear anemia may be indications that further diagnosis may be helpful or necessary.
Read more: What to do in heartburn?

What helps immediately?

As an acute therapy for heartburn Riopan ® (an antacid) is often advertised. This is a remedy intended to neutralize stomach acid, thus making it less acidic / corrosive. The effect should occur quickly and last for several hours. Riopan® is available as a tablet or as a gel for swallowing.
However, proton pump inhibitors such as pantoprazole or omeprazole are considered to be the most effective treatment for frequent heartburn with mucosal inflammation of the esophagus. The effect occurs relatively quickly and lasts for a long time.

What to eat with heartburn?

Since heartburn is due to increased gastric acid production, it is recommended to consume foods whose digestion is not dependent on much stomach acid. The acid-producing cells in the stomach react mainly to fats and simple sugars, but also to proteins.

Those affected should therefore avoid high-fat meals (eg fatty steak with gravy) and do not consume any sugary drinks. Coffee and alcohol should also be avoided because they potentiate the acidic environment inside the stomach. It is recommended to consume basic foods, such as low-fat dairy products (attention, often extra sugared!) And potatoes, rice and wholemeal pasta. The total amount of a meal should also be reduced. Patients with heartburn should take frequent small meals instead of consuming large, voluminous portions. For pain caused by stomach movements and pulpy foods are low, as they do not stress the stomach activity too much (mashed potatoes, soft pasta, rice pudding, soups). It is also advisable to banish spicy spices from the diet as they can further damage the already irritated gastric mucosa.

Medicines for heartburn

When it comes to heartburn and the resulting consequential damage (for example, inflammation of the esophagus), there is above all a group of drugs that is said to have good efficacy with relatively few side effects: the proton pump inhibitors. They attack certain cells and certain pumps, reducing acid production in the stomach.
The stomach acid is therefore less acidic and therefore less "corrosive". To this group of medicines belong the two main representatives Pantoprazol and Omeprazol. For occasional heartburn, intake is sufficient if necessary. For regular complaints and already present inflammation of the esophagus, a daily therapy over several weeks is recommended. In the case of persistence of the complaints, an idea should be given to the treating GP. Pantoprazole and omeprazole can be purchased over the counter at the pharmacy.

Home remedies for heartburn

There are numerous home remedies that are said to help fight heartburn. Overall, however, there is no proof of efficacy in any of these home remedies. One person in the end helps one agent better than the other agent; The best thing to do is to try those who get the best results. Possible home remedies for heartburn are warm tea (for example camomile), a handful of nuts, chewing gum, milk, soda dissolved in warm water and others.
More important than these home remedies, however, is the prevention of the onset of complaints by abstaining from alcohol, nicotine and sensitive people. In addition, sleeping with a slightly elevated upper body and taking a small meal for supper can be helpful.


  • Home remedies for heartburn
  • Homeopathy for heartburn

Milk in heartburn

Milk is one of the home remedies that is said to have a beneficial effect on heartburn. Allegedly it should come to a neutralization of the gastric acid. All in all, it must be said that the therapeutic benefits of milk for the treatment of heartburn are rather questionable, but sufferers can, of course, try out what helps them, which is individually very different.

Diet for heartburn

The wrong diet can lead to a high incidence of heartburn. In particular, spicy, greasy, and very sweet foods can stimulate acid production in the stomach, triggering reflux into the esophagus. Alcohol also increases gastric acid secretion, but at the same time also lowers the tone of the lower esophageal sphincter muscle, thus facilitating reflux into the esophagus.

Soda for heartburn

A teaspoon of soda dissolved in a glass of lukewarm water is supposed to work wonders against heartburn. This is due to the fact that soda is alkaline, stomach acid but sour, so soda should contribute to a neutralization of gastric acid. That's not scientifically proven. However, many sufferers notice a positive effect. Certainly, the intake of soda should not be permanent in heartburn, with recurrent heartburn should therefore possibly be consulted the doctor, who can then decide whether further diagnostics is necessary.

homeopathy

Since the art of homeopathy is based on empirical medicine and involves the entire organism in its deliberations, no general recommendation from a conventional medical point of view can be given here. However, which homeopathic remedies are most frequently used are the following: Nux vomica D6, Robinia pseudoacacia, Arsenicum album, Bismuthum subnitricum, Chamomilla and Lycopodium.

Cell salts

The effect of Schüssler's salts is based on the theory that diseases are due to an imbalance in the acid-base balance of the body. However, since the body has an excellent system (kidneys and lungs), a systemic imbalance occurs only in severe diseases, such as renal insufficiency. Only then does a systemic therapy with certain salts make sense. However, if a certain Schuessler salt is exclusively alkaline in nature, it may be helpful to compensate for the acidic environment of a symptomatic stomach in the short term. Similar to homeopathy, these are empirical values ​​apart from conventional medicine. Frequently used is the Schüssler salt No. 9 sodium phosphoricum.

What helps in pregnancy?

In pregnancy, agents such as Riopan and Omeprazole are generally allowed, but it should be weighed each drug intake and first clarified with the attending gynecologist. In pregnant women, therefore, the focus should initially be on other options, such as sleeping with an upper body and avoiding large meals in the evening, also can be tried here first home remedies, such as a warm chamomile tea or a handful of nuts.

Can heartburn be a sign of pregnancy?

About half of all pregnant women develop heartburn in the stages of advanced pregnancy. This is due to the increased pressure inside the abdomen, that is, the space occupied by the growing child.

This is not an early sign of pregnancy, such as pregnancy-induced nausea, which is most common in the first three months of pregnancy.

complications

The constant chemical irritation of gastric acid to the oesophageal mucosa due to heartburn may lead to esophagitis (reflux oesophagitis) over time. Heavy inflammation heals by scarring. Strong hubs, in turn, can narrow the esophagus (scar stenosis), which affects the transport of food into the stomach.

In 10% of cases of reflux oesophagitis arises a beret esophagus (synonym endobrachy esophagus = esophageal shortening). This leads to a change in the shape and function of a part of the esophageal cells due to chronic irritation of the mucosa (metaplasia). In the case of the esophagus, metaplasia is a transformation of the natural squamous epithelium of the esophagus (inner cell layer, protective layer) into a columnar epithelium. This transformed tissue is less resistant, so that ulceration of the esophagus with persistent irritation can easily occur.

This multiple-layer esophageal ulcer (beret ulcer) can lead to life-threatening blood loss. In the worst case, such a baret ulcer can cause a malignant (esophageal) esophageal cancer. In principle, however, there is the possibility of Zellerhohlung, ie the metaplasia is reversible (reversible), when the chronic mucosal irritation disappears.

The vagus nerve (vagus nerve), which runs in the immediate vicinity of the esophagus and supplies all organs (lungs, heart, etc.) parasympathetic to the diaphragm (part of the autonomic nervous system), can be stimulated during heartburn (reflux). So it is not uncommon for some patients to report chronic cough or for their already existing asthma to get worse. The reason for this is that the irritated vagus nerve causes bronchoconstriction (bronchoconstriction) to contract.

Often, chronic cough and hoarseness are also caused by a disease-related irritation of the pharynx and the vocal cords. A mixed picture of both causes can be present.

The irritation of the vagus nerve may also lead to a convulsive contraction of the coronary arteries (coronary spasm). The resulting heart pain is very similar to a heart attack pain (angina pectoris), so that the distinction to a heart disease can cause difficulties.

In very rare cases of heartburn, it may come to the reflux of bile acids or secretions of the pancreas (lyes) into the esophagus. Alkali burns are greater in their potential for damage than acid burns, as they spread more easily in the tissue. Treacherously, this can result in much greater tissue damage despite lower symptoms compared to acid burns.

In addition, it can come to a narrowing of the esophagus due to heartburn, as the mucous membrane of the esophagus is irritated by gastric acid and it can lead to an inflammation of those.

Diagnosing heartburn

A suspected diagnosis of heartburn can be quickly made on the basis of the symptom complex described above. In case of unclear cases or to determine the extent of the damage, additional diagnostics are necessary:

Sonography (ultrasound):
It is a simple and quick to carry out examination procedure for the evaluation of single episodes of reflux, gastric emptying and hiatal hernia. The sonography is radiation-free, so no side effects are to be expected and the ultrasound examination can be repeated as often as desired.

Long-term esophageal pH monitoring:
Heartburn diagnosis is measured using a pH electrode for acid measurement, which is placed in the esophagus via the nose for 24 hours. The electrode detects the ph value in the stomach near the esophagus every 4-6 seconds. A portable recorder that creates a long-term profile records how many times reflux events occur and how strong the acid is. Measurements of ph values ​​below 4 are likely to have a reflux event. About the extent of mucosal damage already made, this investigation method makes no statement.

X-ray Breischluck (upper gastrointestinal passage):
To diagnose complications such as scars and narrowing ( stenosis ), the X-ray Breisch Luck is a non-invasive imaging technique. In cases of stenosis (bottlenecks) can be seen hourglass-like narrowing of the esophagus in the radiograph. In addition, statements about transport disorders of the esophagus and about the gastric emptying are possible.

Endoscopy (esophagogastroduodenoscopy):
The "mirroring" (endoscopy) of the esophagus, stomach and upper small intestine portions is the drug of choice for the direct diagnosis and classification of mucosal damage in the correct diagnosis of heartburn. A tube camera (endoscope) is used to transfer images to a monitor. During endoscopy, tissue samples (biopsy) can also be taken from suspicious mucous membrane areas. The examination of the tissue under the microscope (histological findings) is more informative than the (macroscopic) findings recorded with the naked eye. Only in the histological examination the proof of a tissue transformation ( metaplasia ) or the proof and the type of a tumor can be furnished. In addition, a therapy can take place, for example, the staunching of bleeding mucous ulcers.

  • endoscopy
  • Pain Sternum.

Anatomy of the esophagus

  1. Trachea
  2. Right lung (lung)
  3. Diaphragm (diaphragm)
  4. throat
  5. Esophagus
  6. left lung
  7. stomach

Classification of mucosal damage according to Savary and Miller

Grade I: Circumscribed, single, superficial mucosal damage (erosions)

Grade II: Longitudinal Connected Mucosal Damage (Longitudinal Confluent Erosion)

Grade III: Circular mucosal damage (circular erosions)

Grade IV: ulcer (ulcer), stenosis (narrow), brachyesophagus (see above)

Bernstein test:
If, despite pathological symptoms, an inconspicuous endoscopic finding does not confirm the suspected diagnosis of reflux disease (10-15% of patients), then the Bernstein test can help to ensure the diagnosis. In this test, acidity is simulated on the esophageal mucosa. A little corrosive acid is trickled onto the esophageal mucosa from the outside via a probe. If this causes symptoms that are the same as those of the underlying disease, reflux disease (reflux oesophagitis) is very likely. In these cases there is a chemical hypersensitivity of the esophagus.

Esophageal manometry:
In rare cases, the function of the lower sphincter must be checked by means of the pull-pressure measurement. In this case, a thin tube (catheter) through the nose is first placed in the stomach and then slowly withdrawn towards the mouth, whereby the patient regularly has to be swallowed some water. Upon retraction, the internal esophageal pressure is permanently measured at the end of the catheter. A computer graphic shows the pressure conditions in the course of the esophagus. Dysfunction of the feed tube can be diagnosed this way. Reflux disease is therefore only indirectly detected by evidence of esophageal dysfunction.

Heartburn, Acid Reflux, GERD-Mayo Clinic (December 2019).


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