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Heartburn, also known as pyrosis, cardialgia or acid indigestion, is a burning sensation in the central chest or upper central abdomen. Heartburn is usually due to regurgitation of gastric acid (gastric reflux) into the esophagus. It is the major symptom of gastroesophageal reflux disease (GERD).

Other common descriptors for heartburn (besides burning) are belching, nausea, squeezing, stabbing, or a sensation of pressure on the chest. The pain often rises in the chest (directly behind the breastbone) and may radiate to the neck, throat, or angle of the arm. Because the chest houses other important organs besides the esophagus (including the heart and lungs), it is important to remember that not all symptoms related to heartburn are esophageal in nature.

The cause will vary depending on one's family and medical history, genetics, if a woman is pregnant or lactating, and age. As a result, the diagnosis will vary depending on the suspected organ and the inciting disease process. Work-up will vary depending on the clinical suspicion of the provider seeing the patient, but generally includes endoscopy and a trial of antacids to assess for relief.

Definition

The term indigestion includes heartburn along with a number of other symptoms. Indigestion is sometimes defined as a combination of epigastric pain and heartburn. Heartburn is commonly used interchangeably with gastroesophageal reflux disease (GERD) rather than just to describe a symptom of burning in one's chest.

Differential diagnosis

Heartburn-like symptoms and/or lower chest or upper abdomen may be indicative of much more sinister and/or deadly disease. Of greatest concern is to confuse heartburn (generally related to the esophagus) with a heart attack as these organs share a common nerve supply. Numerous abdominal and thoracic organs are present in that area.

Heart

The most common symptom for a heart attack is chest pain. However, as many as 30% of chest pain patients undergoing cardiac catheterization have findings that do not account for their chest discomfort. These are often defined as having "atypical chest pain" or chest pain of undetermined origin. Women experiencing heart attacks may also deny classic signs and symptoms and instead complain of GI symptoms instead. One article estimates that ischemic heart disease may appear to be GERD in 0.6% of people.

Esophagus

• GERD (most common cause of heartburn) occurs when acid refluxes from the stomach and inflames the esophagus.
• Esophageal spasms typically occur after eating or drinking and may be combined with difficulty swallowing.
• Esophageal strictures
• Esophageal cancers

Esophagitis

• GERD
• Eosinophilic esophagitis - a disease commonly associated with other atopic diseases such as asthma, food allergies, seasonal allergies, and atopic skin disease
• Mallory-Weis tears - tears of the superficial mucosa of the esophagus that are subsequently exposed to gastric acid commonly due to vomiting and/or retching
• Chemical esophagitis - related to the intake of caustic substances, excessive amounts of hot liquids, alcohol, or tobacco smoke

Stomach

• Peptic ulcer disease - can be secondary to H. Pylori infection or heavy NSAID use that weakens stomach mucosal layer
• Stomach cancer

Gallbladder

• Gallstones

Pancreas

• Pancreatitis - can be autoimmune, due to a gallstone obstructing the lumen, related to alcohol consumption.

Pregnancy

Heartburn is common during pregnancy. This can be a result of hormonal changes relaxing the esophageal sphincter and increasing intrabdominal pressure of the growing uterus.

Unknown Origin

Functional heartburn is heartburn of unknown cause. It is associated with other functional gastrointestinal disorders 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 one of elimination, based upon the Rome III criteria: 1) burning retrosternal discomfort; 2) elimination of heart attack and GERD as the cause; and 3) no esophageal motility disorders. It was found to be present in 22.3% of Canadians in one survey.

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. In young persons (typically <40 years) who present with heartburn symptoms consistent with GERD (onset after eating, when laying down, when pregnant), a physician may begin a course of PPIs to assess clinical improvement before additional testing is undergone. Resolution or improvement of symptoms on this course may result in a diagnosis of GERD.

Other tests or symptoms suggesting acid reflux is causing heartburn include:

• Onset of symptoms after eating or drinking, at night, and/or with pregnancy, and improvement with PPIs
• Endoscopy looking for erosive changes of the esophagus consistent with prolonged acid exposure (eg - Barrett's esophagus)
• Upper GI series looking for the presence of acid reflux

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.

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.

Mechanical

Manometry: in this test, a pressure sensor (manometer) is passed via the mouth into the esophagus and measures the pressure of the lower oesophageal sphincter directly.

Endoscopy: the oesophageal 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 oesophagus 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 oesophagus is removed. It is then studied to check for inflammation, cancer, or other problems.

Treatment

Antacids such as calcium carbonate are often taken to treat the immediate problem, with further treatments depending 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.

Epidemiology

About 42% of the United States population has had heartburn at some point.

References

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• Symptoms and signs: Digestive system and abdomen