Is It “Just” Heartburn or Something More Serious?

By John Dowd, DO, Concord Gastroenterology Associates

10/28/2021

When is the occasional bout of heartburn not “just heartburn”? If you are experiencing heartburn on a daily basis, it is likely time to be evaluated for gastroesophageal reflux disease (GERD). Persistent, untreated GERD may lead to more serious conditions. Sometimes, it can be a precursor to other diseases, including cancer.

John Dowd, DO, a gastroenterologist with Concord Gastroenterology Associates, provides insight into what GERD is, what it is not, and how you can address symptoms in a safe, healthy way.

Reflux Signs & Symptoms

The stomach makes a very powerful acid. This acid works to sterilize the food you eat. When acid enters the esophagus, the defense mechanisms other parts of the digestive tract possess are lacking — which causes a burning sensation.

Beyond burning, reflux can cause damage to the esophagus in the form of ulcerations or erosions, especially if it occurs on a chronic basis. “Heartburn is really a symptom of acid reflux,” states Dr. Dowd. Other symptoms that can occur as a result of reflux include cough, hoarseness, throat pain, throat clearing, chest pain, nausea, and even vomiting.

And it can be very painful — even mistaken for a heart attack. It is not infrequent that Dr. Dowd’s colleagues in the emergency department see patients for GERD-related heart attack symptoms. The first step in these cases is to assess the patient for a cardiac issue and then treat them accordingly.

In some cases, the opposite occurs. Dr. Dowd recounts situations where patients came to him for a GERD evaluation and he ultimately sent them to a cardiologist. “One patient said, ‘Every time I am going up this hill, walking my dog, I get this bad pain in my chest. And my doctor sent me here for an evaluation of reflux.’ I picked up the phone and got him an appointment with a cardiologist.”

Mild, Moderate, or Severe?

Per Dr. Dowd, “Everybody has reflux. What defines whether it is a disease or not is how long the acid is in contact with the esophagus. We do specialized testing to evaluate reflux. When we see very high quantities, for very long periods of time, that’s pathologic. That designates a disease state. When it is minimal and is cleared rapidly, people usually do not have a problem.”

Reflux is considered mild if it occurs no more than twice a week. Take this GERD risk quiz to learn more about your GERD symptoms and risks.

When Is Reflux Severe?

When individuals report suffering with symptoms more than twice a week, or if any of the below symptoms are associated with reflux, the condition requires further evaluation by a gastroenterologist.

• Difficulty swallowing
• Painful swallowing
• Evidence of gastrointestinal bleeding
• Unexplained weight loss
• Coughing at night

Typically, patients will undergo an endoscopy to determine if there is damage to the esophagus — and to what extent. According to Dr. Dowd, only about a third of patients who experience reflux have evidence of damage.

“When we identify patients who have more severe symptoms or longstanding duration of symptoms, that rate of damage goes up significantly. The rate of abnormalities seen in endoscopy is much higher. So, those patients are the ones who really need a gastroenterologist.”

Treatment Options

Patients with mild GERD symptoms are often advised to try over-the-counter antacids called H-2 blockers (e.g. Tagamet, Axid). Patients who require the next level up in therapy are given a class of drug called proton pump inhibitors (PPIs). However, these medications should not be used for long periods of time.

Ultimately, Dr. Dowd urges individuals who are suffering with symptoms to get checked out — especially those with significant indications. “Anyone who has difficulty swallowing, painful swallowing, weight loss, loss of appetite, or signs or symptoms of gastrointestinal bleeding should be evaluated by a gastroenterologist.”

Listen to the Podcast

Dr. John Dowd discusses heartburn and when you should seek help from a doctor.

Visit our podcast page to find the latest episode or subscribe to the Health Works Here Podcast on Apple Podcasts, Spotify, Google Podcasts, and wherever podcasts can be heard.

Request an Appointment

Dr. John Dowd is a board-certified gastroenterologist. For more information, or to make an appointment, fill out the form on this page or call (978) 287-3835.

Related Content

• Take this GERD risk quiz to learn more about your GERD symptoms and risks
• Learn About Concord Gastroenterology Associates
• When to See a Doctor About Common Digestive Disorders

Treating Severe, Chronic Heartburn

Written by Amanda Gardner

Medically Reviewed by Jennifer Robinson, MD on April 16, 2022

• Watch What You Eat, Drink, and Do
• Treatments
• Surgery
• Endoscopic Treatment

If you feel uncomfortable in the middle of your chest every time you finish a meal, you may have chronic heartburn. This is when the acid from your stomach leaks up into the tender tissue of your esophagus (food pipe), causing pain and burning. You need treatment. If you don’t control your heartburn, it could damage your esophagus and even lead to cancer. There are some simple ways to make sure this doesn’t happen to you.

Making some changes to your lifestyle can go a long way toward easing the pain of heartburn.

Say goodbye to cigarettes. Smoking causes your body to make less saliva, a liquid that helps stamp out stomach acid. That can lead to burning in your esophagus. Tobacco may also cause your stomach to make more acid and relax the muscles at the lower end of your esophagus that can shut down the opening between the stomach and the esophagus. Chewing gum and sucking on lozenges can help you make more saliva.

Avoid trigger foods. For many people, these are spicy and high-fat foods, chocolate, peppermint and other mints, coffee, citrus fruits or juices, tomato products, carbonated drinks, and onions.

Don’t lie down after you eat. If you need an afternoon siesta, snooze upright (or almost upright) in a chair. Eat dinner at least 2-3 hours before you go to bed, and don’t make the last meal of the day your biggest one.

Raise the head of your bed. If the top of your bed is higher than the bottom, it’s harder for the acid to travel up. You can do this with a block of wood under the bed or a foam wedge under the mattress.

Be careful what medications you use. Aspirin, ibuprofen, and other medications, such as some sedatives and blood pressure drugs, can trigger heartburn. Ask your doctor if any of your medications might be causing your symptoms. There may be something else you can take.

Eat several small meals during the day. Your stomach produces acid based on how much food you eat. Less food means less acid. Don’t overload your stomach.

Limit alcohol. Alcohol can relax the muscles around the lower end of your esophagus, making it easier for acid to bubble up.

Stay slim. One study found that overweight people who lost weight were more likely to have their heartburn go away. Another reason to lose weight: You’ll respond better to heartburn medications.

Wear loose clothing. Tight clothing, including belts, can cause stomach contents to push upward.

Relax. Stress causes stomach acid to bubble up.

If you have chronic severe heartburn, you may need medications. Both over-the-counter and prescription drugs are available.

Antacids are usually the first type of drugs doctors recommend for chronic heartburn. You can get them over the counter. They work by stamping out the acid in your stomach. Antacids work right away, but they don’t last long. They also don’t help a damaged esophagus heal. Look for products that have both magnesium and aluminum salts. They’re less likely to cause diarrhea and constipation.

h3 blockers are available over the counter and by prescription. Although they don’t kick in as quickly as antacids, they last longer. They work by slowing down how much acid your stomach makes. They include cimetidine (Tagamet) and famotidine (Pepcid, Zantac 360). Ranitidine was removed from the market in 2020 after it was found to contain a cancer causing agent.

Proton pump inhibitors (PPIs) also block acid production. You can get them over the counter or with a prescription.

You may need more than one type of medication. Talk to your doctor about the best treatment plan for you. Make sure you’re aware of the side effects of all the medication you take.

The most common surgery for extreme heartburn is fundoplication. The surgeon wraps the top of your stomach around the bottom of your esophagus to strengthen it and help keep the acid where it belongs. This often can be done laparoscopically — it involves only a small cut and typically lets you go home in 3 days or less.

The goal of this treatment is the same as surgery. But instead, your doctor puts a thin tube called an endoscope down your throat and into your esophagus. They then use stitches or heat to create scar tissue to tighten the sphincter and stop stomach acid from leaking.

Newer treatments involve using implants (such as the LINX system, which involves titanium beads linked together to form a retaining wall) to keep acid from seeping out of the stomach.

Transoral Incisionless Fundoplication (TIF) is the newest therapy performed with an endoscope, which seems to have good short-term results.  

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Morning heartburn ⛑ symptoms of morning heartburn

If the morning starts not with coffee, but with an unpleasant burning pain in the stomach or esophagus, this may indicate diseases of the gastrointestinal tract (GIT). Morning heartburn can occur after a heavy dinner, a party with excessive alcohol consumption. But regular bouts of heartburn in the morning may indicate health problems and require examination.

What is heartburn

Heartburn is a very broad concept. These are sensations of discomfort, which can manifest themselves in different ways for everyone. People describe it as “burning”, “irritation”, some experience pain and nausea, they say that it bakes in the throat.

Medically, heartburn is not considered a disease, but the condition may indicate the presence of other disorders. Unpleasant sensations usually occur after eating, but there is a special condition – heartburn in the morning. A person wakes up already with discomfort in the stomach and a “burning” throat.

The most common cause of heartburn is reflux, which is the reflux of stomach contents back into the esophagus. The mucous membrane of the esophagus is irritated by the acids of the gastric juice and heartburn occurs. Reflux disease in medical terminology is called GERD (gastroesophageal reflux disease). In addition to it, heartburn is caused by other diseases of the gastrointestinal tract: ulcers, gastritis, esophagitis, increased acidity of the stomach. With these pathologies, heartburn often occurs on an empty stomach and morning burning in the esophagus.

Heartburn in the morning: causes

Food enters the stomach through a kind of gate – the lower esophageal sphincter. These are multiple pleats that open and close like a flap. Gastric juice contains hydrochloric acid, ammonia, nitrogen-containing substances and digestive enzymes – these substances are responsible for the digestion of food. If the sphincter is relaxed, food is thrown back from the stomach along with acids that irritate the esophageal mucosa, from which it becomes inflamed, bakes and hurts.

Active production of gastric juice occurs during meals, as well as when the body wakes up, that is, in the morning.

If you skip breakfast, the stomach begins to “digest itself”, acids irritate its walls and heartburn sets in. Another point is a cup of morning coffee or some chocolate on an empty stomach. These are aggressor products, they activate the production of gastric juice and in themselves irritate the mucous membrane. These are common causes of heartburn in the morning. Gastrointestinal diseases increase acid secretion and relax the esophageal sphincter.

An unbalanced diet and disturbed daily routine contribute to the development of morning heartburn. Dinner after 19.00, and even more so at 22.00, is not a good solution. If you eat dinner before bed, the pressure on the sphincter in the supine position will be increased, and food will begin to be digested more slowly. This leads to reflux and heartburn. Some simply do not notice it at night, and in the morning it makes itself felt.

Signs of morning heartburn

Signs of heartburn in the morning are hard not to feel: a person gets up already with an unpleasant sensation in the stomach, often heartburn is intertwined with a feeling of hunger, but the discomfort disappears after a hearty breakfast.

Heartburn itself is a symptom in the morning. When it is supplemented by other conditions, this may indicate diseases of the internal organs:

• nausea and pain in the upper abdomen are signs of peptic ulcer;
• bloating appears with gastritis;
• increased acidity of gastric juice accompanies GERD;
• cough and perspiration, together with heartburn, may be due to diseases of the bronchi and lungs;
• Increasing burning behind the sternum is a common symptom of a heart attack.

Heartburn in the morning can occur in pregnant women.

Some symptoms are classified as “alarming” [1]:

• sudden weight loss;
• blood in stool;
• heartburn for more than 3 weeks;
• rapid feeling of fullness of the stomach.

If these symptoms occur, seek specialist advice.

Diagnosis

Diagnosis of morning heartburn includes examinations aimed at identifying the underlying disease:

• analysis of gastric acidity;
• FGDS (fibrogastroduodenoscopy) – examination of the stomach with a probe or endoscope;
• laboratory tests – biochemical blood test, fecal analysis, determination of Helicobacter pylori;
• pH-metry – monitoring of daily changes in stomach acidity;
• endoscopy with contrast for difficult diagnosis of the disease [2];
• esophagomanometry – measurement of pressure inside the esophagus.

Women with heartburn may be advised to take a pregnancy test in the morning (unless, of course, there are other signs of pregnancy).

Treatment

To quickly eliminate heartburn on an empty stomach, you need to have breakfast on time. Food should not be dense, but satisfying and nutritious. Heavy fats and high-calorie chocolate are best replaced with light cereals and fruits. In diseases of the gastrointestinal tract, it is recommended to eat oatmeal in the water, because it has a beneficial effect on the gastric mucosa.

Heartburn in the morning can be removed with antacids, which are salt-based preparations that neutralize the action of hydrochloric acid and increase the pH of gastric juice. For example, calcium carbonate and magnesium carbonate act within a few minutes [3]. Rennie ^® is a preparation containing both of these components. It does not need to be taken with water, these are chewable tablets with a pleasant mint or orange flavor. Rennie ^® – tablets that begin to eliminate heartburn within 2 minutes. It is a drug with a favorable safety profile, even for pregnancy heartburn.

Antacids are recommended by the World Organization of Gastroenterology in the treatment of reflux disease and to eliminate heartburn [4]. But before taking it, you need to read the instructions and visit a doctor.

[1] UMHS GERD Guideline, September, 2013. Guidelines for Clinical Care Ambulatory, University of Michigan Medical.

[2] UNIFICATION OF CLINICAL PROTOCOL OF PRIMARY, SECONDARY (specialized) MEDICAL CARE. GASTROESOPHAGEAL REFLUX ILLNESS. Decree of the Ministry of Health Protection of Ukraine dated 31 July 2013 No. 943.

[3] Mironycheva TS. “Comparative evaluation of the neutralization rate and buffering time of magnesium hydroxoaluminate” Science and Modernity, no. 6-2, 2010, pp. 289-293.

[4] Global guidelines of the World Gastroenterological Organization. GERD. Global perspective on gastroesophageal reflux disease. 2015

Why does heartburn appear and how to get rid of it?

The orchestra played its last blues, and the guests began to disperse little by little. Our hero slowly wandered along the street lit by lonely lanterns. It was already well after midnight, it would be time to go home. But sleep could not keep up with him, and the reason for this was not at all high spirits, woven from incendiary rhythms, jokes of friends and alluring aromas of a richly laid festive table. An unpleasant feeling grew and strengthened inside, it flared up and soon blazed in full, rising higher and higher, until it got stuck in a sour-bitter burning lump in the throat. Perhaps, almost everyone easily recognized this feeling as heartburn. It is this unexpected guest who so often comes to us when the music subsides and the lights of the celebration go out.

We sacredly honor our culinary traditions, and therefore any holiday, be it a birthday or a meeting of friends who have not seen each other for several years, is always an occasion for a magnificent meal with a table simply bursting with various dishes. Such an abundance can not leave anyone indifferent, besides, you can’t offend the hostess – we persuade ourselves, alternating Caesar salad with baked pork, generously seasoned with mustard and horseradish, smoked salmon, flavoring all this splendor with a piece of goose stuffed with apples, and to top it off ” delighting your stomach with the classic Sacher chocolate cake. All this – tasty, high-calorie, fried, salty and spicy foods, flour products, all kinds of drinks – is the cause of increased secretion of gastric juice, an excess of which provokes gastroesophageal reflux – a pathological reflux of acidic stomach contents into the esophagus. And as a result, heartburn will not take long.

Perhaps there are few lucky people who do not know this unpleasant burning sensation behind the sternum, which can poison life at the most inopportune moment. Indeed, according to statistics, 20–40% of the adult population of the planet is familiar with heartburn (Zvyagintseva T.D., Shargoroa I. I., 2007). And according to the results of a large-scale study conducted in the USA, 44% of adults experience heartburn at least once a month, 20% at least once a week, and 7% of respondents suffer from heartburn every day (Lapina T.L., 2003). And among our compatriots, this condition is noted even more often – in our country, about 60% of men and 64% of women suffer from heartburn. At the same time, heartburn can ruin not only a wonderful evening, but also negatively affect the quality of life in general. Thus, according to surveys, patients with symptoms of heartburn rate their quality of life lower than patients with untreated angina pectoris or arterial hypertension. Unfortunately, despite the extremely high prevalence, heartburn is often ignored by patients and only 5-7% of them seek medical help (Zvyagintseva T.D., Shargoroa I.I., 2007). Therefore, the question naturally arises: how to normalize the work of the gastrointestinal tract and what to do if heartburn still begins to overcome?

Who is starting this fire?

First, let’s figure out what lies behind this unpleasant burning sensation and, no less important, what contributes to its occurrence. Heartburn is a consequence of reflux and prolonged contact of acidic gastric contents (pH<4) with the esophageal mucosa. At the same time, hydrogen ions penetrate into the intercellular space of the esophageal mucosa and irritate the nerve endings, causing excessive nerve impulses, resulting in an unpleasant burning sensation. There can be many reasons for heartburn, and this is not only the excessive consumption of fatty foods, chocolate, carbonated drinks, flour products, fried foods, hot spices, but also foods containing caffeine (coffee, cola, tea), taking certain medications, smoking , flatulence, alcohol, hurried, fast, plentiful food intake with air swallowing (aerophagia), horizontal position of the body after eating, and much more.

Heartburn Ambulance

Given the negative impact of heartburn on the quality of life, it is very important to stop it promptly. To combat this unpleasant sensation, antacids have been widely used for more than 100 years – substances that can neutralize hydrochloric acid, which is part of gastric juice. Among the substances that neutralize the acidic environment of gastric juice, one of the most commonly used are sodium bicarbonate and sodium carbonate.

In this context, the EHO dietary supplement, which includes sodium bicarbonate, citric acid and sodium carbonate, seems relevant. Thanks to these components, ENO is used to improve the digestion process, as well as for stomach disorders, which are manifested by heartburn, nausea and a feeling of heaviness.

What happens when you pour EHO powder into a glass of water? Sodium bicarbonate and citric acid, interacting with water, turn into sodium citrate, while carbon dioxide is released. As a result, a buffer solution is formed, the acidity of which is lower than the contents of the stomach, as a result of which its acidity decreases, eliminating the cause of heartburn.

The Science of Heartburn

The substances that make up the EHO product have long been used for digestive disorders manifested by heartburn, and their properties have already been studied quite well in the course of various studies. Thus, a study was conducted to determine the time required to neutralize the acidic environment of gastric juice with a combination of sodium bicarbonate + citric acid compared to placebo in healthy volunteers (Johnson S.M., Suralik J., 2009). Previous studies have shown that an antacid taken alone causes a rapid and significant increase in gastric pH. Sodium citrate, formed by the interaction of sodium bicarbonate and citric acid, is a fast-acting acid neutralizer that, in appropriate doses, is able to increase the pH of the stomach within a few minutes.

This study included 29 healthy volunteers aged 18-55, of which 24 completed the study. The study participants were randomized into 2 groups of 12 people each: participants in the 1st group received a combination of sodium bicarbonate + citric acid, the 2nd – plain water (placebo). According to the results of the study, the use of a combination of sodium bicarbonate + citric acid led to a statistically significant change in pH already 6 seconds after administration. Thus, the combination of sodium bicarbonate + citric acid quickly reduces (starting from the 6th second) the increased acidity of the gastric contents, which is the cause of heartburn. At the same time, the average time required to reach a pH ≥3.5 was 40.5 seconds for sodium bicarbonate + citric acid. The combination of sodium bicarbonate + citric acid was statistically significantly better than placebo in achieving clinically meaningful gastric acid neutralization. At the same time, the combination of sodium bicarbonate + citric acid was well tolerated.

Clinical studies have shown that sodium bicarbonate and citric acid, the components of EHO, are more effective than placebo, starting to neutralize gastric acid as early as 6 seconds after ingestion and reaching a pH ≥3.5 after only 40.5 seconds.

It should also be noted that the properties of this combination of active substances were studied in the course of a comparative clinical study conducted in the EU – Prague (Czech Republic) (Kvasnicka F.