We’ve all experienced heartburn at some point in our lives, maybe after a heavy meal or an alcohol binge. Understandably, it would concern you if you experience a burning feeling in your chest, and you may wonder if it is your run-of-the-mill heartburn or indicative of a more worrisome disease.
Let Dr Tan Chi Chiu walk you through all there is to know about heartburn, gastroesophageal reflux disease and how to best manage it.
What is heartburn? What is the difference between heartburn, acid reflux, and GERD?
What many people don’t know is that heartburn is actually a symptom and not a disease. It is a classic symptom of Gastroesophageal Reflux Disease (GERD). GERD is a condition in which reflux of stomach contents causes problematic symptoms and/or complications. The two main symptoms of GERD are heartburn and acid reflux or regurgitation into the throat and mouth. 
Those with GERD may also experience the following symptoms:
- Chronic sore throat or chronic cough
- Difficulty or pain when swallowing
- Water brash — Excessive saliva that mixes with acid that refluxed into the mouth
- Sour taste in the mouth
- Halitosis — Chronic bad breath
- Gingivitis — Inflammation of the gums
- Tooth enamel erosion
Although the term “heartburn” is often used to describe the burning sensation in the chest area, some may use other descriptions such as:
- Discomfort in the chest
- Pressure on the chest
- Heaviness of the chest
- Pain in the chest
Note that discomfort in the chest may not always be heartburn. It is important to seek a doctor to rule out other underlying reasons such as a heart attack due to coronary artery disease, especially if you are in an older age group, or have a family history of heart disease.
In severe cases, heartburn may last anywhere from a few minutes to hours, or even over 24 hours. For minor cases, some may feel better after drinking some water or swallowing a simple over-the-counter antacid. If it is severe and happens at night, it may interrupt sleep. In some patients, heartburn is particularly bothersome at night, because in the supine position, stomach liquid content more easily passes through into the oesophagus.
The other classic symptom of GERD — acid reflux — is the regurgitation of acid from the stomach into the throat or mouth region. Again, it is the symptom and not the disease.
When acid reflux occurs, the acid and contents of the stomach gush into the throat, causing a burning sensation and a bitter, sour taste in the mouth.
What causes heartburn?
GERD happens because the muscular valve at the gastroesophageal junction (GEJ) is too weak and causes acid to back up into the oesophagus. This often causes inflammation of the oesophageal lining, especially if the lining is exceptionally sensitive, and this is why acid reflux results in heartburn.
Those who are obese are more likely to suffer from acid reflux and heartburn due to the pressure that the fat in the abdominal cavity around the organs, as well as the fat in the abdominal body wall exerted on the stomach.
Pregnant women also experience heartburn easily due to two reasons — the pressure exerted by the baby and progesterone levels. 
- The pressure exerted by the baby:
The baby is a large mass in the abdomen that pushes up against the stomach, making it more likely for acid to rise up due to pressure.
- Progesterone levels:
Especially towards the latter part of pregnancy, progesterone levels rise as the body prepares for childbirth. This increase in progesterone causes a widespread effect throughout the body — the relaxation of all the smooth muscles. This is necessary so that the pelvic muscles are relaxed for the child to be born.
However, this also means that the ring of muscle between the oesophagus and the stomach at the gastro-oesophageal junction also becomes more relaxed, thereby allowing more acid reflux.
Both of the above factors combined make pregnant women more vulnerable to acid reflux and hence, heartburn.
What’s the difference between heartburn and a heart attack?
For heartburn, the discomfort is due to the regurgitation of stomach acid and digestive enzymes that causes heartburn or discomfort in a vertical line behind the breast bone and sometimes up into the throat. Acid reflux or regurgitation can lead to a sour or bitter fluid being felt in the throat or mouth.
A heart attack is a serious condition which can be life-threatening. It is when the arteries supplying the heart are blocked and part of the heart muscle starts to die. Consequences include heart failure or heart rhythm abnormalities which could be fatal. In a heart attack, the discomfort feels more like a great pressure atop your lower chest over a wider area. It is often described as a stone sitting on your chest. Oftentimes, the chest pain moves up the left side of the neck and travels down the left arm too. There may also be nausea, dizziness, or perspiration accompanying a heart attack.
What complications could arise from untreated heartburn?
GERD doesn’t necessarily always cause complications such as in cases of non-erosive reflux disease (NERD).
On the other hand, there might be some inflammatory damage to the oesophagus, leading to mucosal breaks or erosions. In severe cases, the acid may cause deep erosions and ulcers, or even bleeding when the blood vessels rupture, which results in vomiting of blood.
If the oesophagus is scarred, it may cause stricture whereby the oesophagus becomes narrow. This may cause difficulties in swallowing, called dysphagia and even pain when swallowing, called odynophagia.
In some patients, chronic reflux oesophagitis leads to a condition called Barrett’s Oesophagus, whereby the type of cells (columnar cells) normally seen in the stomach spreads upwards above the gastro-oesophageal junction into the tubular oesophagus. These cells can be unstable and can present a future risk of cancer of the oesophagus. Fortunately, Barrett’s Oesophagus is less common in Asia than in the west, but this complication is still something that we would be looking out for. Should Barrett’s Oesophagus be identified, surveillance may be offered, by interval gastroscopies with biopsies to check that the cells do not turn “dysplastic”, that is, start to change towards cancer. 
When should I see a doctor for heartburn?
There are 2 circumstances under which you should seek help from a doctor for heartburn.
The first would be if it is severe and alarming, and the other would be if it is troublesome, repetitive or persistent.
If it is mild and goes away after a while, it may just be a small blip and no cause for concern. However, if it lasts many hours or throughout the night, or there is significant pain in the chest, you are advised to seek medical help as soon as possible.
Read also: How to cure heartburn?
What kind of tests are carried out when diagnosing GERD?
We should first assume that symptoms are typical of GERD and that there is no suspicion of other serious diseases such a heart attack. If there is doubt, such as symptoms that overlap with those of heart attack, an older patient with risk factors such hypertension or diabetes, or with a family history of heart disease, then tests should be done to exclude heart disease. Such tests could include an electrocardiogram (ECG), blood tests, 2D echocardiography, CT coronary angiography or direct angiography according to the circumstances. The more sophisticated tests would normally be done by a cardiologist. 
In patients with significant symptoms, the most common diagnostic examination is a gastroscopy. A gastroscopy or upper gastrointestinal endoscopy is a procedure where a thin, flexible tube called the gastroscope is inserted into the upper gastrointestinal tract to examine the oesophagus, stomach and first part of the small intestine.
The gastroscope is a thin, flexible tube fitted with a camera head and light guides. Designed with patient comfort in mind, this gentle device moves smoothly through your gastrointestinal tract to provide a clear picture of the insides of your oesophagus, stomach and duodenum. 
Contrary to popular belief, a gastroscopy nowadays is virtually painless and isn’t at all uncomfortable! The tube is very thin and flexible, and a combination of local anaesthetic — to numb your throat — and a mild intravenous sedative will be applied before you begin the gastroscopy.
Because the sedative gets you into a comfortable, dream-like state, some of our patients don’t even realise they’ve had the procedure when they wake up!
Sometimes, if we find any suspicious features, we may take tissue samples of the oesophageal, stomach or duodenal lining during the gastroscopy for the pathologist to study under the microscope.
Despite symptoms, a fair proportion of patients do not exhibit signs of severe inflammation such as erosions. Indeed there may be no physical signs seen on gastroscopy. Such patients may be said to have Non Erosive Reflux Disease (NERD) and we may just treat the symptoms empirically.
Sometimes, more sophisticated tests are needed to evaluate GERD, especially in patients who have atypical symptoms or whose symptoms do not respond to conventional treatment. Such tests could include 24 hour pH monitoring, manometry or pH-impedance monitoring (to detect fluid shifts inside the oesophagus)
What can I expect during my first consultation? How can I prepare?
We would first want to take a detailed history of your symptoms and ask questions to ascertain whether there are other possibilities besides GERD.
If you would like to prepare for this, try recalling your symptoms and jot them down so you don’t forget, and think about how to best describe them to us. If you’ve previously undergone certain tests and examinations with other doctors, do compile those results and bring them to us as it would help your doctor better understand your condition.
It may also help to recall certain foods you have eaten that you could attribute to the symptoms, such as heavy alcohol consumption. This may also help us determine the cause of your heartburn.
Next up would be a physical examination. Usually, there are no obvious, external signs for GERD. However, there could be signs that something is in the upper abdomen when there is a tenderness in the epigastrium on examination. The examination could uncover signs of other significant diseases if an enlarged liver is felt, or the gallbladder area under the ribs on the right side is tender.
Then, we would sit with you and go through the possible diagnoses in what is known as differential diagnosis, where we rank the possibilities according to their likelihood based on the symptoms and examination.
Depending on the situation, we may offer to carry out other, more detailed tests which will lead to a more definitive diagnosis.
How do you treat heartburn?
Assuming GERD is the diagnosis, for milder symptoms, we would want to reduce the amount of acid produced, or neutralise it using medication. These can range from simple antacids to H2 receptor blockers, or even the stronger proton pump inhibitors. In more severe cases, the most powerful acid suppression medicine, potassium channel blockers, may be used.
If these are sufficient to control the symptoms, we would want to monitor for recurrence.
Sometimes, prokinetics are used. These are medicines used to help pump the contents of the stomach into the intestines to clear them more quickly.
A combination of methods to reduce acid production and clear stomach contents can reduce heartburn. Meanwhile, having reduced the exposure to acid and digestive enzymes, inflammation in the oesophagus usually heals through the body’s own repair mechanisms.
Only in rare instances will surgery be necessary to treat gastro-oesophageal reflux disease. Should maximum medical treatment still not be sufficient to alleviate symptoms or deal with complications, and provided no other causes of treatment failure are found, surgery to tighten the muscular ring at the gastro-oesophageal junction may be offered.
When will I recover from heartburn?
Recovery from heartburn is typically relatively fast. Symptom relief takes only about 24 to 48 hours, while complete healing of any erosions may take 8 weeks to 3 months depending on how severe these are.
Depending on the severity of damage in the oesophagus, repeated gastroscopies may be required to ensure that healing is satisfactory. If there has been narrowing of the oesophagus due to scarring, sometimes stretching of the narrowed segment is done by using dilators during gastroscopy.
What are the side effects of treatment for heartburn?
The side effect profile of the various types of heartburn medications is generally pretty good. There should be little to no side effects for short courses of medication.
Long term side effects are also few and far between. The small risk of side effects can be justified by its benefits. Some websites may list alarming side effects, but we have never seen a patient with side effects significant enough to cause problems. Do be sure to read authoritative articles rather than alarming or sensational ones.
There can be random allergies to any new medicines. This is uncommon and these are often mild, occurring in the form of rashes that will subside once you stop the medication.
Some proton pump inhibitors can rarely cause headaches. Once again, this does not pose a significant danger and will go away once the medicine is stopped. Other drugs in the same class may not cause the same side effect and there are many alternatives.
What are the alternative medications or home remedies for heartburn?
Over-the-counter medications such as antacids are simple, tried-and-true medications that are recommended. On the other end of the spectrum, potassium channel blockers are extremely powerful acid inhibitors and are useful for the most severe cases.
Home remedies such as apple cider vinegar with or without manuka honey have no clear evidence of being effective, though a placebo effect may be at play.
Another common home remedy that some people believe in is drinking milk. However, it is important to note that milk is not an antacid, and, in fact, contains fats and proteins that stimulate the production of acid and enzymes in the stomach which can worsen heartburn. Besides, it would only add on to the total volume of contents in the stomach, making it all the easier to suffer from heartburn.
How can I prevent heartburn?
Don’t become obese— Becoming obese can cause more pressure on the stomach which may cause heartburn.
Don’t drink too much alcohol - Alcohol relaxes the muscles of the gastro-oesophageal junction and together with the increased volume of fluids in the stomach, can worsen heartburn
Don’t eat and drink too close to bedtime - Often patients have heartburn on going to bed and having a large volume of stomach contents on lying down makes reflux worse.
There is no evidence that acidic fruits like citrus or lemon can worsen acid reflux as the acid is very mild as compared to the strong hydrochloric acid in the stomach. That said, it still holds true that certain strong acids like strong vinegar could exacerbate heartburn as it goes down the oesophagus.
Some patients report heartburn after eating spicy food. However, this may just be the effect of stimulation, similar to the effect of taking caffeine. Spicy food or caffeine doesn’t damage the walls of the stomach and oesophagus nor does it increase the production of acid.
Will I have to change my lifestyle post-treatment?
There may be certain lifestyle changes such as going on a weight loss regime. It has been shown that even a 10% reduction in weight can improve symptoms of heartburn.
It is also best to avoid smoking or alcohol consumption. Other changes you might have to make involve avoiding late-night snacks or elevating the top end of the bed when sleeping to prevent heartburn or fluid regurgitation.
Diet-wise, there are no standard restrictions other than avoiding too much alcohol and not eating to obesity. Generally, a balanced diet and an active lifestyle are conducive to improved health on many fronts.
Read also: What type of diet reduces acid reflux?
What are some misconceptions about heartburn?
- Acid reflux and heartburn are not dangerous — Severe heartburn may be a sign of GERD that can lead to complications if left untreated!
- Gastroscopy is painful and should be avoided — This is not true at all! The entire process can be really comfortable due to the anaesthetic and sedative provided.
- Proton pump inhibitors have terrible side-effect profiles — There are actually few side effects that rarely occur. The evidence for serious side effects thus far is unconvincing. Given 40 years of its usage and monitoring of the outcomes, the low side effect profile of such medications should be reassuring.
GERD is a common condition that can impact quality of life and when severe, can have serious consequences. If heartburn is bothering you, it is always best to consult a doctor to seek medical advice, diagnosis or treatment. Thankfully, with help from doctors and the right medication, it can be treated and come under control, so do seek help early!
You may also read more about the topic of gastroenterology here. We have an array of gastroenterology-related articles and questions which will definitely be helpful for you.