Heartburn and Acid Reflux

You may think that every burning feeling in the chest is acid reflux, or that repeated heartburn can be managed indefinitely with non prescription medicines. Heartburn is common, but similar symptoms can occur with heart disease. Persistent reflux or reflux accompanied by swallowing difficulty, bleeding, vomiting or weight loss requires medical assessment.

Heartburn is a symptom rather than a heart condition Heartburn is a burning feeling behind the breastbone. It often rises from the lower chest towards the throat. Despite its name, heartburn usually comes from the digestive tract rather than the heart. Acid reflux occurs when acidic stomach contents travel upwards into the oesophagus, the muscular tube connecting your mouth to your stomach. If reflux occurs repeatedly or causes troublesome symptoms or complications, it may be called gastro oesophageal reflux disease, shortened to GORD. The stomach and oesophagus have different protections The stomach lining is adapted to tolerate acid. The oesophagus is less well protected. A ring of muscle near the lower end of the oesophagus normally helps prevent stomach contents moving upwards. Reflux can occur when this barrier relaxes, is placed under increased pressure or does not work effectively. One reflux episode does not necessarily mean you have a long term disease. Many people experience occasional heartburn. Regurgitation is different from vomiting Regurgitation means stomach contents or sour fluid rise into your throat or mouth without the forceful muscular action of vomiting. Typical reflux symptoms include burning in the middle of the chest, sour or acidic taste, regurgitation, symptoms after eating, symptoms when lying down, and symptoms when bending over. Other possible symptoms include recurrent cough, hiccups, hoarseness, bad breath, bloating or nausea. These symptoms are not specific to reflux and may have other causes. Pattern helps, but does not prove the diagnosis A reflux pattern may be more likely when symptoms start after meals, follow large or fatty meals, occur when lying flat, worsen when bending forwards, improve with an antacid or alginate, or include a sour taste or regurgitation. A response to an antacid does not prove that the discomfort came from reflux. Some cardiac chest discomfort can improve temporarily or fluctuate by itself. Personal triggers vary Possible contributors include large meals, eating shortly before bed, alcohol, smoking, coffee, chocolate, fatty or spicy food, pregnancy, increased abdominal pressure, some medicines, and a hiatus hernia. A hiatus hernia occurs when part of the stomach moves upwards through the diaphragm. You do not need to avoid every food commonly associated with reflux. Focus on triggers that repeatedly affect your own symptoms. NHS and NICE advice supports avoiding known individual triggers rather than imposing one universal restrictive diet. Weight can be relevant without becoming a judgement If you are above your healthy weight, increased pressure within the abdomen can contribute to reflux. Weight reduction may improve symptoms for some people. This should be approached through realistic health support rather than blame. Reflux also occurs in people of every body size. Weight alone does not explain persistent or severe symptoms. Medicines may cause or worsen symptoms Medicines that may contribute include some anti inflammatory painkillers, nitrates, calcium channel blockers, bisphosphonates, corticosteroids, and theophylline containing medicines. The effect depends on the medicine and how it is taken. Tell a clinician or pharmacist about all prescribed and non prescription products. Do not stop a prescribed medicine simply because reflux is listed as a possible side effect. NICE recommends reviewing medicines that may contribute to dyspepsia or reflux symptoms. Occasional uncomplicated symptoms may respond to simple measures Possible measures include: Eating smaller meals. Avoiding your known triggers. Avoiding meals for three to four hours before bed. Reducing excessive alcohol. Stopping smoking. Addressing weight where appropriate. Raising the head end of the bed if symptoms occur at night. Avoiding tight clothing around the waist. Raising the entire head end of the bed is different from adding several pillows. Extra pillows may bend the body and increase abdominal pressure. You do not need to follow every measure. Choose changes linked to your own pattern. A pharmacist can advise on short term treatment A pharmacist may recommend an antacid, which neutralises stomach acid, an alginate, which forms a barrier above stomach contents, or another short term medicine where appropriate. Antacids and alginates may relieve symptoms, but they do not identify or cure every underlying cause. Some products affect the absorption of other medicines and need to be separated from them. Pregnancy, kidney disease, heart failure and sodium restriction can also affect product choice. Tell the pharmacist about your conditions and regular medicines. NHS guidance advises against taking antacids or alginates regularly for prolonged periods without review. Proton pump inhibitors reduce acid production A proton pump inhibitor, or PPI, reduces the amount of acid produced by the stomach. Examples include omeprazole, lansoprazole and pantoprazole. NICE recommends a time limited full dose PPI trial for many adults with GORD, followed by review. If symptoms recur, treatment may be stepped down to the lowest dose that controls them when clinically appropriate. A PPI may take longer to work than an antacid. Follow the timing and dosing instructions provided. Long term treatment may be appropriate for some people, but the reason, dose and continuing need should be reviewed. Helicobacter pylori is not the same as reflux Helicobacter pylori, often shortened to H. pylori, is a bacterium that can infect the stomach lining and contribute to ulcers and dyspepsia. Testing may be considered when upper digestive symptoms suggest dyspepsia rather than straightforward reflux, or according to your symptoms and background. PPIs can reduce the accuracy of breath and stool antigen testing. NICE advises a two week PPI washout before these tests when it is clinically safe to pause treatment. This should be planned with the clinician or pharmacist responsible for your care. Heartburn like discomfort can come from the heart Heart attack symptoms can feel like pressure, tightness, squeezing, burning, indigestion, or heaviness in the chest. The discomfort may spread to an arm, both arms, the neck, jaw, stomach or back. You may also feel sweaty, sick, light headed or breathless. Do not use age, previous reflux or the fact that symptoms followed food to rule out a heart problem. Call 999 for sudden chest discomfort that does not go away, particularly with pressure, spreading pain, breathlessness, sweating, nausea or light headedness. Difficulty swallowing is not routine heartburn Food sticking or difficulty swallowing is called dysphagia. Dysphagia may result from reflux related inflammation or narrowing, but it can also occur with disorders of swallowing movement or cancer. Adults presenting with dysphagia should be referred through a suspected cancer pathway for upper gastrointestinal assessment under current NICE guidance. This is intended to investigate the symptom promptly, not to state that cancer is present. Weight loss changes the level of concern Unexplained weight loss may mean that eating has become difficult, symptoms are reducing intake, persistent vomiting is present, a narrowing or other upper digestive condition requires investigation, or another illness is contributing. NICE recommends a suspected cancer pathway referral for people aged 55 or over who have unexplained weight loss with reflux, dyspepsia or upper abdominal pain. Younger people with weight loss still require assessment. The age threshold describes a specific pathway, not a boundary below which symptoms are harmless. Bleeding requires urgent assessment Possible upper gastrointestinal bleeding may appear as vomiting fresh red blood, vomit resembling coffee grounds, black, sticky or tar like stool, collapse or faintness, or symptoms of anaemia. Significant acute gastrointestinal bleeding requires same day specialist assessment. Do not assume black stool is caused by food or iron without considering the full clinical context. Other reasons to arrange a GP review See a GP when heartburn occurs most days, symptoms repeatedly wake you, lifestyle measures and pharmacy treatment are not helping, you need regular non prescription medicines, symptoms are worsening or changing, you frequently vomit. Food feels stuck, you have unexplained weight loss, you have anaemia or unusual tiredness, the symptoms began after a new medicine, or you are uncertain whether the symptom is chest pain or reflux. Tests are selected according to the clinical question Many people with typical uncomplicated reflux do not initially require an endoscopy. Possible tests include blood tests, H. pylori testing, upper gastrointestinal endoscopy, biopsies, acid monitoring, tests of oesophageal movement, and cardiac assessment when chest pain is possible. An endoscopy uses a flexible camera to examine the oesophagus and stomach. Testing is more likely when symptoms are persistent, treatment resistant, unusual or accompanied by alarm features. Treatment should be reviewed rather than continued automatically A review should ask whether the original diagnosis is still likely, whether symptoms are controlled, whether the medicine is being taken correctly. Whether the dose is higher than needed, whether warning features have appeared, whether another diagnosis is possible, and whether there are side effects or interactions. Do not reduce or stop a prescribed PPI without advice when it is being used to treat severe oesophagitis, ulcer disease, bleeding risk or another continuing indication.

Heartburn describes a symptom. Acid reflux describes a process. GORD describes a recurring condition. A safe approach asks whether the pattern fits reflux, whether this could be heart or another chest pain, whether there are warning features requiring investigation, which triggers or medicines contribute, and whether continuing treatment is still necessary and safe.