Heartburn

Overview
Heartburn or pyrosis is a painful or burning sensation in the esophagus, just below the breastbone caused by regurgitation of gastric acid. The pain often rises in the chest and may radiate to the neck, throat, or angle of the jaw. Heartburn is also identified as one of the causes of chronic cough, and may even mimic asthma.

Heartburn actually has nothing to do with the heart. It is so called because of a burning sensation of the breastbone where the heart is located although some heart problems do have a similar sensation to heartburn. The term "heartburn" may come from the fact that hydrochloric acid from the stomach comes back up the esophagus because of a problem with the cardiac sphincter, a valve which misleadingly contains the word "cardiac" (an adjective referring to the heart) in its name.

Pathophysiology
The sensation of heartburn is caused by exposure of the lower esophagus to the acidic contents of the stomach. Normally, the lower esophageal sphincter (LES) separating the stomach from the esophagus is supposed to contract to prevent this situation. If the sphincter relaxes for any reason (as normally occurs during swallowing), stomach contents, mixed with gastric acid, can return into the esophagus. This return is also known as reflux, and may progress to gastroesophageal reflux disease (GERD) if it occurs frequently. Peristalsis, the rhythmic wave of muscular contraction in the esophagus, normally moves food down and past the LES and is responsible for ultimately clearing refluxed stomach contents. In addition, gastric acid can be neutralized by buffers present in saliva.

Biochemical

 * Ambulatory 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, such monitors must be left in place for at least a 24-hour period to confirm the diagnosis of GERD.  The test is particularly useful when the patient's symptoms can be correlated to episodes of increased esophageal acidity.
 * Upper Gastrointestinal (GI) Series : A series of x-rays of the upper digestive system are taken after drinking a barium solution. These can demonstrate reflux of barium into the esophagus, which suggests the possibility of gastroesophageal reflux disease.  More accurately, fluoroscopy can be used to document reflux in real-time.

Mechanical

 * Manometry : In this test, a pressure sensor (manometer) is passed through the mouth into the esophagus and measures the pressure of the lower esophageal sphincter directly.
 * Endoscopy : The esophageal mucosa can be visualized directly by passing a thin, lighted tube with a tiny camera attached (an endoscope) through the mouth to examine the esophagus 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 track 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 esophagus is removed. It is then studied to check for inflammation, cancer, or other problems.

Differential Diagnosis of Heartburn

 * Angina / ischemia
 * Ascites
 * Asthma
 * Barrett's Esophagus
 * Cardiotomy
 * Caustic agent ingestion with resultant mucosal injury
 * Chagas Disease
 * Cholelithiasis
 * Clothes (elevated internal stomach pressure)
 * Constipation
 * Coronary Artery Disease
 * Coughing
 * CREST syndrome (Calcinosis Raynaud's phenomenon Esophagus Sclerodactyly Telangiectasias)
 * Direct irritation of esophagus:
 * Aspirin
 * Cigarette smoke
 * Citrus fruits, juice
 * Ibuprofen
 * Spicy foods
 * Tomatoes
 * Tomato sauces


 * Diabetes
 * Drugs:
 * Albuterol
 * Anticholinergics
 * Caffeine
 * Calcium channel blockers
 * Cigarette smoking
 * Nitrates
 * Progesterone
 * Theophylline


 * Esophageal atresia or fistula
 * Esophageal carcinoma
 * Esophageal diverticulum
 * Esophageal varices
 * Foods:
 * Alcohol
 * Chocolate
 * Coffee
 * Fatty foods
 * Peppermint
 * Soft drinks with caffeine
 * Tea


 * Fundectomy (postoperative)
 * Gastrectomy (postoperative)
 * Gastritis
 * Gastroesophageal Reflux Disease (GERD)
 * Hiatal hernia
 * Infectious esophagitis
 * Lifting
 * Mallory-Weiss Tear
 * Motility disorders
 * Muscle strain
 * Myasthenia gravis
 * Myocardial Infarction
 * Obesity
 * Peptic Ulcer Disease
 * Pericardial Disease
 * Pregnancy
 * Primary reflux esophagitis
 * Pulmonary Embolism
 * Raynaud's Phenomenon
 * Scleroderma
 * Strictures, webs, or rings
 * Vagotomy (postoperative)

Causes
Foods that may cause heartburn:
 * Sodas (including cola), and other carbonated beverages
 * Chocolate
 * Citrus fruits and juices
 * Tomatoes and tomato sauces (such as pizza and pasta sauce)
 * Spicy foods
 * Red pepper (capsicum)
 * Peppermint and spearmint
 * Dry foods such as peanuts
 * Fatty foods such as ice cream
 * Garlic
 * Bread and other foods derived from grains
 * Wine

Drugs are also known to cause or trigger heartburn symptoms.


 * Tobacco products (cigarettes, snuff, etc.)
 * Cocaine, and especially Methamphetamine is known to trigger heartburn.
 * Alcohol
 * Caffeine, as found in Coffee, tea, cola, and other beverages

It can also be psychosomatic, primarily in relation to stress and fatigue

Prevention
If heartburn occurs when lying down, raising the head of the bed, or raising the upper body with pillows or sleeping sitting up frequently provides relief. Avoid pillows that raise the head only, as this does little for heartburn and places continuous strain on the neck. To minimize attacks, a sufferer may find benefit in avoidance of certain foods that relax the opening between the stomach and esophagus, such as chocolate, peppermint, and chamomile tea shortly before bedtime.

Medications
Antacids, H2-receptor antagonists, alginates and proton pump inhibitors are used (in that order) to treat heartburn.

Antacids
Antacids work by neutralizing excess stomach acid. So although stomach acid will still splash up into the esophagus (acid reflux) the stomach acid will be neutralized and therefore will lead to lesser or no heartburn symptoms (the burning feeling). Antacids provide fast relief of symptoms, but relief typically last for just 30-60 minutes.

Sodium bicarbonate
A simple and relatively harmless way to treat a one-off heartburn is to drink a solution of a small amount of Sodium bicarbonate mixed with water, which quickly neutralizes the acid that causes the pain. Excess sodium intake does, however, raise blood pressure and cause other undesirable health effects if resorted to with any frequency.

H2-receptor antagonists
Often called H2 Blockers, H2-receptor antagonists work by decreasing the amount of acid the body releases into the stomach. H2s are systemic, meaning they require absorption into the bloodstream in order to work. Therefore, H2s can often take 30 minutes or longer before they start working, and therefore are often taken to prevent heartburn rather than for fast relief of symptoms.

Alginates
Alginates work differently than antacids and H2 Blockers, by forming a protective barrier in the stomach that prevents stomach acid from refluxing back up into the esophagus. Alginic acid is naturally derived (from brown seaweed) and is non-systemic. Alginates provide faster relief than H2-receptor antagonists and PPIs and longer-lasting relief than antacids.

Proton-pump Inhibitors
Proton pump inhibitors, called PPIs, are a class of medications which can be effective for people who do not respond to antacid or acid blockers. Proton-pump inhibitors are systemic and directly block acid production in the stomach cells. In order to prevent heartburn the medication disfigures and disables the proteins (proton pumps) that control the pH of the stomach, allowing the body to digest them. Proton-pump inhibitors are not fast-acting, but provide long-lasting relief. PPIs are intended to be short-term medications only.

Restricting Diet
Restricting diet is very important, since 90-95% of sufferers of heartburn or esophageal disorder can link their symptoms to specific foods. Therefore, it is important that heartburn sufferers manage their diets as a way to treat their heartburn. Sufferers should choose the kinds of foods and drinks which have little risk of causing acid reflux, while some kinds of foods or drinks should be avoided as they are major heartburn triggers.

Bananas
Are a natural antacid so eat one for instant relief of heartburn. The inside of the banana skin is also good for soothing mosquito bites.