What is heartburn and what causes it?

What Causes Heartburn?

Heartburn symptoms can start up because of a problem with a muscular valve called the lower esophageal sphincter (LES). It’s located where the esophagus meets the stomach — below the rib cage and slightly left of center.

Normally, with the help of gravity, the LES keeps stomach acid right where it should be — in your stomach. When it’s working right, the LES opens to allow food into your stomach or to let you belch, then closes again. But if the LES opens too often or doesn’t close tightly enough, stomach acid can seep into the esophagus and cause a burning sensation.

If your LES doesn’t tighten as it should, there are often two things that contribute to the problem. One is overeating, which puts too much food in your stomach. Another is too much pressure on your stomach, often due to obesity, pregnancy, or constipation.

Certain foods can relax your LES or increase stomach acid, including:

  • Tomatoes
  • Citrus fruits
  • Garlic and onions
  • Chocolate
  • Coffee or caffeinated products
  • Alcohol
  • Peppermint

Meals high in fats and oils (animal or vegetable) often lead to heartburn, as do certain medications. Stress and lack of sleep can raise how much acid your stomach makes and can cause heartburn.

If you’re pregnant, the hormone progesterone can relax your LES and lead to heartburn. Smoking also relaxes the LES and increases stomach acid.

Heartburn Causes, Symptoms, and Diagnosis

Heartburn is most often triggered by certain foods, but it can also be a symptom of a more serious condition.

Heartburn often occurs after a decadent and delicious meal that’s spicy or heavy in fat. iStock

After a decadent and delicious meal that’s spicy or heavy in fat, you may feel satisfied and happy. That is, until, the heartburn kicks in and sends you running to the medicine cabinet for your antacids, groaning in discomfort.

Heartburn is a familiar feeling to many people. It involves an uncomfortable burning sensation in your chest, which is often accompanied by a sour taste in the back of your mouth, creeping up from your throat.

While heartburn is most commonly caused by eating problematic foods, it can also be a symptom of certain medical conditions, including gastroesophageal reflux disease (GERD).

Occasional heartburn can usually be treated successfully with over-the-counter options and doesn’t tend to cause lasting damage.

But over time, persistent heartburn can damage your esophagus and may cause bleeding, inflammation, or difficulty swallowing. If you experience regular heartburn, it’s important to seek medical treatment. (1)

A Digestive Problem That Affects Roughly 18 Percent of the US Population

More than 60 million people in the United States experience heartburn at least once a month, according to the American College of Gastroenterology (ACG).

The group also notes that according to some studies, over 15 million Americans have heartburn symptoms every single day.

Heartburn is more common in older people and pregnant women. (2)

In fact, between 17 and 45 percent of pregnant women report episodes of heartburn, according to a study published in September 2015 in the journal BMJ Clinical Evidence. (3)

Harvard Medical School notes that according to one survey, 65 percent of people with heartburn experience symptoms both during the day and at night. (4)

Among those who report nighttime symptoms, 75 percent experience trouble sleeping as a result, and 40 percent say that it affects their job performance the next day.

While both occasional and frequent heartburn commonly cause discomfort, only about 6 percent of the population has heartburn that causes ongoing functional problems, according to the ACG. (5)

Symptoms Can Last up to Several Hours After Onset

Heartburn involves a burning, painful sensation behind your breastbone (sternum) in the center of your chest.

This pain often gets worse after you eat, in the evening, when you bend over, or when you lie down.

Episodes of heartburn can last between a few minutes and several hours.

In addition to burning sensations in your chest, heartburn may also involve:

  • A burning sensation in your throat
  • Fluid in your throat that tastes bitter, sour, or salty
  • Difficulty swallowing
  • A sense that food is stuck in your chest or lower throat

Heartburn often begins after you’ve eaten a large meal, but it can also be triggered by certain foods even if you don’t eat very much. (1,6)

Food and Lifestyle Habits Can Cause Stomach Acid to Flow Back Up

Heartburn occurs when the contents of your stomach flow up into your esophagus.

A ring of muscle at the end of your esophagus where it joins your stomach — known as the lower esophageal sphincter — normally prevents your stomach contents from flowing back up into your esophagus by tightening after you swallow food.

But sometimes this muscle doesn’t tighten completely, and the entrance to your stomach doesn’t fully close. When this happens, stomach acid can enter your esophagus and cause heartburn. (6)

There is a wide range of potentially problematic foods and other factors that can contribute to heartburn.

Foods that can trigger heartburn for many people include:

  • Tomatoes and tomato-based foods, including ketchup and sauces
  • Peppermint
  • Chocolate
  • Alcoholic beverages
  • Coffee and other caffeinated beverages
  • Onions
  • Garlic
  • Spicy foods
  • Fatty and fried foods
  • Full-fat dairy products
  • Citrus fruits and their juices
  • Soda and other carbonated drinks (1,6,7)

Certain immediate behaviors can contribute to heartburn, including:

  • Eating a large meal
  • Wearing tight pants
  • Lying down too soon after eating

Some people are more likely than others to experience heartburn. Common risk factors for heartburn include:

  • Smoking
  • Emotional stress
  • Being overweight or obese
  • Pregnancy
  • Having GERD
  • Having a hiatal hernia (in which part of your stomach pushes up through the opening in your diaphragm for your esophagus) (1,6)

There’s evidence that psychological distress may be linked to the perceived severity of heartburn in people who experience symptoms but show no signs of acid reflux in medical tests.

In a study published in September 2017 in The American Journal of Gastroenterology, researchers looked at a group of adults with heartburn and related symptoms who didn’t experience relief from taking a proton pump inhibitor (PPI) drug. (8) Participants were asked about the severity of their symptoms, as well as their overall stress and quality of life. They also had the acidity of their esophagus measured, which is a standard way to determine the severity of acid reflux.

Among participants whose tests confirmed acid reflux, the perceived severity of their symptoms was directly related to the measured degree of reflux. Their symptom severity wasn’t related to their answers about stress and quality of life. But among participants whose tests didn’t show acid reflux, having more severe symptoms was related to reporting more stress and a worse quality of life.

The higher risk of heartburn seen in people with excess body weight was confirmed in a study of GERD patients published in March 2017 in the journal Liver Disease. (9)

Participants were divided into two groups based on their body mass index (BMI): normal weight, and overweight or obese. All participants took PPI drugs as needed to treat their symptoms during a follow-up period of 10 years.

Normal-weight participants reported an average of seven relapses involving heartburn each year, out of which only two qualified as severe. Overweight or obese participants reported an average of 11 heartburn episodes, six of them severe.

Overweight or obese participants were also more likely to show inflammation in their esophagus when it was examined with a scope (a tube with an attached camera).

Heartburn can also be a side effect of certain drugs, including:

  • Tricyclic antidepressants
  • Theophylline,used to treat asthma and other lung diseases
  • Beta-blockers, used to treat heart disease and high blood pressure
  • Calcium channel blockers, used to treat high blood pressure
  • Progestin, a hormone found in birth control pills
  • Sedatives, used to treat anxiety and insomnia
  • Dopamine-like drugs for Parkinson’s disease
  • Anticholinergics, used to treat sea sickness (7)

Prevent Heartburn by Changing Lifestyle Habits

A number of preventive measures may help reduce the frequency and severity of your heartburn, or even eliminate it.

First, try eliminating any potentially problematic foods and beverages from your diet. Don’t forget that alcohol and fatty meals in general can be major triggers for some people.

If you’re not sure what foods give you heartburn, keep a diary of what you eat and any symptoms you experience.

If eliminating food triggers from your diet doesn’t relieve your symptoms, try changing your eating habits in the following ways:

  • Eat smaller meals.
  • Eat slowly to avoid overstuffing yourself.
  • Drink warm, caffeine-free beverages, like herbal tea.
  • Don’t bend over soon after eating.
  • Don’t exercise soon after eating.
  • Leave 3 to 4 hours between eating and lying down or going to bed.

Other steps that may help relieve your heartburn include:

  • Lose weight if you’re overweight.
  • Don’t smoke.
  • Dress in loose, comfortable clothing.
  • Raise the head of your bed by about 6 inches to elevate your head (raise your bed’s legs or mattress; extra pillows don’t work well).
  • Exercise to improve your fitness and reduce stress.
  • Try to relieve stress through meditation, yoga, or deep breathing. (1,6,7)

Treat Heartburn With Over-the-Counter Drugs or Prescription Medication

If preventive measures aren’t effective at reducing your heartburn, you may consider over-the-counter or prescription medication.

Taking an antacid often delivers quick relief from heartburn symptoms. Common over-the-counter antacids include:

  • Maalox (calcium carbonate)
  • Mylanta (magnesium hydroxide, simethicone, and aluminum hydroxide)
  • Tums (calcium carbonate)

While antacids can offer symptom relief, they won’t prevent heartburn from recurring and aren’t a good solution for frequent heartburn. (7)

If antacids aren’t effective, or if you need longer-lasting relief from heartburn, you may consider taking over-the-counter H2 blockers, which reduce stomach acid production. These drugs include:

  • Pepcid AC (famotidine)
  • Tagamet (cimetidine)
  • Zantac (ranitidine)

PPIs reduces stomach acid production even more. Over-the-counter options include:

  • Nexium 24HR (esomeprazole)
  • Prevacid 24HR (lansoprazole)
  • Prilosec OTC (omeprazole) (6,7)

If your heartburn is severe or frequent, you may have GERD, and would benefit from seeing a doctor for evaluation — even before you begin taking any over-the-counter treatments regularly.

You should see a doctor about your heartburn in the following cases:

  • Your symptoms worsen or become more frequent.
  • You have trouble or pain while swallowing.
  • Your symptoms worsen while taking over-the-counter drugs.
  • You suspect a medication may be causing your heartburn.
  • Your heartburn causes vomiting.
  • Your heartburn makes you hoarse or causes wheezing.
  • You experience unexplained weight loss.
  • Your heartburn causes discomfort that interferes with your daily life. (1,7)

Your doctor will ask you questions about your symptoms and what might be causing them, and may perform tests to evaluate your esophagus and measure any acid reflux.

In addition to recommending certain lifestyle and behavioral changes, your doctor may prescribe a stronger, prescription version of over-the-counter drugs that reduce stomach acid production. (7)

Additional reporting by Quinn Phillips.

By: Caul Corbell, Pharm.D.

Gastroesophageal reflux disease, or GERD (better known as acid reflux or even just reflux), is a medical condition that occurs when gastric contents of the stomach are spilled into the esophagus. This causes many troublesome symptoms including: heartburn, chronic cough, sore throat, tooth enamel loss, and chest pain.

It is estimated that over half of Americans suffer from GERD annually, and roughly $10 billion is spent to treat the condition each year! While diet, stress, and other lifestyle factors often play the largest role in the prevalence of GERD, many medications can cause or exacerbate GERD.

There are 2 primary mechanisms can lead to acid reflux: decreasing the pressure of the lower esophageal sphincter and direct irritation of the esophagus

Lower Esophageal Sphincter (LES)

Several medications decrease the pressure of the lower esophageal sphincter (LES), which forms the junction between the esophagus and the stomach. This decrease in pressure allows acidic contents of the stomach to reflux into the esophagus. The first class having this effect are the anticholinergic drugs. Oxybutynin, benztropine, scopolamine, cyclobenzaprine, tricyclic antidepressants, and many other medications have anticholinergic properties that not only decrease LES pressure but also slow GI motility, which can worsen GERD symptoms. Other medications that decrease LES pressure include: beta-blockers, dihydropyridine calcium channel blockers, barbiturates, caffeine, estrogens, nitrates, progesterone, tetracycline, and theophylline.

Direct Irritation of the Esophagus

Another mechanism of exacerbating GERD is by direct irritation of the mucous lining of the esophagus. NSAIDs are by far the most commonly used medications with this adverse affect. Both NSAIDs and aspirin inhibit the enzymes COX-1 and COX-2. This is how these medications decrease pain and inflammation, but by doing this they also inhibit the body’s natural ability to maintain a strong stomach and esophagus lining. This leads not only to GERD symptoms but can also result in ulcers and potentially serious GI bleeds.

Therefore, all patients known to have GERD or peptic ulcer disease (PUD) and are taking NSAIDs regularly should be aware of the potential risks and the signs and symptoms of GI bleeding and be placed of preventative therapy if no contraindications exist. One of the easiest solutions to this interaction for many patients would be transition to acetaminophen, provided that the patient does not have liver disease or any other contraindications.

Other medications that cause direct esophageal irritation are bisphosphonates (Fosamax, Boniva, etc.), iron supplements, quinidine, potassium, and tetracyclines (doxycycline, minocycline, etc.). With all these medications it is important to take them with a full glass of water and remain upright for at least 30 minutes after administration. This will ensure that the tablet or capsule has passed into the stomach and will not irritate the esophagus through prolonged direct contact.

What can I do if I’m on a medication gives me Acid Reflux?

Nearly all medications that cause GERD have therapeutic alternatives so it is important to ask your pharmacist if better options exist and if you should consider switching. In cases where such therapeutic options are not available, ask your pharmacist for tips on how administration, diet, lifestyle, and preventative strategies can help you head off GERD symptoms before they present themselves. Our pharmacists are happy to educate you on the non-irritating alternatives to provide better outcomes for patients with GERD.

Gastroesophageal reflux – discharge

You can make many lifestyle changes to help treat your symptoms. Avoid foods that cause problems for you.

  • DO NOT drink alcohol.
  • Avoid drinks and foods that have caffeine, such as soda, coffee, tea, and chocolate.
  • Avoid decaffeinated coffee. It also increases the level of acid in your stomach.
  • Avoid high-acid fruits and vegetables, such as citrus fruits, pineapple, tomatoes, or tomato-based dishes (pizza, chili, and spaghetti) if you find that they cause heartburn.
  • Avoid items with spearmint or peppermint.

Other lifestyle tips that may make your symptoms better are:

  • Eat smaller meals, and eat more often.
  • Lose weight, if you need to.
  • If you smoke or chew tobacco, try to quit. Your health care provider can help.
  • Exercise, but not right after eating.
  • Reduce your stress and watch for stressful, tense times. Stress can bother your reflux problem.
  • Bend at the knees, not your waist, to pick things up.
  • Avoid wearing clothes that put pressure on your waist or stomach.
  • Do not lie down for 3 to 4 hours after eating.

Avoid medicines such as aspirin, ibuprofen (Advil, Motrin), or naproxen (Aleve, Naprosyn). Take acetaminophen (Tylenol) to relieve pain. Take any of your medicines with plenty of water. When you start a new medicine, remember to ask if it will make your heartburn worse.

Try these tips before going to sleep:

  • DO NOT skip meals or eat a large meal for dinner to make up for missed meals.
  • Avoid late night snacks.
  • DO NOT lie down right after you eat. Remain upright for 3 to 4 hours before you go to bed.
  • Raise your bed 4 to 6 inches (10 to 15 centimeters) at the head of your bed, using blocks. You can also use a wedge support that raises the top half of your body when you are in bed. (Extra pillows that raise only your head may not help.)

Is Medication Causing Your Heartburn?

If you get frequent heartburn, you may think that food or drink is to blame. But the culprit may actually be lurking in your bathroom: Certain pain relievers and other common medications can cause heartburn, the most common symptom of gastrointestinal reflux disease, also known as acid reflux.

Almost everyone has experienced heartburn at one time or another. In fact, almost 40 percent of Americans have heartburn symptoms at least once a month.

Heartburn and acid reflux occur when acid or other stomach contents back up into your esophagus, the long tube that carries food from your mouth to your stomach. Sometimes, acid reflux causes a sour taste in your mouth or a burning sensation that may begin under your breastbone before traveling up to your throat.

In some instances, the lower esophageal sphincter (LES), a ring of muscle that helps keep food in the stomach after you swallow, may also become weakened, allowing food and stomach acid to travel back toward the mouth.

If you generally follow a healthy diet but find that you’re experiencing heartburn, or if your heartburn symptoms coincide with starting a medication, you may want to look in your medicine cabinet for possible culprits.

Heartburn Causes: Common Medications

The following common medications can trigger or worsen acid reflux:

  • Ibuprofen. This common pain reliever belongs to a family of medications known as non-steroidal anti-inflammatory drugs (NSAIDs). They are available over-the-counter (Advil, Motrin) and also by prescription. Heartburn, abdominal pain, and nausea are common side effects since these medications irritate the lining of the stomach and esophagus. Long-term use can even result in bleeding and stomach ulcers. The best way to avoid these effects is by following the dosage directions on the packaging and by not taking these medications on an empty stomach.
  • Aspirin. The “wonder drug” is another NSAID that can cause heartburn and other digestive problems. If you take aspirin for pain relief, acetaminophen (Tylenol) is a good alternative because it has a minimal, if any, effect on the stomach lining. If you take aspirin to help protect your heart, however, be sure to tell your doctor if you experience any stomach trouble or bleeding. Again, most of these issues can be avoided by taking aspirin with food to help minimize its effects on the esophagus and stomach.
  • Osteoporosis medications. Bisphosphonates, such as alendronate sodium (Fosomax), ibandronate sodium (Boniva), and risedronate sodium (Actonel), can cause heartburn, nausea, and other gastrointestinal problems. Make sure you take these pills as directed in the patient information insert. Report any new or worsening heartburn, chest pain, or trouble swallowing to your doctor right away.
  • Iron supplements. This mineral can help your body to make more red blood cells and fight iron-deficiency anemia, but it can also cause acid reflux, upset stomach, and constipation. Try taking iron pills with food and avoid taking them at bedtime.
  • High blood pressure medications. Calcium channel blockers such as nifedipine (Procardia) and beta blockers such as propranolol (Inderal) can also cause heartburn. Speak to your doctor if you are experiencing problems. There are many high blood pressure medications available, and a different type of drug might be just as effective and yet cause fewer side effects.
  • Anti-anxiety drugs. Diazepam (Valium) or lorazepam (Ativan) can sometimes cause nausea and heartburn. If your heartburn symptoms persist, your doctor will likely be able to prescribe another anti-anxiety medication instead.
  • Tricyclic antidepressants. Amitriptyline (Vanatrip, Endep), imipramine (Tofranil), and nortriptyline (Pamelor, Aventyl) are among the tricyclic antidepressants that can cause acid reflux. Ask your doctor if a drug in another class of antidepressants might have fewer gastrointestinal side effects.
  • Antibiotics. The antibiotic tetracycline isused to treat bacterial infections, including pneumonia, but can cause diarrhea, heartburn, and other side effects.

If you suspect that a medication is triggering heartburn, don’t stop taking you prescription drugs on your own. Call your doctor before you take the next dose. Your medical team may be able to make a substitution or suggest ways to prevent heartburn symptoms. Sometimes, simply changing the time of day you take your medication can help.

Cool the Burn With Heartburn Medicine

It’s important to treat heartburn, especially if you experience frequent symptoms. Over time, acid reflux can actually damage your esophagus. Talk to your doctor about whether prescription or non-prescription heartburn medicine is right for you.

There are many over-the-counter heartburn medicines available:

  • Antacids like Mylanta or Maalox can counteract the effects of stomach acid.
  • vH2 blockers such as ranitidine (Zantac), famotidine (Pepcid AC), and cimetidine (Tagamet) cut down on stomach acid production.
  • Proton pump inhibitors such as omeprazole (Prilosec, Prilosec OTC) and esomeprazole (Nexium) stop almost all acid production.

Making lifestyle changes, including losing weight if you are overweight, avoiding late night meals, and quitting smoking may also help put out the fire and ease your heartburn.

10 Tips When Medication Causes Heartburn

If your heartburn is caused by a medicine, here are tips for finding relief:

1. Don’t stop taking any prescription medication without first talking with your doctor.

2. With any medication, don’t take more than the recommended dose. Check the label.

3. Pay attention to when and how you take the drug. Some medications and supplements should be taken right after a meal to make heartburn less likely. Others should be taken on an empty stomach. If you are unsure, ask your doctor or pharmacist when to take each of your medications.

4. Ask your doctor or pharmacist to review everything you are taking. “It’s very important to let them know not only about your prescriptions, but about any vitamins, minerals, and over-the-counter products you are taking,” says Heather Free, PharmD, a pharmacist in Washington, DC. Your health professional may be able to change the dose of a medication, switch you to a different medication, or suggest other ways to ease your heartburn.

5. Ask if you can change the way you get your medication. For example, if you take an NSAID for arthritis, you might be able to switch from a pill to a cream that is less likely to cause heartburn.

6. Don’t lie down right after you take certain medications. You should stay upright, for instance, for at least 30 minutes after taking bisphosphonates and at least 15-20 minutes after taking anti-anxiety medication or sleep aids in order to prevent heartburn.

The Deadly Truth Behind Painkillers

Consumption of NSAIDs and Acetaminophen
The two major categories of pain relievers, or analgesics, are NSAIDs and acetaminophen. They can be available either over the counter or by prescription.

The Statistics

According to the U.S. Food and Drug Administration (FDA), 980 deaths each year are attributed to drugs containing acetaminophen. However, the American Association of Poison Control Centers (AAPCC) attributes 113 annual deaths to overdosing on medications with acetaminophen. These estimates can be highly inaccurate. Studies use mathematical models and assumptions instead of using reported cases, and data sets fail to account for the number of deaths resulting from chronic NSAID usage.

Acetaminophen

Acetaminophen is not an NSAID. Common brand-name drugs containing acetaminophen include Pain-Eze and Tylenol. It is often used to treat headaches, and over 25 billion doses are sold each year.

NSAIDs

Aspirin is one of the most prevalent NSAIDs, with over 100 billion tablets being produced per year. Aspirin is used to prevent stroke and heart attacks, and it is sold under the following brand names: Anacin, Bayer, Bufferin and Excedrin. Ibuprofen is commonly used to treat sore muscles, fevers, hangovers, menstrual cramps and sinusitis. This drug is available under the brand names Advil, Motrin and Nuprin, and over 20 million prescriptions are written for it each year. Naproxen is often used to lessen symptoms of hangovers and arthritis, and it is available under several brand names, including Aleve and Naprosyn. Over 10 million Naproxen prescriptions are filled per year.

The Side Effects and Adverse Events

While uncommon, acetaminophen and NSAIDs are capable of causing unpleasant side effects and adverse events, which may make individuals hesitate before taking a painkiller.

How Painkillers Work

Painkillers interfere with pain messages sent to the brain via nerve endings, which affects the brain, spinal cord or injured area.
NSAIDs work by blocking the creation of prostaglandins by special enzymes Cox-1 and Cox-2. The tissue does not swell, and the pain message coming from the nerves becomes muted without prostaglandins.

Researchers have been debating whether acetaminophen targets serotonin (5HT) neurotransmission within the central nervous system. However, the currently prevailing hypothesis claims that acetaminophen works by inhibiting the COX enzyme, which relieves pain and reduces fever.

How Side Effects Are Caused

NSAIDs can cause high blood pressure and kidney damage by reducing blood flow to kidneys, making them work more slowly. This could lead to a build-up of fluids and high blood pressure.

NSAIDs can also cause gastrointestinal problems by preventing prostaglandins from being created. Prostaglandin helps protect the stomach lining and GI tract. Without a sufficient amount of prostaglandins, the GI tract can become irritated and damaged by gastric acids, leading to gastric bleeds and gastritis.

Painkillers may make people with asthma more susceptible to extreme allergic reactions, but experts are not sure about what causes this problem.

Aspirin can cause heartburn, nausea, stomach pain and vomiting. Adverse events connected to aspirin use include hives, stomach bleeding and stroke, among others.

Ibuprofen can cause nausea, diarrhea, peripheral edema and more. Some adverse events associated with ibuprofen use include liver injury, liver failure and severe hypersensitivity reactions.
Naproxen can cause an array of side effects, including dizziness, headache, heartburn, dyspepsia and nausea. Adverse events resulting from naproxen use can include acute hepatitis and liver failure.

Healthier and Safer Alternatives

Long before pharmaceutical companies created fast-acting painkillers, humans learned how to utilize a variety of natural remedies to treat ailments like joint pain, headaches or digestive discomfort. Nowadays, individuals are using yoga or mindfulness meditation to manage pain. Natural alternatives for back and joint discomfort include turmeric, capsicum/capsaicin, glucosamine/chondroitin, and herbs such as comfrey and devil’s claw root. Natural alternatives for headaches include caffeine, white willow bark and a type of tree resin known as boswellia.

Yoga may be able to reduce chronic lower back pain and improve function while lessening symptoms of anxiety and depression.
Meditation “may reduce blood pressure, symptoms of irritable bowel syndrome, anxiety and depression, and insomnia. Ultimately, deciding whether to take a painkiller as the first course of action to relieve pain or discomfort is up to the individual. However, seeking out information explaining the positive and negative aspects of a painkiller is recommended in order to make an informed decision.

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