Heartburn and acid reflux

Definition and Overview
Heartburn and acid reflux are closely related digestive conditions. Acid reflux occurs when stomach acid flows back into the esophagus due to a weak or relaxed lower esophageal sphincter (LES). Heartburn is the burning sensation in the chest or throat caused by this acid backflow. Persistent or severe acid reflux is referred to as gastroesophageal reflux disease (GERD).

Causes

• Weak or relaxed LES muscle

• Obesity or being overweight

• Hiatal hernia

• Pregnancy (due to hormonal changes and abdominal pressure)

• Smoking and alcohol consumption

• Certain foods: fatty, spicy, chocolate, caffeine, citrus, tomatoes, peppermint

• Lying down or bending after eating

• Medications such as NSAIDs, calcium channel blockers, bisphosphonates, and certain antidepressants

Symptoms

• Burning chest pain (heartburn), often after meals or at night

• Regurgitation of sour or bitter-tasting fluid

• Difficulty swallowing (dysphagia)

• Chronic cough, hoarseness, or sore throat

• Feeling of a lump in the throat

• Worsening symptoms when lying flat or bending forward

Complications (if untreated)

• Esophagitis (inflammation of the esophagus)

• Esophageal ulcers

• Strictures (narrowing of the esophagus)

• Barrett’s esophagus (precancerous changes)

• Increased risk of esophageal cancer

Diagnosis

• Clinical history and symptom review

• Upper endoscopy (to check for inflammation or complications)

• Ambulatory pH monitoring (measures acid exposure in the esophagus)

• Esophageal manometry (measures muscle function of the esophagus)

• Barium swallow X-ray

Treatment

Lifestyle and Self-care

• Eat smaller, more frequent meals

• Avoid trigger foods and drinks (fatty, spicy, acidic, caffeinated, carbonated)

• Maintain a healthy weight

• Avoid lying down within 2–3 hours of eating

• Elevate the head of the bed

• Stop smoking and limit alcohol

Medications

• Antacids (neutralize stomach acid, for quick relief)

  • Generic: calcium carbonate, magnesium hydroxide, aluminum hydroxide

  • Dose: as directed, usually after meals and at bedtime

• H2 Receptor Antagonists (H2RAs) (reduce acid production, slower but longer relief)

  • Generic: ranitidine (withdrawn in many markets), famotidine, nizatidine

  • Dose: famotidine 20–40 mg orally once or twice daily

• Proton Pump Inhibitors (PPIs) (most effective for healing and long-term control)

  • Generic: omeprazole, esomeprazole, pantoprazole, lansoprazole, rabeprazole

  • Dose: omeprazole 20–40 mg orally once daily before meals; similar dosing for others

• Prokinetic agents (enhance gastric emptying, less commonly used due to side effects)

  • Generic: metoclopramide 10 mg orally up to four times daily before meals and at bedtime

Surgical Options (for severe or resistant GERD)

• Nissen fundoplication (strengthens the LES by wrapping the upper stomach around the esophagus)

• LINX device (magnetic ring placed around LES to prevent reflux)

Precautions

• Long-term PPI use may increase risk of kidney disease, osteoporosis-related fractures, and infections (e.g., Clostridioides difficile)

• Avoid self-medicating for long periods without medical supervision

• Seek urgent care if experiencing chest pain with sweating, shortness of breath, or radiation to arm/jaw (to rule out heart attack)

Drug Interactions

• PPIs may reduce absorption of drugs needing stomach acid (e.g., ketoconazole, atazanavir)

• Omeprazole and esomeprazole inhibit CYP2C19, reducing effectiveness of clopidogrel (antiplatelet)

• H2RAs may interact with warfarin, phenytoin, theophylline (especially cimetidine, which has many drug interactions)

• Metoclopramide should not be combined with antipsychotics or other dopamine antagonists (risk of extrapyramidal symptoms)