Heartburn is the name given to pain in the chest commonly associated with indigestion. As the name suggests the pain is often burning in nature and occurs in the central chest region over the heart. However the pain is not always a burning sensation and will sometimes radiate to the throat or jaw and occasionally the arms. In this respect heartburn pain can mimic angina. The pain of heartburn does not come from the heart but the oesophagus.
Anatomy of the Oesophagus
The oesophagus is the muscular tube that runs from the throat to the stomach. After swallowing food is passed down the oesophagus by muscular action to the sphincter at the junction with the stomach. The sphincter is a muscular ring which acts as a one-way valve preventing the stomach contents finding its way back into the oesophagus and up to the mouth.
Causes of Heartburn
Heartburn or indigestion occurs when stomach contents (acid, food and sometimes bile) enter the oesophagus and cause irritation; this is known as gastro-oesophageal reflux. There are various reasons for this, mostly to do with the sphincter at the junction of the stomach and oesophagus.
- Overweight: especially those with fat concentrated around the abdomen. The upward pressure of the fatty tissue on the stomach makes it more difficult for the sphincter to operate effectively.
- Pregnancy: again upward pressure, this time from the enlarged womb. It's also thought that hormonal changes in pregnancy weaken the sphincter.
- Diet: fatty foods, chocolate, coffee and alcohol are known to affect the muscles of the stomach – oesophageal junction. Eating large meals in the late evening can cause problems in some.
- Smoking: irritates the lining of the oesophagus, excess alcohol can do this as well.
- Posture: many sufferers find the problem worse when lying down or bending.
- Hiatus hernia: a condition in which the top end of the stomach protrudes through the diaphragm (it should only be the lower end of the oesophagus that does this). This will compromise the sphincter.
- Drugs: some medicinal drugs are known to cause heartburn particularly those which interfere with muscle action - drugs used for angina and hypertension for example.
- Neurological disease: any disease which affects the nervous control of muscles can interfere with proper functioning of the oesophagus.
Complications of Gastro-oesophageal Reflux
Heartburn caused by gastro-oesophageal reflux is very common but serious complications arising from it are rare. However they can occur when the irritation of the lining of the oesophagus turns into inflammation (oesophagitis), then swelling, bleeding and ulceration can result.
Barrett's Oesophagus
This is a particular type of complication of long standing oesophagitis. Over time the cells lining the lower part of the oesophagus change in nature and come to resemble the cells lining the stomach. It's easy to see why this occurs when the lower part of the oesophagus is constantly being exposed to the strong acid that normally stays in the stomach.
A proportion (around 1 in 10) of sufferers from Barrett's oesophagus will develop cancer in the area so it's important that those with this condition are monitored frequently.
Management of Gastro-oesophageal Reflux
Simple life style adjustments are usually all that is needed in many cases. Lose weight if appropriate, stop smoking, cut down on alcohol, chocolate, fat and coffee. Avoid eating late and raise the head of the bed so that gravity is helping to keep the food going the right way.
Medication is usually effective. Simple compounds such as antacids will neutralise stomach acid. Some of these contain alginates which form a barrier layer on top of the food in the stomach and prevent reflux.
Other drugs used are the proton pump inhibitors: these cut down the acid production by the stomach. Yet other classes of medication will increase the rate at which the stomach empties.
Gastro-oesophageal reflux is generally more of a nuisance than anything else, however, if your heartburn is severe or very persistent, if you have trouble swallowing or any unexplained voice hoarseness you should consult your doctor.
This article is for information only, if you have any health concerns at all you should seek professional advice.
Resources
Medicine Eds. Souhami and Moxham. Pub. Churchill Livingstone 2002
Case Notes by Dr Mark Porter. BBC Radio 4, 29 July 2009
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