What Causes Heartburn?

Heartburn is a burning, hot, sour or uncomfortable sensation felt in the upper abdomen, over the stomach, or behind the breastbone. In some people it comes on after meals; in others it becomes noticeable at night on lying down, or when the stomach is empty.

Heartburn is a very common complaint. Most of the time it is not due to a serious disease. Heartburn that recurs often, lasts a long time, or comes with other symptoms should nevertheless be investigated.

What are the commonest causes of heartburn?

Gastro-oesophageal reflux

One of the commonest causes of heartburn is gastro-oesophageal reflux. The stomach contents escaping back towards the gullet can cause burning and irritation there.

In reflux, the burning may be accompanied by:

• Burning behind the breastbone
• A bitter or sour taste coming up into the mouth
• Symptoms worsening after meals
• Burning becoming more marked on lying down or bending forwards
• A night-time cough or irritation in the throat
• Belching and bloating

Gastritis

Inflammation or irritation of the inner surface of the stomach can cause burning, pain, nausea and indigestion in the upper abdomen.

Helicobacter pylori infection, the use of certain painkillers and a range of other conditions may be associated with gastritis.

Gastric and duodenal ulcer

Ulcers that develop in the stomach or the duodenum can cause a burning or gnawing pain in the upper abdomen.

How the complaint relates to meals varies from person to person. Helicobacter pylori infection and the use of certain painkillers are among the important causes.

Functional dyspepsia

Although gastroscopy and other investigations show no obvious structural disease, some people have long-standing:

• burning over the stomach,
• early satiety,
• fullness after meals,
• pain in the upper abdomen.

This picture is called functional dyspepsia.

Foods and drinks

Although it is not the same for every patient, in some people:

• excessively fatty or heavy meals,
• very large portions,
• coffee,
• chocolate,
• alcohol,
• the spicy or acidic foods that trigger the complaint in that particular person

can increase the burning.

For this reason, rather than giving everybody the same long “list of forbidden foods”, it is a sounder approach for each person to identify the foods that increase their own symptoms.

Why does heartburn occur at night?

On lying down, the protective effect of gravity is reduced, and the stomach contents may escape into the gullet more easily.

Eating a large meal late in the evening, and lying down shortly after eating, can increase night-time symptoms in particular.

For people who have night-time burning, stopping eating about three hours before going to bed, as far as this is possible, may help.

What helps heartburn?

Treatment should be determined first of all by the cause of the burning.

In some people the following measures may help:

• Avoiding very large meals
• Not lying down immediately after eating
• Losing weight, in those who are overweight
• Not eating late at night if there are night-time symptoms
• Stopping smoking, if the person smokes
• Reducing the foods and drinks that have been found to increase that person’s own symptoms

Where reflux or an acid-related disease is suspected, acid-suppressing medicines may be used after assessment by a doctor. Where the complaint is long-standing or recurrent, however, it is important to evaluate the underlying cause rather than merely suppressing the symptoms with medication.

Is gastroscopy needed for every case of heartburn?

No.

Gastroscopy is not obligatory at the outset in every young patient who has typical reflux symptoms and no alarm features.

In certain situations, on the other hand, gastroscopy or other investigations may be required.

Which symptoms matter?

If heartburn is accompanied by any of the following, seeing a doctor is particularly important:

• Difficulty swallowing
• Pain on swallowing
• Recurrent or persistent vomiting
• Blood in the vomit
• Black, tar-coloured stools
• Unexplained weight loss
• Anaemia
• Loss of appetite
• Newly started symptoms that are steadily increasing
• Symptoms that persist despite treatment

Does burning in the chest always come from the stomach?

No. This distinction is very important.

Chest pain or burning due to heart disease can sometimes be mistaken for reflux.

In particular, where a newly started complaint of pressure, tightness or burning in the chest is accompanied by breathlessness, sweating, nausea, or pain radiating to the arm, the back or the jaw, it must not be assumed that this arises from the stomach, and urgent medical assessment is required.

How is the cause of heartburn established?

The doctor first assesses:

• how long the complaint has been present,
• its relationship to meals,
• whether it comes on at night,
• the medicines being taken,
• the other symptoms accompanying it.

Depending on the patient’s condition, Helicobacter pylori tests, gastroscopy, blood tests, oesophageal pH/impedance studies or other investigations may be required.

Remember

Heartburn is not the name of a disease; it is a symptom.

Although reflux is one of the common causes, gastritis, ulcer, functional dyspepsia and a range of other diseases can cause similar complaints.

In heartburn that recurs often or has been going on for a long time in particular, the aim is not merely to settle the burning but to establish what is causing it.