Heartburn: When Should You Be Concerned?
Almost everyone has experienced heartburn. Usually, it passes, but recurring symptoms that disrupt daily life warrant medical evaluation.
“Heartburn is the symptom,” explains Professor Amir Klein, director of the Gastroenterology Institute at Rambam Health Care Campus. “In most cases, it is caused by gastroesophageal reflux, but nothing in medicine is absolute. Bile reflux is another possibility.”
Reflux occurs when stomach contents flow back into the esophagus. A hiatal hernia, a weakened lower esophageal sphincter or increased abdominal pressure can contribute. Stress can intensify symptoms, while altered communication between the brain and esophagus can cause functional heartburn, which requires a different treatment approach. Physicians must rule out cardiac and other dangerous causes before attributing chest pain to reflux.
About 10% of people experience heartburn weekly. Occasional symptoms do not necessarily indicate gastroesophageal reflux disease (GERD), but persistent symptoms may require medication and investigation.
Who is at risk?
Age, obesity, and smoking are significant risk factors, and men tend to develop more severe disease. Studies have also linked greater alcohol consumption to reflux. Some weight-loss medications can worsen symptoms, even though weight loss generally improves them.
“Smoking reduces saliva production,” explains Professor Klein. “Saliva helps neutralize acid in the esophagus, so reduced production can increase acid exposure.” Smoking also increases the risk of reflux complications and esophageal cancer.
What complications can develop?
Most people do not develop complications, but prolonged reflux can damage the esophagus, particularly without treatment.
“Some people develop esophagitis, or inflammation of the esophagus,” says Professor Klein. “During an upper gastrointestinal endoscopy, we can see damage to the lining: redness, erosions, and sometimes ulcers."
Scarring can narrow the esophagus, making swallowing difficult. Another complication is Barrett’s esophagus, a precancerous change in the lining. A small proportion of patients with this condition develop esophageal cancer.
How is reflux diagnosed?
Physicians can often begin treatment based on typical symptoms. An unclear diagnosis, persistent symptoms despite treatment, or warning signs require further investigation.
“Difficulty or pain when swallowing, bleeding, or weight loss are red flags,” comments Professor Klein.
During an upper gastrointestinal endoscopy, physicians use a flexible tube with a camera to examine the esophagus and stomach.
A normal endoscopy does not rule out reflux. Additional tests can measure esophageal acid exposure or help identify other causes of symptoms.
Treatment
Treatment depends on symptom frequency, severity, and esophageal damage. Lifestyle changes may help: losing excess weight, quitting smoking, reducing alcohol consumption, and avoiding foods or drinks that trigger symptoms.
Over-the-counter antacids can relieve occasional heartburn. Frequent or severe symptoms may require proton pump inhibitors (PPIs), which reduce stomach acid production and help heal esophagitis.
When medication provides insufficient relief or patients cannot take it long-term, physicians may consider surgery. One option is fundoplication, in which the surgeon wraps the upper stomach around the lower esophagus to reinforce the barrier against reflux, sometimes repairing a hiatal hernia during the same procedure.
Two endoscopic techniques available in Israel allow physicians to strengthen this junction through the mouth, without conventional surgery. These procedures suit selected patients only and physicians must first confirm that GERD causes their symptoms.
New treatment approaches for chronic heartburn and GERD are emerging, offering patients more options for managing persistent symptoms.
