Heartburn

What is heartburn?

Heartburn is a painful, burning feeling in the middle of your chest. It’s not really in your heart, though. It’s caused by stomach acid rising into your esophagus (reflux), which runs through your chest, close to your heart. Heartburn is an occasional symptom for many people, and a chronic condition for others, occurring frequently. When it’s chronic, you might have GERD (gastroesophageal reflux disease).

Who gets heartburn?

Many people have heartburn occasionally. It can be triggered by an especially rich or acidic meal, or by extra abdominal pressure, such as during pregnancy. Heartburn that occurs regularly is a symptom of chronic acid reflux (GERD), which is also relatively common. Approximately 20% of people in the U.S. have GERD. Risk factors include having obesity (a body mass index or BMI greater than 30) and overweight (a BMI greater than 25), smoking and exposure to second-hand smoke.

What does heartburn feel like?

Heartburn feels like acid burning in your chest, which is pretty close to what it actually is. Your esophagus, the swallowing tube that begins at your throat, travels down through the middle of your chest to reach your stomach. Heartburn begins in this tube, but the feeling often radiates through your chest and sometimes into your throat. It’s a burning sensation that can be mild to severe.

When does heartburn occur?

You may notice heartburn more when:

• Lying down.
• Bending over.
• You had a late dinner.
• You had a rich, acidic or spicy meal.

How long does heartburn last?

Heartburn may last anywhere from a few minutes to a few hours. It should go away when the last meal you ate has passed out of your stomach. Once your stomach has emptied its contents, there should be nothing left to come back up (reflux). Depending on the meal, it can take two to five hours for your stomach to finish digesting. Rich and fatty meals take longer to break down in your stomach.

What are the other symptoms of heartburn?

It may be hard to tell the difference between heartburn and other types of chest pain. If you’re unsure about the type of pain you’re feeling, it’s always a good idea to discuss it with a healthcare provider. It may also help to focus on other symptoms that you might have with it. These accompanying symptoms can help you distinguish heartburn from a heart attack or from other esophageal disorders.

If your heartburn is from acid reflux, you may have:

• Burping.
• A sour taste in the mouth.
• Nausea.
• Regurgitation of food.

Other atypical symptoms of acid reflux, include:

• Stomach bloating and overfullness.
• Hiccups.
• Chronic cough.
• Worsening asthma.
• Sore throat.
• Laryngitis.
• Difficulty swallowing or feeling like there’s a lump in your throat.
• Chest pain similar to angina (noncardiac chest pain).

What causes heartburn?

When related to GERD, heartburn occurs when stomach juices, including acids and enzymes, backwash into your esophagus. Your stomach has a thick mucous lining that protects it from these substances, but your esophagus doesn’t. A valve at the bottom of your esophagus called the lower esophageal sphincter is supposed to keep stomach contents from coming back up. But sometimes it’s weak or doesn’t close all the way.

Different things can cause your lower esophageal sphincter to weaken or relax too much, such as:

• Inhaling smoke.
• Extra abdominal pressure from body weight, tight clothing or pregnancy.
• Hiatal hernia, when your stomach pushes up through your diaphragm.
• A heavy meal that stretches your stomach and stays in it longer.
• Indigestion and gas, when gas bubbles rise up through your GI (gastrointestinal) tract.
• Lying down too soon after eating.
• Certain foods, including coffee, chocolate, citrus fruits, mint and tomato sauce.
• Certain medications, including birth control pills and blood pressure medications.

Often, more than one of these factors contributes to acid reflux and heartburn.

Why am I suddenly getting heartburn when I’ve never had it before?

If heartburn is relatively new to you, and you haven’t recently changed your diet or lifestyle, you may be getting it for other reasons that can develop gradually over time. For example:

• Aging. Heartburn may develop or worsen as you age because your muscles weaken, including your lower esophageal sphincter.
• Weight gain. Most people gain weight gradually, but symptoms of weight gain (like heartburn) can appear suddenly when you reach a certain threshold.
• Medications. If you’ve recently changed or added new medications, ask your healthcare provider if they could be causing acid reflux.

Is heartburn always caused by acid reflux?

Heartburn is usually a disorder of the esophagus with acid reflux as the most likely cause. But there are a few other conditions that can cause the same sensation. For example:

• Esophageal ulcers. Ulcers are sores caused by erosion of the lining in your GI tract. They cause a telltale burning kind of pain. Ulcers in your esophagus are much less common than in your stomach or intestine. When they do occur, it’s usually due to acid reflux. But reflux isn’t the only possible cause. Overusing NSAIDs, like aspirin and ibuprofen, can also cause ulcers.
• Esophagitis. Severe inflammation in your esophagus may cause a burning sensation. Causes include GERD itself, viruses, fungal infections and certain medications. An allergic condition of the esophagus (eosinophilic esophagitis) can also lead to heartburn.
• Functional heartburn/reflux hypersensitivity. Functional gastrointestinal disorders are disorders of the gut-brain connection — how your nervous system conveys sensations in your digestive system to your brain. Functional heartburn feels like classic heartburn, but there’s no sign of acid reflux, erosion or inflammation. Reflux hypersensitivity is caused by non-acid reflux. Overactive nerves can contribute to the burning sensation (visceral hypersensitivity).

Is heartburn serious?

Occasional heartburn is uncomfortable, but it won’t do any real damage. In fact, some amount of acid reflux is normal, and most people don’t even feel it. If you’re feeling it, you may be getting more acid reflux than your esophagus can tolerate. If this happens occasionally, it’s a minor wound that will heal quickly. If it happens regularly though, your esophagus lining may not have enough time to heal in between.

When your esophagus lining is consistently injured, it can lead to long-term complications, like:

• Esophageal strictures. When the tissues lining your esophagus are constantly inflamed, eventually they might begin to replace themselves with scar tissue. Since the esophagus is essentially a long tube, that inflammation and scarring will cause your esophagus to narrow (stricture). This can lead to swallowing problems and food getting stuck in your esophagus.
• Intestinal metaplasia. Sometimes instead of scarring, the tissues undergo a different kind of change. It’s called intestinal metaplasia because they change to look more like the lining of your intestines. When it happens in your esophagus, it’s also called Barrett’s esophagus. This is considered a precancerous condition.
• Esophageal cancer. Only a small percentage of people develop esophageal cancer. But there’s a direct pathway from persistent inflammation (esophagitis) to cellular changes (Barrett’s esophagus) that lead to cancer. The risk increases the more severe your heartburn is and the longer it goes untreated.

Acid reflux that causes heartburn may also indicate other hidden problems in your digestive system. For example, you may have too much acid in your stomach, which can cause complications like gastritis and stomach ulcers. Acid reflux may also aggravate your asthma or other chronic respiratory conditions. If reflux rises into your throat, it can cause swelling and lead to ulcers and growths there.

How is heartburn diagnosed?

Heartburn is a feeling that you’ll describe to your healthcare provider. Most providers will recognize heartburn by its description. They may not need to investigate if it’s occasional or mild. But if they suspect you have a chronic condition, they might want to take a look at your esophagus for signs of damage. They may refer you to a gastroenterologist, a specialist in the GI tract, to diagnose you.

What tests will I have to evaluate my heartburn?

Tests to examine your esophagus include:

• Upper endoscopy. Endoscopy exams look at your organs from the inside. They involve passing an endoscope — a small, lighted camera on the end of a long tube — into your body. An upper endoscopy, also called an EGD procedure, examines your upper GI tract, from your esophagus to your stomach and into the top of your small intestine. The endoscope goes down your throat (with medication to make you comfortable). It can look for signs of esophagitis, hernia or Barrett’s esophagus.
• Esophageal pH test. This test involves implanting a wireless capsule into your esophagus, which detects the pH (acid levels) in your esophagus over time. It may be implanted during an upper endoscopy or through a nasogastric tube. It transmits readings to a receiver you wear on your waistband. You’ll also record your symptoms and the times they occur in a journal to compare with the readings. After a designated period, your healthcare provider will retrieve the capsule and collect the data.

What is the treatment for heartburn?

You can treat occasional heartburn at home with over-the-counter (OTC) medications and lifestyle adjustments. But for frequent heartburn, you might need prescription medications. Medications reduce the acid coming out of your stomach into your esophagus. But they don’t fix the original problem with your lower esophageal sphincter. If medications don’t work, you might need additional treatment.

Medications for heartburn include:

• Antacids. Antacids (like Tums® and Rolaids®) neutralize your stomach acid so that when reflux happens, it isn’t corrosive to your esophagus. They often have ingredients that may treat other symptoms, as well. For example, simethicone can help with gas, and magnesium can help relieve mild constipation. Antacids work great if you have occasional heartburn, but they can have side effects if you take them too often.
• Alginates. Alginates are naturally occurring sugars derived from seaweed. They help block acid reflux by floating on top of the acid, creating a physical barrier between the acid and your esophagus. You can get alginates by themselves if you can’t take antacids due to another condition. You can also get antacids that contain alginates to increase their impact.
• Histamine receptor antagonists (H2 blockers). These reduce stomach acid by blocking the chemical that tells your body to produce it (histamines). Some H2 blockers are available OTC, and some are by prescription only. You can take them more frequently than antacids, but they don’t always work long-term. If your body adapts to them, they can stop working effectively.
• Proton pump inhibitors (PPIs). These are stronger acid blockers that also promote the healing of the tissues. Your provider may prescribe them as a first-line treatment if your heartburn is relatively severe or you have signs of tissue damage in your esophagus. They’re 90% effective in reducing acid reflux. If you have esophageal ulcers, they’re the only medicine that helps heal them.

Additional treatments for heartburn might include:

• Antibiotics or antivirals for an infection.
• Topical steroids or dupilumab to treat the inflammation itself.
• Low-dose neuromodulators and complementary therapies for functional heartburn.
• Hernia repair surgery if your heartburn is caused by a hiatal hernia.

For GERD that doesn’t respond to medication — or as an alternative to long-term medication — your provider might suggest a procedure, such as:

• Nissen fundoplication. This is a minor surgical procedure to tighten the junction between your stomach and your esophagus. It’s very effective in treating GERD and its symptoms.
• Transoral incisionless fundoplication. This is the same procedure done nonsurgically, through an endoscope instead.
• LINX device. This is another minimally invasive surgery that implants a LINX device, a ring of tiny magnets that help keep the junction between the stomach and esophagus closed to reflux.

What is the prognosis for heartburn?

Heartburn is treatable. In the best-case scenario, you may be able to manage it by making some diet and lifestyle adjustments and keeping some antacids handy for occasional use. If you need them, long-term prescription medications are also very effective for acid reflux. Functional disorders can be trickier to manage, but with persistence and a combination of different therapies, they often improve over time.

What lifestyle changes can I make to manage heartburn?

To help prevent acid reflux:

• Eat smaller meals throughout the day. With less to digest, your stomach will produce less acid.
• Loosen your waistband. Abdominal pressure contributes to reflux. Weight loss can also help.
• Don’t go to bed with a full stomach. Wait three to five hours before lying down.
• Sleep on your left side. This positions your lower esophageal sphincter in an air pocket above your stomach contents. Lying on your back or your right side submerges the valve.
• Avoid trigger foods. Pay attention to which foods and drinks make your heartburn worse.
• Quit smoking. Heartburn is just one of many reasons to quit smoking. Your provider can help.

When should I seek medical care for heartburn?

See a healthcare provider if:

• You have heartburn on a weekly basis.
• You have atypical symptoms.
• You have difficulty swallowing or getting enough calories.
• You’re over the age of 60.
• You have chest pain that feels like angina (tightening or squeezing).
• Your treatment plan isn’t working.

A note from Cleveland Clinic

Occasional heartburn is common, and most people can manage it with small adjustments. But if you have it all the time, you may need medical care. Don’t leave chronic heartburn untreated. Pain in your esophagus usually means it’s being injured, and this can do real damage over time. Chronic heartburn may also be a sign of other problems that need treatment. See a healthcare provider about chronic heartburn.