Fuel for the fire

Think of your stomach as a finely crafted container built to hold acid. As long as the container does its job, the acid isn't likely to cause any trouble. But the valve that connects the stomach to the oesophagus sometimes leaks, allowing acid to splash upwards.
Normally, everything that's in the stomach is kept from escaping upward by a band of muscle called the lower oesophageal sphincter, or LES, located where the bottom of the oesophagus intersects with the stomach. The LES valve opens when you're swallowing food, but otherwise is supposed to be clamped tight. If it begins to open too easily, the contents of the stomach -- food or acid -- can back up into the oesophagus. The oesophagus isn't designed to handle acid, so the leakage usually causes discomfort and a burning pain.

Most people have heartburn every once in awhile. But if acid frequently escapes into your oesophagus, the pain will be a regular part of your life. This condition is known as gastroesophageal reflux disease, or GORD. Heartburn is the most important symptom of GORD, but it's not the only one. Instead of a searing pain, some people have a sour taste in their throat (acid regurgitation). Other symptoms include a pain in the chest, as if food was "stuck" there, and abdominal pain. Nausea may also be a symptom of GORD. Anything that weakens the valve can set the stage for heartburn and GORD. Diet is a common culprit. Large meals, fatty foods, citrus or tomato-based foods, chocolate, peppermint, and caffeine can all make the LES valve open abnormally. Alcohol can irritate the valve as well as the mucous membrane of the oesophagus. Smoking relaxes the valve, leading to symptoms of acid reflux; it can also cause the stomach to secrete more acid. Pregnancy and obesity put extra strain on the valve, often causing frequent heartburn.
Some people with severe, chronic heartburn have a hiatal hernia, a condition in which a small portion of the stomach slides up into the chest through the opening that the normal oesophagus passes through. This means the stomach joins the oesophagus higher in the chest, often leading to a weaker LES. The hernia is an anatomic abnormality, or defect, that may or may not be associated with GORD -- though recent studies suggest that it may contribute to the disease. (Many people with heartburn don't have hiatal hernias, and some hiatal hernias cause no symptoms.)

Heartburn -- or a heart attack?

Believe it or not, the symptoms of a heart attack can closely mimic the symptoms of heartburn and indigestion, especially among women.
You can avoid a potentially fatal mix-up by paying close attention to your symptoms. Heartburn usually ignites a burning pain that runs from your stomach to your breastbone, and it's often accompanied by a sour taste in your mouth. Heart attacks, on the other hand, may cause a prolonged heavy feeling or squeezing pain in your chest. (Angina, or heart pain, causes similar pain that lasts just a minute or two.) Although pressure chest pain is more commonly associated with heart disease, spasm of the oesophagus may cause the same symptoms. It's best to assume the pain is coming from the heart, get emergency help to rule the heart out as a cause, then focus on the oesophagus. Other potential symptoms of a heart attack include dizziness, nausea, sweating, shortness of breath, weakness, overwhelming anxiety, and pain that spreads into the jaw, shoulder, or down the arm.
Timing is also important. While heartburn usually flares up after a meal, heart attacks and angina are often triggered by exercise, but may come on at any time.


Trouble down the road

An occasional bout of heartburn isn't anything to worry about. But frequent bouts of pain may be a sign that your oesophagus is in danger. Over time, acid can eat away at the lining of the oesophagus, causing painful sores and even bleeding and scarring. This condition is called oesophagitis.

In some people with acid reflux, the oesophagus produces cells that closely resemble cells from the intestines. This condition is called Barrett's oesophagus. Barrett's oesophagus, in turn, increases the risk of cancer of the oesophagus -- the fastest increasing cancer in the Western world. If you have Barrett's oesophagus, your doctor will want to follow you regularly for signs of cancer by doing endoscopy on a regular basis.
So if heartburn is causing you pain or discomfort, or if you have trouble swallowing, see a doctor right away.
 
Controlling the burn

A few simple lifestyle changes -- perhaps combined with a couple of not-so-simple changes -- often bring great relief from heartburn. Even if your case is severe, a little self-help can go a long way. Here are some important steps to take:

• If you smoke, do whatever it takes to quit. This will not only improve your symptoms of GORD, but also greatly lower your risk of heart disease, cancer, and many other serious health problems.
• Avoid high-fat foods such as oils, fried foods, butter, and mayonnaise, and monitor your reactions to citrus, chocolate, mints, and any other items that give you trouble. Try to avoid the things that cause symptoms of heartburn, especially if they're on the above list.
• Eat smaller meals, and avoid those late-night snacks.• Try to eat three or four hours before getting into bed. Don't lie down within three hours of a meal, because lying flat just after eating is likely to result in a bad case of acid reflux.
• Go for a walk after meals if possible (this may also help with gas and bloating).• If heartburn bothers you at night, try raising the head of the bed four to six inches, perhaps by sliding blocks of wood under the bedposts. (Putting an extra pillow under your head probably won't help and can even make heartburn worse.) Lying on your left side or back seems to be better than lying on the right side of stomach.
• Lose weight if you're overweight: getting rid of a few pounds can make a big difference.• Avoid tight clothing, including restrictive belts and "control-top" underwear.• Don't bend over from your waist after a big meal.• Cut back on alcohol. Some specialists in GORD recommend gradually quitting alcohol entirely.• Eat more yoghurt. Although there is no firm data on this issue, some physicians interested in complementary medicine recommend this food to heartburn patients. Yoghurt with live cultures of beneficial bacteria may aid in digestion and help promote a healthy intestinal tract.
• Chewing an antacid tablet, as necessary, may offer relief by stimulating saliva as well as bathing the oesophagus with antacid. Chewing gum 30 minutes after a meal may also help prevent heartburn by stimulating saliva. Don't chew mint-flavoured gum, however, because that can affect the valve between your stomach and oesophagus. Because people tend to swallow air when they chew, it's also a good idea to avoid gum if you suffer from gas.

Should I try over-the-counter remedies?

When heartburn does flare up, an antacid usually brings quick relief. It works best when taken at the first sign of symptoms. Over time, however, regular doses of antacids that contain magnesium salts can cause diarrhoea, while antacids containing calcium can lead to constipation. (If they're taken for a long period of time, high doses of calcium salts can even cause kidney disease in rare cases.) For these reasons, some specialists, recommend that you not take antacids for more than a week at a time three or four times a year unless advised otherwise by your doctor. Antacids help relieve symptoms but don't promote healing of acid-induced damage.

In addition, taking antacids that are mint-flavoured, such as certain Tums, is a bad idea because mint can lower the pressure in the oesophageal sphincter, or valve, and make acid reflux more likely.
To prevent future attacks -- and break your antacid habit --you can try an over-the-counter H-2 blocker (Zantac 75, or Pepcid AC), which reduce the stomach's production of acid. (Many are also available in prescription strengths, see your GP.) The possible side effects of acid blockers include diarrhoea, rash, dizziness, nausea, and headache. Ideally, you should talk to your doctor before trying any of these remedies. Besides having side effects, these medications can interact with certain other drugs, particularly heart medications, in harmful ways. If heartburn is still a problem after a few weeks of self-treatment, don't put off that doctor's appointment any longer.
The medical approach

Your doctor may ask you a lot of questions about your diet and make suggestions for lifestyle changes that you can implement one by one. If your pain is severe and your heartburn isn't responding to lifestyle changes, your GP can offer several effective treatments for heartburn. One option is a prescription strength version of an H-2 receptor antagonist or other acid blocker. These medicines provide short-term relief, but should be used in conjunction with long-term lifestyle changes.

More severe cases of GORD may call for a relatively new medication known as a proton pump inhibitor, which strongly block the production of acid. Pill for pill, these drugs are more expensive than H-2 blockers, but they're also more effective. If you have severe GORD, proton pump inhibitors may be cheaper in the long run because it takes fewer pills to bring relief and they're the only drugs known to keep you in remission. They have also been shown to help heal sores in the oesophagus.

Proton-pump inhibitors rarely cause side effects, but they may cause headache, stomach pain, diarrhoea, or an allergic reaction. Even if you feel fine after taking the drugs, don't go on a binge and consume a lot of alcohol and fatty food: they'll irritate your GI tract even if you don't get heartburn.

In the rare event that medications and lifestyle changes fail to control your heartburn, surgery may be your best chance for long-term relief. Surgery may also be necessary if you have severe damage to your oesophagus or other complications. Although the surgery is not without risk, many patients who undergo such an operation are completely cured.