Understanding heartburn: symptoms, causes and treatment

Heartburn is a common condition and refers to a burning sensation in your upper chest, specifically, behind or just below your breastbone (sternum). Most people will occasionally experience heartburn, often after eating a large, spicy and/or fatty meal. However, if you experience heartburn more than two to three times a week and/or it is reducing your quality of life, it is important to see your GP. 

Causes of heartburn

The most common cause of heartburn is acid reflux, where stomach acid leaks out of your stomach and into your gullet (oesophagus). This is due to weakness in the ring of muscle located where your oesophagus connects to your stomach called the lower oesophageal sphincter. 

Heartburn caused by acid reflux is often triggered by spicy and/or fatty foods and fizzy and/or caffeinated drinks. However, it can also be triggered by certain health conditions. This includes gastroparesis (delayed gastric emptying), where it takes longer than normal for your stomach contents to pass into your small intestine. Consequently, your stomach becomes distended, making it easier for stomach acid to escape into your oesophagus. 

A hiatus hernia can similarly increase your risk of acid reflux and, therefore, heartburn, as it causes part of your stomach to push up into your chest area by protruding into your oesophagus. 

Certain medications that relax your lower oesophageal sphincter can also increase your risk of heartburn due to acid reflux. This includes non-steroidal anti-inflammatory drugs (NSAIDs), muscle relaxants, high doses of paracetamol, and bisphosphonates used to treat osteoporosis.

In some cases, physical activity can cause stomach acid to be pushed upward into your oesophagus, resulting in heartburn eg bending over and lifting heavy objects. Wearing very tight clothes can have a similar effect.

Conditions that do not cause acid reflux but can mimic the sensation of heartburn include motility disorders of the oesophagus where the muscles of the oesophagus contract abnormally, gallstones and inflammation of the gallbladder.

Risk factors for heartburn

Certain lifestyle factors can increase your risk of heartburn. This includes eating spicy, fatty and/or acidic foods, drinking caffeinated and alcoholic beverages, and smoking. Stress and anxiety can also worsen symptoms of heartburn. 

Another significant risk factor is being overweight or obese, as carrying extra weight puts greater pressure on your abdomen, which increases the risk of your stomach contents being pushed upwards into your oesophagus and triggering heartburn. 

Pregnancy also makes heartburn more likely due to both hormonal changes that relax the lower oesophageal sphincter and increasing pressure applied to the stomach by the growing baby. 

Age is another risk factor for heartburn as the lower oesophageal sphincter becomes weaker in older people.

When to see a doctor

Occasional heartburn is not a cause for concern; however, if it occurs more than two to three times a week and/or it is reducing your quality of life, see your GP. 

Similarly, if you have tried over-the-counter medications, but they are no longer effective and your symptoms are getting worse, it is time to see your GP. Depending on your symptoms, they may refer you for further investigations. 

You should also see your GP urgently if your heartburn occurs alongside increased difficulty swallowing (dysphagia) liquids or solid foods, or unintentional weight loss. 

Treating heartburn

Heartburn due to acid reflux can be managed through simple lifestyle changes, including avoiding fatty, spicy and acidic foods, reducing how much alcohol and how many caffeinated beverages you drink, eating smaller but more frequent meals and quitting smoking. 

To reduce night-time symptoms, you can raise your head and shoulders on a pillow and avoid eating at least two hours before bedtime. 

If you are overweight or obese, losing any excess weight can help reduce the frequency and severity of your bouts of heartburn. 

You can also take over-the-counter antacids or reflux suppressants. However, if these aren't effective, your doctor can prescribe medications to reduce how much stomach acid you produce. 

Complications of heartburn

Left untreated, heartburn can reduce your quality of life and if your symptoms persist at night, it can also interfere with your sleep. 

Persistent irritation of your oesophagus and/or back of your throat due to acid escaping from your stomach can lead to aspiration, where some of your stomach contents pass into your airways. This can lead to frequent chest infections. 

Persistent irritation of your lower oesophagus by stomach acid can also cause oesophagitis, that is, inflammation of your oesophagus. This can cause scar tissue to develop along your oesophagus, which leads to narrowing and can make swallowing difficult. 

Long-term heartburn due to acid reflux can cause changes in the cells that line your oesophagus. This is called Barrett’s oesophagus and increases your risk of oesophageal cancer.