As many as sixty million Americans suffer from heartburn. The vast majority of these people can find relief in over-the-counter medications from their local drugstore and by making adjustments in when and what they eat. But for some, the burning pain is actually a symptom pointing to a more serious problem. Below, Stuart Spechler, MD, Chief of the Division of Gastroenterology at the Dallas VA Medical Center, talks about heartburn, when you can safely self-medicate and how to recognize warning signs that warrant medical evaluation.
Symptoms for heartburn and heart attack are sometimes confused. What are the differences?
Heartburn is a burning sensation that's usually located in the chest. A lot of patients will say, "I feel it behind the breastbone. It's just a burning discomfort." Some people don't even call it a pain. They just say it's a sensation or an uncomfortable feeling.
A lot of patients describe their heartburn using an open hand to the chest. They move the hand up and down because it has kind of a rolling quality to it. That's very much different than patients who have angina from heart disease. A person who is having a heart attack might say, "Gee, that feels like a squeezing sensation," and they will often clench the fist over the chest.
Another good clue that a person is suffering from heartburn and not heart attack is if it occurs after meals. People sometimes get it if they eat a fatty meal, for example. And another very common feature of it is it goes away with medicines that eliminate acid. So either antacids, which you can buy over-the-counter, or medications that we have for treating the acid in the stomach, will typically stop the heartburn.
What are the alarm symptoms that accompany heartburn that should be evaluated?
There are a number of symptoms that, when experienced together with heartburn, warrant a trip to a physician for evaluation. If heartburn is accompanied by weightloss or if food gets stuck in your chest on the way down, it could be indicating something more than just simple heartburn, and we would be concerned about it. If you have heartburn and you have also thrown up blood, or if you notice that your stools have become black, that's a sign that there could be internal bleeding. If it hurts when you swallow, that is, whenever you're swallowing you're feeling pain in your chest at the same time, or if you're having fevers in association with any of these symptoms, you should be evaluated. So those are the symptoms that would say this is not just simple heartburn—that it could be more complicated.
Now, if you have just simple heartburn—meaning you have heartburn and none of these warning symptoms—then I think you could try some of the over-the-counter medications and see how they work for you.
Is frequent heartburn also a warning sign that something more serious could be happening?
We often see patients who complain of frequent heartburn, but there is no specific evidence that more frequent heartburn is more worrisome than occasional heartburn. Still, the most common advice is, "If you're getting frequent heartburn, get yourself evaluated," and I think that makes sense. But no one's ever shown that the person who has frequent heartburn is more at risk than the person who has intermittent heartburn.
How does the acid of heartburn pose a threat?
Heartburn is a warning that acid is getting into the esophagus. The reason we worry about it is because acid makes contact with the lining of the esophagus and it can damage the normal lining. When it heals back it is a different type of lining, a lining that looks more like the lining of the stomach and intestine. That's a condition we call Barrett's esophagus. The esophagus has changed to an intestinal type of lining.
You could look at it as the body's way of trying to protect itself. The small intestine and the stomach is normally is exposed to acid every day, and so it tends to be a more resistant type of lining. So you would think, "Well, that's great, the esophagus is just becoming more resistant." The trouble is, this more resistant lining also increases your risk for developing a cancer of the esophagus and that's what we really worry about.
How many people with heartburn develop cancer of the esophagus?
The odds are definitely in your favor not to develop any of those complications. Barrett's esophagus is found in 5 to 10% of people who have frequent heartburn symptoms—meaning at least once a week—and only 5 to 10% of people with Barrett's esophagus will develop a cancer of the esophagus. So it's a fairly small percentage of people with heartburn who are ever going to get a serious complication of the magnitude.
We don't know what causes some people with Barrett's esophagus to go on to develop cancer while others to just remain with benign disease, so the recommendation is that we recommend everybody with this condition have regular endoscopies at intervals of every three to five years, to look and see whether they're developing changes that are suggestive of cancer.
What advice would you give the 60 million Americans who suffer from heartburn?
I think most people who have heartburn will do very well with over-the-counter medications. If all their symptoms disappear with those medications, I think that they're probably just fine. If the heartburn persists, if it does not respond to over-the-counter medications, and if they have any warning symptoms, they should be evaluated by a physician.
