When, Why, and How Heartburn Strikes

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By Dr. Sanjay Gupta

Q&A with gastroenterologist Gina Sam, MD, of Mount Sinai Hospital.

“Gastroenterology is an extremely important field in public health,” says Gina Sam, MD, MPH, director of the Mount Sinai Gastrointestinal Motility Center at the Mount Sinai Hospital in New York. “[It] allowed me to see patients with very different diseases including GERD [gastroesophageal reflux disease], achalasia, inflammatory bowel disease, colon cancer, and irritable bowel syndrome.”

In the Q&A that follows, Dr. Sam discusses what causes heartburn, how it can be misdiagnosed, and when someone with symptoms should consult a gastroenterologist.

Heartburn symptoms occur when muscles at the bottom of the esophagus fail to keep stomach acids from backing up. What are some other digestive issues that can trigger it?

The symptoms of heartburn can be similar to a motility disorder called gastroparesis or “slow stomach.” This occurs usually in patients with diabetes when the high glucose levels cause the nerves of the stomach to not be able to move properly, which affects how food is digested. This condition causes heartburn because food sits in the stomach and ferments, and the acidic content goes into the esophagus and causes heartburn. These patients can have nausea, vomiting, and abdominal pain. Gastroparesis can also [have] unknown causes and [is] seen in patients with anxiety and depression.

One disease that can mimic heartburn is another motility disorder called achalasia, where the lower esophageal sphincter does not relax and the esophagus does not contract. This is a pretty rare disease. Most patients will have difficulty swallowing solids and liquids, but a small portion may have heartburn that does not respond to cutting acidic foods out or acid-suppressing medications.

People usually turn to over-the-counter medications as a first line of defense against heartburn, but how do you know when it’s time to see a doctor?

Usually heartburn will respond to cutting out the triggers like tomatoes, high-fat foods, lemon juice, orange juice, chocolate, mints, or large meals. If a patient has symptoms despite doing the anti-reflux diet and taking acid-suppressing medications, then I would suggest that they see a gastroenterologist.

Heartburn symptoms can resemble signs of cardiovascular problems. How do you determine the underlying cause?

Cardiac and esophageal causes may share similar symptoms because the nerve supply is similar. Cardiac disease must be excluded in patients with unexplained chest pain with a workup including EKG [electrocardiogram] and cardiac enzyme [test]. Approximately 30 percent of chest pain patients undergoing cardiac catheterization [a procedure to diagnose and treat heart conditions] have findings which do not account for their chest discomfort, and are often defined as having “atypical chest pain” that may be due to heartburn. Many of these patients go on to have testing called esophageal manometry [which measures pressure in the esophagus while swallowing] and this will tell whether there are esophageal spasms, which can be due to heartburn.

Gastroesophageal reflux disease (GERD) is sometimes confused with indigestion. What is indigestion, and when is it cause for concern?

Indigestion, or dyspepsia, is quite common and often related to diet. It is a chronic or recurrent pain in the upper abdomen, upper abdominal fullness, and feeling full earlier than expected when eating. It can be associated with bloating, belching, nausea, or heartburn. Indigestion is frequently caused by gastroesophageal reflux disease or gastritis. In some patients, it may be the first symptom of peptic ulcer disease — an ulcer of the stomach or duodenum [the first section of the small intestine] — and occasionally cancer. Unexplained newly onset dyspepsia in people over 55 or the presence of other alarming symptoms, like weight loss, anemia, blood in the stool, or vomiting blood, will require an evaluation by a gastroenterologist.

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