Recurring heartburn is a burning feeling that rises behind the breastbone, usually after a meal or when lying down, sometimes with a sour or bitter taste in the mouth. Heartburn now and then after a heavy meal is ordinary. When it appears twice a week or more, wakes you from sleep or persists despite medication, it may be reflux, a condition in which stomach contents rise again and again into the esophagus. It is worth seeing a gastroenterologist when heartburn lasts for weeks, or when there is difficulty swallowing, unexplained weight loss, repeated vomiting or signs of bleeding.
What happens in the body during heartburn
Between the esophagus and the stomach sits a ring of muscle that works like a valve. It opens to let food into the stomach and closes straight afterwards. When the valve relaxes or opens at the wrong time, stomach acid rises into the esophagus. The lining of the stomach is built to withstand acid, but the lining of the esophagus is far more sensitive, and that is where the burning comes from.
A brief rise of acid happens to everyone, mainly after meals, and is not considered a disease. Doctors speak of reflux when the rise is frequent, causes symptoms that interfere with daily life or damages the lining of the esophagus. Sometimes the cause is a hiatal hernia, in which a small part of the stomach slides upwards through the diaphragm and weakens the valve.
How reflux shows up beyond heartburn
Heartburn is the most familiar symptom, but reflux can appear in other ways, and it is not always easy to connect them to the stomach:
- Sour fluid or food rising into the throat and mouth, mainly when bending over or lying down.
- A dry cough that lasts for weeks, mainly at night or after meals.
- Hoarseness in the morning, frequent throat clearing and a feeling of a lump in the throat.
- Chest pain or pressure that is not related to exertion.
- Bad breath and erosion of tooth enamel.
- Broken sleep because of waking with a sour taste or a cough.
Chest pain always calls for caution. Pressing pain that appears with exertion, spreads to the arm or jaw or comes with shortness of breath and sweating is an emergency that needs immediate medical help, even in someone with a history of heartburn.
What makes heartburn worse
Several factors raise the pressure in the abdomen or relax the valve between the esophagus and the stomach, and so increase the rise of acid:
- Large meals, especially in the evening, and lying down soon after eating.
- Fatty and fried food, chocolate, mint, coffee, fizzy drinks and alcohol.
- Tomatoes, citrus fruit and spicy food, which irritate a lining that is already sensitive.
- Smoking, which relaxes the valve and reduces the saliva that neutralises acid.
- Excess weight, mainly around the abdomen, and pregnancy.
- Clothes and belts that press on the abdomen.
- Certain medicines, including some painkillers and blood pressure medicines. Do not stop a regular medicine without talking to your doctor.
Sensitivity to foods differs from person to person. A short diary kept for two weeks, noting what you ate and when the heartburn appeared, helps identify your own triggers without giving up foods that have nothing to do with the problem.
What you can do at home
For many people a change of habits reduces heartburn considerably, and it is worth starting before medication or alongside it:
- Eat smaller meals and finish the evening meal about three hours before going to bed.
- Raise the head of the bed by about ten to twenty centimetres. Extra pillows under the head bend the abdomen and do not help to the same degree.
- Sleep on your left side, a position that reduces the rise of acid.
- Gradually cut down the foods that the diary identified as triggers.
- Stop smoking and reduce alcohol.
- Lose weight if there is an excess. Even a moderate loss often eases the symptoms.
Antacids sold without a prescription give quick relief for occasional heartburn. When you need them several times a week over a long period, it is a sign to be examined and not to continue treating yourself.
When heartburn needs a medical work-up
Most heartburn is not dangerous, but there are situations in which it is important to find the cause and not settle for symptom relief. It is worth booking a visit with a private gastroenterologist in Modi’in in these situations:
- Heartburn that appears twice a week or more for several weeks.
- Heartburn that does not improve after a few weeks of medication, or that returns as soon as the medication stops.
- Difficulty swallowing, pain on swallowing or a feeling that food gets stuck on the way down.
- Unexplained weight loss or a persistent lack of appetite.
- Repeated vomiting, vomiting blood or black stools.
- Anemia found on blood tests.
- Heartburn that appears for the first time after the age of fifty.
- A cough, hoarseness or waking at night that go on for a long time.
Difficulty swallowing, vomiting blood and black stools are signs that should not be put off. In these situations see a doctor promptly, and in the case of significant bleeding go to the emergency room.
What the gastroenterologist checks
The visit begins with a detailed conversation: when the heartburn appears, what makes it worse and what eases it, which medicines you take and whether there are warning signs. In younger patients with typical symptoms and no warning signs, the doctor usually suggests a trial of a medicine that reduces acid production for a few weeks. A clear improvement supports the diagnosis, and no further tests are needed.
When there are warning signs, when the symptoms do not respond to treatment or when they have lasted for years, the doctor refers you for a gastroscopy. In this test a thin flexible tube with a camera is passed through the mouth, and the doctor sees the lining of the esophagus, the stomach and the duodenum. It can identify inflammation of the esophagus, a hiatal hernia, an ulcer or changes in the lining, and a small sample can be taken if needed. The test is usually carried out under sedation and takes only a few minutes.
When the diagnosis is unclear, there are tests that measure the acid level in the esophagus over a full day and the function of the esophageal muscles. Sometimes the doctor also checks for Helicobacter bacteria in the stomach, which are linked to ulcers and to inflammation of the stomach lining.
How reflux is treated
Treatment is built in steps. The foundation is the change of habits described above. On top of it comes medication: medicines that reduce acid production in the stomach allow the lining of the esophagus to heal and ease the symptoms in most patients. The doctor sets the dose and the length of treatment, and later considers whether it is possible to step down to the lowest dose that keeps the relief, or to move to treatment only when needed.
Long-term treatment needs follow-up. It is worth asking the doctor from time to time whether it is still necessary, and not continuing for years out of habit. On the other hand, treatment that was given for inflammation of the esophagus or another finding should not be stopped abruptly without advice.
In a minority of patients, mainly when there is a large hiatal hernia or when symptoms continue despite full treatment, surgery that strengthens the valve comes up as an option. The decision is made after a full work-up and a conversation about the benefits and the risks.
Why long-standing reflux should not be neglected
Acid that rises into the esophagus over years can cause chronic inflammation, ulcers and a narrowing that makes swallowing difficult. In a small share of patients the structure of the lining in the lower esophagus changes, a condition called Barrett’s esophagus that requires periodic follow-up by gastroscopy. These complications are uncommon, and they are the reason long-standing heartburn deserves an orderly work-up and not only temporary relief.
At EliteMed in the Ayala 360 complex in Modi’in you can book a visit with a digestive specialist without a referral, and the consultation can be held in English. If you are also due for bowel screening, read our guide to colonoscopy in Israel. The information here is general and does not replace an examination and advice from a doctor.
Frequently asked questions
How long can I take heartburn medicine without being examined?
Antacids without a prescription suit occasional heartburn. When you need them several times a week for more than two to three weeks, or when the heartburn returns as soon as you stop, it is worth seeing a doctor. The examination makes it possible to fit the right treatment and to make sure there is no other cause for the symptoms.
Does everyone with heartburn need a gastroscopy?
No. In younger patients with typical symptoms and no warning signs, it is accepted practice to start with a change of habits and a trial of medication. A gastroscopy is recommended when there is difficulty swallowing, unexplained weight loss, signs of bleeding or anemia, when the symptoms do not respond to treatment or when they have lasted for years.
Can heartburn cause a cough and hoarseness?
Yes. Acid that rises as far as the throat irritates the vocal cords and the airways, and can cause a dry cough, morning hoarseness and frequent throat clearing, sometimes without a clear feeling of heartburn. When these symptoms last for weeks, the doctor considers reflux alongside other causes.
How do I tell heartburn from pain that comes from the heart?
Heartburn usually appears after eating or when lying down and is eased by an antacid. Pain from the heart usually appears with exertion, feels like pressure, and can spread to the arm or jaw with shortness of breath and sweating. It is not possible to tell them apart with certainty by feeling alone, so new or unusual chest pain needs urgent medical assessment.
Is heartburn in pregnancy dangerous?
Heartburn is very common in pregnancy because of hormonal changes and the pressure of the uterus on the stomach, and it usually passes after the birth. Small meals, not eating before bed and raising the head of the bed help. Talk to your doctor before taking any medicine during pregnancy.