Heartburn (सीने में जलन) — Complete Clinical Guide
- Definition & short intro
- Epidemiology & risk factors
- Pathophysiology & mechanisms
- Clinical features & alarm symptoms
- Differential diagnosis
- Investigations / Pathology tests
- Management overview
- Drugs — dosing tables
- Endoscopic & surgical options
- Diet — Foods to avoid & recommend
- Complications & long-term risks
- Pregnancy & special populations
- Follow-up & when to refer
- Patient counselling points
- FAQ
- References
Definition & Short Introduction
Heartburn (Hindi: सीने में जलन) आमतौर पर retrosternal burning sensation है जो gastro-oesophageal reflux (acid reflux) के कारण होती है — gastric contents का oesophagus में ascend कर के mucosa को irritate करना। जब reflux frequent या chronic हो तो इसे GERD (Gastroesophageal reflux disease) कहा जाता है। Heartburn का spectrum simple intermittent reflux से लेकर erosive reflux disease, Barrett's oesophagus और complications तक जा सकता है।
Internal links: related post — Skin Infection, Heart Disease Basics
Epidemiology & Risk Factors
Population surveys worldwide में heartburn और reflux के लक्षणों की prevalence उच्च पाई गई है — कई देशों में ~10–30% लोग महीने में कम-से-कम एक बार heartburn अनुभव करते हैं. Major risk factors में include करते हैं:
- Obesity (increased intra-abdominal pressure)
- Hiatus hernia — anatomical predisposition (hiatal hernia)
- Pregnancy (progesterone-mediated LES relaxation)
- Smoking, alcohol, caffeine, chocolate, peppermint, fatty meals
- Certain drugs — nitrates, calcium channel blockers, anticholinergics, benzodiazepines can reduce LES tone
- Delayed gastric emptying / gastroparesis
- Connective tissue disorders (e.g., scleroderma) affecting oesophageal motility
Source links embedded in References section.
Pathophysiology & Mechanisms
Heartburn एवं GERD के pathophysiologic mechanisms अक्सर multi-factorial होते हैं — clinician को समझना ज़रूरी है:
- LES dysfunction: reduced resting LES pressure or transient LES relaxations (TLESRs) — major mechanism for reflux.
- Hiatal hernia: loss of gastro-oesophageal junction integrity.
- Impaired oesophageal clearance: poor peristalsis leads to prolonged acid contact time.
- Delayed gastric emptying: increased gastric volume and pressure promoting reflux.
- Visceral hypersensitivity: some patients (functional heartburn) have heightened perception without pathological acid exposure.
Clinical implication: treatment must be tailored — acid suppression alone may not help in functional heartburn or hypersensitivity syndromes.
Clinical Presentation — Symptoms & Signs
Typical Symptoms
- Retrosternal burning sensation (postprandial or when recumbent)
- Acid regurgitation — sour/bitter taste
- Belching, water-brash (hypersalivation)
- Dysphagia (if oesophagitis / stricture)
- Chest pain resembling cardiac pain — always rule out cardiac ischemia when appropriate
Extra-oesophageal Symptoms
- Chronic cough, hoarseness, laryngitis, chronic throat clearing
- Asthma exacerbation in some patients (reflux-induced bronchospasm)
- Dental erosions (acid exposure to teeth)
Alarm features (red flags)
- Unintentional weight loss
- Progressive / persistent dysphagia (especially solids)
- Evidence of GI bleeding (hematemesis / melena)
- Iron-deficiency anemia
Presence of alarm features warrants prompt endoscopic evaluation (esophagogastroduodenoscopy — EGD).
Differential Diagnosis
Important differentials to consider:
- Cardiac ischemia / angina — chest pain evaluation important if risk factors present.
- Peptic ulcer disease
- Eosinophilic oesophagitis — especially young patients with dysphagia and food bolus obstruction
- Esophageal motility disorders (achalasia, diffuse oesophageal spasm)
- Functional heartburn (visceral hypersensitivity without objective reflux)
Investigations / Pathology Tests
Diagnostic approach depends on clinical scenario (typical symptoms without alarm features vs alarm/refractory disease).
Initial approach
- Empiric PPI trial: In typical heartburn without alarm features, many guidelines recommend an 4–8 week once-daily PPI trial as both diagnostic and therapeutic test. If complete response → step-down strategy considered. (PPI)
Investigations for refractory or alarm features
- Upper GI endoscopy (EGD): evaluate oesophagitis, peptic strictures, Barrett's oesophagus (biopsy if indicated).
- Ambulatory 24-hour pH monitoring or pH-impedance: gold standard for quantifying acid exposure and correlating symptoms—useful when endoscopy is normal and symptoms persist.
- High-resolution oesophageal manometry: assesses oesophageal motility and LES pressures — required before anti-reflux surgery.
- H. pylori testing: urea breath test / stool antigen / biopsy-based tests — important if dyspepsia or ulcer history.
- Blood tests: CBC (anemia), LFTs/renal profile if planning long-term therapy or surgery.
- Imaging: Barium swallow may show large hiatal hernia or strictures but less sensitive than endoscopy for mucosal lesions.
Note: pH-impedance testing detects non-acid reflux too — useful for patients on PPI with persistent symptoms.
Management — Stepwise Approach
Goal: symptom relief, mucosal healing (if present), prevention of complications, improve quality of life, and treat underlying causes (e.g., H. pylori or gastroparesis) where indicated.
1. Lifestyle & behavioral measures (foundation)
- Weight reduction in overweight/obese patients (strong evidence for symptom improvement)
- Avoid trigger foods and beverages (details below)
- Avoid lying down for at least 2–3 hours after meals; elevate head of bed by 15–20 cm (6–8 inches)
- Stop smoking and reduce alcohol intake
- Small, frequent meals; avoid late-night heavy meals
2. Stepwise pharmacotherapy
- Antacids / alginates: for immediate symptomatic relief (OTC)
- H2 receptor antagonists (H2RAs): for mild/moderate symptoms or nocturnal relief
- Proton pump inhibitors (PPIs): first-line for frequent/severe symptoms and healing of erosive oesophagitis — typical 4–8 week trial
- Prokinetics: e.g., metoclopramide/domperidone for symptoms with gastroparesis or delayed gastric emptying (use with caution/monitor side effects)
3. Refractory disease
- Evaluate with pH-impedance, manometry, and consider surgical options (e.g., Nissen fundoplication) if proven pathologic reflux and failed or unsuitable for long-term medical therapy
- Pain modulation strategies (e.g., neuromodulators) can help in oesophageal hypersensitivity — specialist input required
Drugs — Practical Dosing Tables & Notes
नीचे सामान्य वयस्क निर्देश (adult) दिए गए हैं। Pediatric dosing weight-based होती है — paediatric gastroenterology reference देखें। Dose adjustments required in renal/hepatic impairment for some agents.
Proton Pump Inhibitors (PPIs)
| Agent | Typical adult dose | Indications / Notes |
|---|---|---|
| Omeprazole | 20 mg once daily, 30–60 minutes before breakfast; erosive oesophagitis may need 20–40 mg once daily or 40 mg BD for severe disease (specialist). Typical trial 4–8 weeks. | Well-studied; many drug interactions (check clopidogrel, CYP interactions). Use lowest effective dose for maintenance. |
| Pantoprazole | 40 mg once daily (oral); IV 40 mg for hospitalized patients where PO not possible. | Fewer CYP interactions vs omeprazole in some studies. |
| Lansoprazole | 15–30 mg once daily | Alternate PPI option |
H2 Receptor Antagonists (H2RAs)
| Agent | Adult dose | Notes |
|---|---|---|
| Famotidine | 20 mg once daily or 20 mg twice daily for nocturnal symptoms | Useful for mild symptoms; tachyphylaxis may develop with continuous use |
Antacids & Alginates (OTC)
- Antacids: magnesium hydroxide, aluminium hydroxide, calcium carbonate — PRN for symptomatic relief
- Alginates (e.g., sodium alginate & antacid combos) — form a raft and reduce reflux episodes — useful postprandially
Prokinetics
| Agent | Adult dose | Notes / Safety |
|---|---|---|
| Metoclopramide | 10 mg up to QID (but limit duration due to extrapyramidal side effects / tardive dyskinesia risk) | Short-term use; caution elderly; avoid long-term high-dose therapy |
| Domperidone | 10 mg TDS (local guidelines vary) | Cardiac QT prolongation risk — ECG & drug interaction check advised |
Sucralfate
1 g PO QID (before meals/bedtime) as mucosal protectant — useful in certain erosive disease settings or as adjunct; binds to mucosa and has local protective effects.
H. pylori therapy (if tested positive)
H. pylori eradication regimens vary — typical triple therapy (PPI + clarithromycin + amoxicillin/metronidazole) or bismuth quadruple therapy depending on local resistance patterns. Follow national guidelines for exact regimens and durations (usually 10–14 days).
Endoscopic & Surgical Options
For carefully selected patients with proven pathologic reflux and persistent symptoms despite optimal medical therapy — options include:
- Nissen fundoplication (laparoscopic): 360° fundoplication to restore LES competence — requires pre-op manometry & pH testing.
- Partial fundoplication: 270° or others based on motility.
- LINX magnetic sphincter augmentation: device placed around LES to augment barrier function — device-specific selection criteria.
- Endoscopic therapies: e.g., radiofrequency (Stretta) — variable evidence; discuss with specialist.
Surgical choice individualized — discuss risks (dysphagia, gas bloat) and long-term outcomes.
Diet — Foods to Avoid & Recommend
Foods commonly associated with triggering heartburn (avoid / limit)
- Fatty & fried foods (delay gastric emptying)
- Chocolate (relaxes LES)
- Mint / peppermint
- Caffeine (coffee, tea) & carbonated drinks
- Tomato-based products, citrus fruits (acidic)
- Spicy foods (may irritate)
- Alcohol (reduces LES tone)
Recommended foods & practices
- Lean proteins, non-citrus fruits, vegetables
- Smaller, frequent meals; avoid large meals before bedtime
- Low-fat dairy (as tolerated), oat-based breakfasts
- Weight-loss diets where indicated; Mediterranean-style diet may help overall GI health
- Keep head elevated at night; sleep on left side may reduce nocturnal reflux events
Complications & Long-term Risks
- Erosive oesophagitis — mucosal breaks on endoscopy
- Peptic strictures — progressive dysphagia requiring dilation
- Barrett's oesophagus — columnar metaplasia of distal oesophagus; premalignant lesion associated with increased adenocarcinoma risk (Barrett's oesophagus) — surveillance protocols exist
- Esophageal adenocarcinoma — relative risk increased in long-standing Barrett's (rare on population basis)
Surveillance & management for Barrett's per gastroenterology guidelines (biopsy protocols, surveillance intervals, endoscopic therapy for dysplasia).
Heartburn in Pregnancy & Special Populations
Pregnancy commonly causes reflux due to progesterone-induced LES relaxation and increased intra-abdominal pressure. Management focuses on lifestyle modifications first (smaller meals, avoid triggers, elevation of head). Antacids (calcium carbonate), alginates and H2RAs considered safe; PPIs (omeprazole/pantoprazole) used when needed — obstetric consultation advised. Avoid certain agents contraindicated in pregnancy. Breastfeeding considerations: choose compatible drugs and consult lactation guidance.
Follow-up, Monitoring & When to Refer
- Assess response after 4–8 weeks of PPI therapy: full response suggests acid-mediated disease; consider step-down to lowest effective dose.
- If inadequate response: proceed to pH-impedance testing and manometry to phenotype (true reflux vs hypersensitivity vs functional).
- Refer to gastroenterology for alarm features, refractory disease, consideration of anti-reflux surgery, or suspicion of Barrett's / neoplasia.
- Long-term PPI use require periodic review for indication and adverse effects (nutrient deficiencies, infection risk).
Patient Counselling Points (Simple language / for patients)
- Heartburn common and often manageable with lifestyle & medicines.
- Take PPIs before breakfast for best effect; do not stop abruptly without discussing with your doctor.
- Report alarm symptoms (weight loss, difficulty swallowing, vomiting blood) immediately.
- Treat underlying causes — weight loss, smoking cessation, changing precipitating medications if possible.
FAQ — Short Answers
क्या heartburn हमेशा दिल का दर्द (heart attack) नहीं होता?
नहीं — heartburn अक्सर acid reflux से होता है; पर chest pain का मूल्यांकन जरूरी है, खासकर यदि risk factors हों या pain atypical हो।
कितनी देर PPI लेना चाहिए?
रूटीन के लिए 4–8 हफ्तों का trial आम है; कुछ रोगियों को maintenance dose की जरूरत होती है। Long-term therapy पर clinician से risks/benefits पर चर्चा करें।
क्या H. pylori eradication से heartburn ठीक हो जाएगा?
H. pylori eradication peptic ulcer disease/ dyspepsia में लाभ देता है; अत्यधिक reflux वाले रोगियों में यह हमेशा heartburn cure नहीं करता — test & treat per indications.