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You’ve just eaten a big meal and leaned back in your favorite chair. Then it happens. Your chest starts to hurt so much it feels like it’s on fire.
Every day, more than 15 million Americans experience heartburn, which produces a burning sensation behind the breastbone. You may also experience a sour taste and the sensation of food re-entering your mouth (regurgitation). It results from gastroesophageal reflux, a condition in which stomach acid or, occasionally, bile salts back up into your food pipe (esophagus). When there’s also evidence of esophageal irritation or inflammation, you have gastroesophageal reflux disease (GERD).
Normally, the lower esophageal sphincter blocks most acid from coming up into the esophagus. This circular band of muscle at the lower end of the esophagus doesn’t open except when you swallow. If the sphincter relaxes abnormally or weakens, stomach acid can back up and cause heartburn.
Most people can manage the discomfort of heartburn with lifestyle modifications, such as improved diet, over-the-counter antacids and weight loss. But if heartburn is severe, these remedies may offer only temporary or partial relief. You may need newer, more potent medications to reduce symptoms.
If you experience heartburn, you may also experience these signs and symptoms:
When you swallow, the lower esophageal sphincter a circular band of muscle around the bottom part of your esophagus relaxes to allow food and liquid to flow down into your stomach. When it relaxes at any other time, stomach acid flows back up into your esophagus, even if you’re in an upright position. The acid backup is worse when you’re bent over or lying down. Some factors that can cause the sphincter to relax abnormally include:
Conditions that cause difficulty with digestion can increase the risk of heartburn. These include:
Usually a description of your symptoms will be all your doctor needs to establish the diagnosis of heartburn. However, if your symptoms are particularly severe or don’t respond to treatment, you may need to undergo other tests:
In addition to irritation and inflammation of your esophagus (esophagitis), chronic reflux of stomach acid into your esophagus can lead to one or more of the following conditions if left untreated:
Whether you have mild, moderate or severe heartburn, many treatment options are available. The most common treatments involve medications, but surgical and other procedures also are available.
If you experience only occasional, mild heartburn, you may get relief from an over-the-counter (OTC) medication. OTC remedies include:
If you have frequent and persistent heartburn, you may have GERD, leading to an inflamed esophagus (esophagitis). GERD usually requires prescription-strength medication. Prescription medications can help reduce and eliminate GERD symptoms, as well as help heal an inflamed esophagus the result of continual exposure to stomach acid. The main types of prescription drugs are:
Because of the effectiveness of medications, surgery for GERD is uncommon. However, it may be an option if you can’t tolerate the medications, the medications are ineffective, or you can’t afford their long-term use. Your doctor also may recommend surgery if you have any of these complications:
Before 1991, a procedure called open Nissen fundoplication was the surgery of choice for severe GERD. Today, doctors are able to perform the same surgery with similar success laparoscopically through a few small abdominal incisions, instead of one large one. The advantages of laparoscopic surgery are a shorter recovery time and less discomfort.
Nissen fundoplication involves tightening the lower esophageal sphincter to prevent reflux by wrapping the very top of the stomach around the outside of the lower esophagus. During laparoscopic surgery, a surgeon makes three or four tiny incisions in the abdomen and inserts small instruments, including a flexible tube with a tiny camera, through the incisions. To provide more space for your surgeon to see and work, your abdomen is inflated with carbon dioxide. The surgery takes about 2 hours and typically requires an overnight hospital stay.
More than 90 percent of the people who undergo Nissen fundoplication remain free of GERD symptoms for at least 1 year. At least 60 percent are symptom-free for several years. This success rate applies to both the laparoscopic and open procedures.
Other surgical procedures include Toupet partial fundoplication, Hill repair and the Belsey Mark IV operation. All involve restructuring the lower esophageal sphincter to improve its strength and ability to prevent reflux. These surgeries are done less often, and their success is often dependent on the skill of the surgeon.
Complications from surgery generally are mild, but may include difficulty swallowing, bloating, diarrhea and a sense of feeling full after eating only a moderate amount (early satiety).
Your doctor may suggest one of several procedures for tightening the lower esophageal sphincter. The procedures generally take an hour or less to perform, they don’t require any incisions, and you can go home the same day. The procedures are performed endoscopically through a long, flexible tube that’s inserted into your mouth and threaded through your esophagus. None of the procedures are recommended if you have a hiatal hernia or Barrett’s esophagus.
You may eliminate or reduce the frequency of heartburn by making the following lifestyle changes:
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