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Heartburn is a burning sensation felt behind the breastbone. It is a symptom that is commonly linked to acid reflux and is often triggered by food. Lying down, bending, lifting, and performing certain can exacerbate heartburn. Causes include acid reflux, gastroesophageal reflux disease (GERD), damage to the esophageal lining, bile acid, mechanical stimulation to the esophagus, and esophageal hypersensitivity. Heartburn affects 25% of the population at least once a month.
Endoscopy and esophageal pH monitoring can be used to evaluate heartburn. Some causes of heartburn, such as GERD, may be diagnosed based on symptoms alone. Potential differential diagnoses for heartburn include motility disorders, ulcers, Esophagitis, and medication . Lifestyle changes, such as weight loss and avoiding fatty foods, can improve heartburn. Over-the-counter alginates or can help with mild or occasional heartburn. Heartburn treatment primarily involves antisecretory medications like H2 receptor antagonists (H2RAs) and proton-pump inhibitors (PPIs).
The sensation of heartburn often spreads to the neck, throat, or Human back and is commonly triggered by food. It tends to occur within an hour after eating, especially after a large meal. Lying down, especially after eating, can make heartburn worse. Some people find their symptoms more severe when lying on their right side. Nightime heartburn can disrupt sleep and affect daily life. Activities that increase abdominal pressure, like bending, lifting heavy objects, or performing certain , can also trigger symptoms. Studies suggest that stress and lack of sleep may make heartburn feel worse by increasing the body's sensitivity to symptoms.
Acid reflux is a common cause of heartburn but is not the only etiology. A study in 1989 demonstrated this by giving participants and basic solutions; the acidic solutions induced heartburn in all participants, though the more basic solution still invoked heartburn in over 40% of the participants. Ambulatory pH monitoring reveals that just a small percentage of acid reflux episodes trigger heartburn. Nerve endings and acid-sensitive in the deepest layer of the esophagus are usually protected by anatomical barriers. However, in gastroesophageal reflux disease (GERD), one of the earliest signs of damage is the development of dilated intercellular spaces (DISs) in the Epithelium. These spaces weaken the protective barrier, allowing acid and other substances to seep in. This triggers Nociceptor, which send signals to the brain and cause the sensation of heartburn.
Esophageal reflux can be classified as acidic (pH < 4), weakly acidic (pH 4–7), or non-acidic (pH > 7) using combined impedance/pH monitoring. Without proton-pump inhibitors (PPIs), heartburn symptoms are commonly linked to acid reflux, but about 15% of cases involve weakly acidic reflux. Factors like high reflux reach, low pH, large pH drops, high reflux volume, and slow acid clearance increase the likelihood of symptoms. When taking PPIs, heartburn may still occur, with 17–37% of cases linked to non-acidic, usually weakly acidic, reflux.
Bile acid rising into the esophagus can cause heartburn, though bile acid is slower and less intense than stomach acid exposure. The mechanism behind bile acid causing heartburn symptoms is thought to be due to bile damaging and releasing intracellular mediators. Studies monitoring acid and bile reflux together show that they often occur simultaneously.
Mechanical stimulation may play a role in heartburn. Esophageal balloon distension, especially in the upper esophagus, can trigger heartburn symptoms. This may be because the upper esophagus has more pressure-sensitive receptors than the lower esophagus. Acid exposure may also make these receptors more sensitive.
Esophageal hypersensitivity plays a major role in heartburn, especially in those with GERD who have normal acid levels. As shown in esophageal balloon studies, these individuals are also more sensitive to mechanical pressure. The likely cause is altered brain processing (central sensitization) rather than issues with esophageal receptors. Anxiety and stress can further heighten heartburn perception, both through brain mechanisms and possibly by weakening the esophageal lining (dilated intercellular spaces).
Functional heartburn is a burning feeling behind the breastbone, similar to GERD, but without signs of acid reflux, esophageal motor disorders, or mucosal damage on diagnostic tests like reflux monitoring, manometry, or endoscopy. After tests have been performed to rule out other causes of heartburn, functional heartburn is diagnosed according to Rome criteria:
Many drugs have been used to treat heartburn, but antisecretory medications such as H2 receptor antagonists and PPIs have the most evidence for the treatment of heartburn. Low doses of tricyclic antidepressants and selective serotonin reuptake inhibitors may be used to manage functional heartburn. Antacids are fast-acting, short-term remedies for heartburn, made from compounds like aluminium hydroxide, magnesium hydroxide, and calcium carbonate, which neutralize acid. While still commonly used today, antacids were used more often before stronger acid-lowering drugs were discovered, mainly for occasional, post-meal heartburn or as needed. Alginate, extracted from seaweed and combined with sodium or potassium bicarbonate, is more effective than antacids for heartburn relief. In short-term GERD treatment (four weeks), alginate works as well as PPIs. It is also used as an add-on therapy for people whose symptoms do not fully resolve with PPIs, improving heartburn control and quality of life more than PPIs alone. H2RAs help lower stomach acid by blocking histamine at specific receptors in the stomach lining. Their effect lasts between four and eight hours, depending on the medication. They are mostly used for quick relief in people with mild acid reflux or as an additional treatment alongside PPIs, especially at night since they are better at controlling nighttime acid levels.
PPIs reduce stomach acid by blocking an enzyme involved in its production (hydrogen potassium ATPase), and their effects last much longer than H2RAs—around 16 to 18 hours. They are stronger and do not lose effectiveness over time. However, they do not work immediately and do not fix the root cause of acid reflux; they simply make the refluxed contents less acidic. Potassium-competitive acid blockers (P-CABs) are a newer type of acid-reducing medication that work by blocking hydrogen potassium ATPase. Vonoprazan is the most researched P-CAB and has been found to be just as effective as PPIs in healing esophagitis and preventing relapses. In more severe cases, it may work even better than PPIs. However, P-CABs have not been more effective than a placebo for treating symptoms in people with nonerosive reflux disease, likely because this condition includes a mix of different underlying issues.
Prokinetic agent help clear stomach acid from the esophagus by improving muscle movement and speeding up stomach emptying, which can be slow in some people with GERD. Common prokinetics include metoclopramide, domperidone, mosapride, itopride, and prucalopride. Since GERD can be a motility issue, these drugs have the potential to address its root cause. However, there is no strong evidence that they effectively treat GERD. They are usually added to PPI treatment for those whose heartburn does not improve with PPIs alone, but their effectiveness in this case is unclear. Baclofen is a GABA agonist that helps reduce reflux by decreasing the relaxations of the lower esophageal sphincter, which are one of the main causes of GERD. However, its use is limited and is usually considered only as an add-on treatment for individuals with persistent heartburn despite taking PPIs.
Because the pain was felt in the chest and the focus was on the heart at the time, doctors initially believed heartburn came from the heart rather than the esophagus. This is why the terms cardialgia or cardialgy were first used to describe heartburn. Symptoms of heartburn were also attributed to the consumption of "poor quality food".
Throughout the 1700s to the 1800s, many different terms were used to describe acid reflux. An English dictionary from the mid-1700s defined cardialgia as "from cardia, the heart, or rather the left orifice of the stomach, and -algia, to be pained, the pain of the mouth of the stomach or heart-burn".
Throughout history, the terms cardialgia, heartburn, pyrosis, dyspepsia, and indigestion were often used interchangeably and there was little advancement in differentiating the terms till the 1900s.
Many different factors lead to the development of heartburn during pregnancy. Hormonal changes, such as higher levels of progesterone, can cause relaxation of the , which lowers stomach tone and motility and reduces pressure in the lower esophageal sphincter. During pregnancy, the lower esophageal sphincter moves into the Thoracic cavity, where pressure is lower. This makes it easier for stomach acid and food to flow back into the esophagus, causing irritation and a burning sensation. Other factors that can cause heartburn during pregnancy include increased pressure on the stomach from the uterus, weight gain, changes in gastric emptying, delayed Small intestine transit, or .
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