Heartburn that keeps coming back: when to see a GI doctor

Almost everyone has felt heartburn: a burning feeling behind the breastbone after a big meal, a spicy dinner or a late night. For many people in Los Angeles it shows up after a rushed lunch at the desk or a heavy meal eaten right before bed. Once in a while, it is usually nothing to worry about. But when it comes back week after week, or when over-the-counter medicine stops working, it is worth understanding what is going on.

What causes heartburn?

Your esophagus is the tube that carries food from your mouth to your stomach. At the bottom is a ring of muscle that acts like a one-way valve. It opens to let food in, then closes to keep stomach acid from coming back up. When that valve relaxes at the wrong time, or when there is extra pressure on the stomach, acid can flow back into the esophagus. This is called acid reflux, and the burning it causes is heartburn.

When reflux happens often or causes damage or troublesome symptoms, doctors call it GERD (gastroesophageal reflux disease). A common rule of thumb is heartburn twice a week or more. Besides burning, GERD can cause a sour or bitter taste in the mouth, food or liquid coming back up (regurgitation), a chronic cough, hoarseness, or a feeling of a lump in the throat. You can read more on our acid reflux and GERD page.

Everyday triggers and what helps

Triggers differ from person to person. Common ones include:

• Large meals, especially late in the evening
• Lying down within two to three hours of eating
• Fatty or fried foods, chocolate, peppermint, coffee and alcohol
• Spicy or acidic foods, such as tomato sauce, citrus and hot sauce, for some people
• Smoking and vaping
• Extra weight around the waist, and pregnancy
• Tight belts or waistbands

The changes with the strongest evidence, according to the American College of Gastroenterology (ACG), are losing weight if you carry extra weight, avoiding meals two to three hours before lying down, and raising the head of your bed if symptoms bother you at night. You can raise the head of the bed with blocks under the bedposts or a wedge pillow; stacking regular pillows usually does not help much. Quitting smoking helps too.

You do not need to give up every food on the list. A food diary for a week or two can show which ones actually bother you. Many families in Los Angeles share big evening meals, and that does not have to stop. Eating the larger meal earlier, taking smaller portions, or taking a short walk afterward instead of heading to the couch can make a real difference.

How long can I treat heartburn on my own?

For mild heartburn now and then, antacids (such as calcium carbonate tablets) work quickly for short relief. H2 blockers (such as famotidine) reduce acid for several hours. Proton pump inhibitors, or PPIs (such as omeprazole, esomeprazole and lansoprazole), reduce acid the most and work best when taken 30 to 60 minutes before breakfast.

Over-the-counter PPI packages are labeled for a 14-day course. The labels say not to take them for more than 14 days, or to repeat a course more often than every 4 months, unless a doctor tells you to. That is a useful guide:

This is not because the medicine is dangerous. It is because frequent heartburn needs a diagnosis. Other conditions can cause similar symptoms, and long-standing reflux sometimes needs a closer look at the esophagus.

Warning signs that need prompt attention

Doctors call certain symptoms "alarm features" because they can point to something more serious than ordinary reflux. Make an appointment soon if heartburn comes with:

• Trouble swallowing, pain when swallowing, or food that feels stuck (see our swallowing difficulties page)
• Weight loss you did not try for
• Vomiting that keeps happening
• Anemia (low blood count) or low iron on a blood test
• New symptoms that start after age 60
• Symptoms that do not improve after about 8 weeks of a daily PPI taken correctly

What does a GI evaluation include?

A visit with a gastroenterologist (a doctor who specializes in the digestive system) starts with a conversation. Dr. Pimienta believes good care begins with listening, so expect questions such as:

• When did your symptoms start, and how often do they happen?
• What makes them better or worse?
• Which medicines have you tried, at what dose, and at what time of day?
• Do you have trouble swallowing, a cough, hoarseness or weight changes?
• Does anyone in your family have esophageal or stomach problems?

Bring a list of your medicines and supplements, including over-the-counter acid reducers. Some medicines, such as anti-inflammatory pain relievers (ibuprofen, naproxen), can irritate the stomach and esophagus.

For many people with typical heartburn and no warning signs, the first step is a structured trial of a daily PPI for about 8 weeks, taken the right way, along with lifestyle changes. If symptoms improve, the next step is often to lower the dose or stop to see whether you still need it.

When is an upper endoscopy recommended?

An upper endoscopy (EGD) lets the doctor look directly at your esophagus, stomach and the first part of the small intestine with a thin, flexible camera. It may be recommended if you have warning signs, if symptoms do not respond to treatment, or if you have had reflux for many years along with other risk factors for Barrett's esophagus. Barrett's esophagus is a change in the lining of the esophagus caused by long-term reflux; it is not cancer, but it needs to be watched because it slightly raises the risk of esophageal cancer.

You receive sedation for the exam and usually do not feel it. Small tissue samples (biopsies) can be taken during the procedure. Dr. Pimienta performs upper endoscopy at Specialty Surgical Center of Beverly Hills, less than a mile west of his Wilshire office. Your plan depends on your health; Dr. Pimienta will talk with you about what fits you.

Questions about long-term acid medicine

Many people worry about taking a PPI for years after reading news stories about possible side effects. Here is a calm way to think about it.

• For many people, PPIs are safe and helpful. They heal irritation of the esophagus and prevent complications. If you have a clear reason to take one, such as healing damage seen on endoscopy or having Barrett's esophagus, the benefits usually outweigh the risks.
• Many reported risks come from studies that show a link, not a cause. People who take PPIs are often older or have other health problems, which makes the studies hard to interpret.
• The goal is the lowest dose that works. If you are taking a PPI without a clear ongoing reason, your doctor may suggest stepping down to a lower dose, taking it only when needed, or switching to an H2 blocker.
• Do not stop suddenly on your own. Stopping a PPI abruptly can cause a temporary burst of heartburn, called rebound. Tapering slowly with your doctor's guidance is usually easier.

When to see a GI doctor

See a GI doctor if you have heartburn twice a week or more, if you need repeated 14-day courses of over-the-counter medicine, if symptoms return when you stop, or if you have any of the warning signs above. You may also want a visit if you have been on a PPI for a long time and are not sure you still need it. If heartburn comes with belly pain that does not go away, our abdominal pain page may help too.

Dr. Pimienta sees adults from across Los Angeles County in English and Spanish, in person at the Wilshire office or by secure video for patients who are in California. To get started, request an appointment and the team will call you back.

References

1. American College of Gastroenterology. ACG Clinical Guideline for the Diagnosis and Management of Gastroesophageal Reflux Disease. 2022.
2. National Institute of Diabetes and Digestive and Kidney Diseases. Acid Reflux (GER and GERD) in Adults.
3. National Institute of Diabetes and Digestive and Kidney Diseases. Treatment for GER and GERD.
4. American College of Gastroenterology. Acid Reflux.