Heartburn
Symptoms, Causes & Treatment
Heartburn is the most common symptom of GORD, affecting up to 20% of UK adults every week. It causes a burning sensation behind the breastbone and can significantly disrupt sleep, eating, and daily activities. Most heartburn responds well to lifestyle changes and acid-suppressing medication.
What is Heartburn?
Heartburn is the burning sensation caused by gastric acid refluxing into the oesophagus. It is the hallmark symptom of GORD. Contributing factors include obesity, hiatus hernia, smoking, alcohol, high-fat diet, pregnancy, and certain medications. Chronic untreated heartburn can cause oesophagitis, Barrett’s oesophagus, and oesophageal adenocarcinoma.
Symptoms of Heartburn
Heartburn is typically worse after eating, on lying down, and at night. Alarm symptoms require urgent assessment.
Burning sensation behind the breastbone · Worse after eating, bending, or lying down · Acid taste in mouth · Bloating and belching · Worse at night · Relieved by antacids · Associated with regurgitation
Heartburn with dysphagia (difficulty swallowing) · Vomiting blood · Black tarry stools · Unexplained weight loss with heartburn · Persistent heartburn not responding to 4 weeks of PPI · New heartburn in adults over 55 — urgent endoscopy required
Dysphagia · Vomiting blood · Black stools · Unexplained weight loss with heartburn · New onset over age 55 — see a GP urgently or attend A&E.
What Causes Heartburn?
Heartburn is primarily caused by GORD. Understanding contributing factors allows effective lifestyle and medical management.
GORD is the primary cause of heartburn. Gastric acid and bile reflux into the oesophagus cause mucosal irritation, producing the characteristic burning substernal pain. The lower oesophageal sphincter pressure is reduced by fatty foods, chocolate, caffeine, alcohol, and nicotine.
Oesophageal dysmotility — including diffuse oesophageal spasm — causes intermittent severe crushing chest pain that can mimic cardiac pain. It often occurs with reflux and responds to nitrates or calcium channel blockers.
Pregnancy causes heartburn in up to 80% of women due to progesterone-mediated relaxation of the lower oesophageal sphincter and increased intra-abdominal pressure. Alginate antacids (Gaviscon) are safe and effective in pregnancy.
Medications including tricyclics, nitrates, calcium channel blockers, bisphosphonates, NSAIDs, and iron tablets can cause or worsen heartburn by relaxing the lower oesophageal sphincter or directly irritating the mucosa.
Barrett’s oesophagus is a complication of chronic GORD where normal oesophageal epithelium is replaced by columnar cells. It is diagnosed at endoscopy and requires regular surveillance biopsies due to the risk of oesophageal adenocarcinoma.
Eosinophilic oesophagitis (EoE) causes dysphagia, food bolus obstruction, and heartburn-like symptoms from eosinophilic infiltration of the oesophagus. It is an increasingly recognised cause of treatment-resistant reflux, particularly in young atopic patients.
Key Risk Factors
Diagnosing Heartburn
Heartburn is usually diagnosed clinically. Endoscopy is indicated for alarm features, failure to respond to PPI, or in adults over 55 with new onset symptoms.
Treatment for Heartburn
PPIs are first-line for heartburn. Lifestyle modification is essential. Alginate antacids provide rapid relief. Surgery is reserved for refractory cases confirmed on pH study.
Supportive Measures
Elevate the head of the bed 20cm. Avoid eating 2–3 hours before lying down. Gaviscon Advance after meals and at bedtime. Wear loose clothing. Maintain a healthy weight. Avoid dietary triggers identified in a food diary.
Managing Chronic Heartburn
Chronic heartburn requires ongoing management with PPIs at the lowest effective dose, annual review, Barrett’s surveillance where applicable, and consideration of laparoscopic fundoplication for refractory cases confirmed on pH study.
When to Seek Help
Chest pain that may be cardiac · Vomiting blood · Black tarry stools · Dysphagia with weight loss — call 999 or attend A&E immediately. Do not assume chest pain is heartburn.
See a GP if heartburn is occurring more than twice a week, not responding to OTC antacids, or if you are over 55 with new onset symptoms. Online consultation is appropriate for heartburn without alarm features.
Preventing Heartburn
Heartburn is largely preventable through weight management, dietary modification, and lifestyle changes.
Elevate the head of the bed by 20cm using a wedge pillow or bed riser. Gravity helps keep acid in the stomach during sleep and significantly reduces nocturnal heartburn and laryngopharyngeal reflux.
Avoid eating within 2–3 hours of bedtime. Large late meals increase acid production and gastric volume, maximising the risk of nocturnal reflux when lying flat. A light early dinner is the most effective single dietary change.
Reduce or eliminate personal heartburn triggers: fatty and fried foods, chocolate, caffeine, alcohol, citrus, peppermint, and carbonated drinks. Keeping a food diary helps identify individual triggers.
Lose excess weight. Even a 5–10% reduction in body weight significantly reduces heartburn frequency and severity by reducing intra-abdominal pressure on the lower oesophageal sphincter.
Stop smoking. Nicotine reduces lower oesophageal sphincter pressure, increases acid secretion, and reduces saliva production. Stopping smoking reduces GORD symptoms significantly within weeks.
Any new heartburn in adults over 55, or heartburn with dysphagia, weight loss, or anaemia, requires urgent endoscopy to exclude oesophageal or gastric cancer. Do not assume heartburn is benign without assessment.
Getting Treatment for Heartburn
A GP can prescribe PPIs, arrange H. pylori testing, and refer for urgent endoscopy. Lifestyle advice and weight management are central to long-term heartburn management. Online GP consultations are appropriate for heartburn without alarm features.
Expert clinical advice, when you need it.
Heartburn — Frequently Asked Questions
Heartburn is a burning sensation behind the breastbone, caused by acid reflux from the stomach into the oesophagus. It is worse after eating, when lying down, or when bending forward. It is the most common symptom of GORD (gastro-oesophageal reflux disease). Up to 20% of UK adults experience heartburn weekly.
Heartburn and heart attack can both cause chest pain or discomfort. Heart attack pain is typically crushing, radiates to the left arm or jaw, is accompanied by sweating and breathlessness, and occurs with exertion. If in doubt, call 999. Do not assume chest pain is heartburn without assessment if you have cardiac risk factors.
A proton pump inhibitor (PPI) such as omeprazole or lansoprazole taken 30 minutes before breakfast is the most effective treatment for heartburn. For mild heartburn, alginate antacids (Gaviscon) provide rapid relief. Lifestyle changes — weight loss, elevating the bed, and avoiding triggers — reduce the need for medication.
Yes. Pregnancy commonly causes heartburn because progesterone relaxes the lower oesophageal sphincter and the growing uterus increases intra-abdominal pressure. Gaviscon Advance and calcium carbonate antacids are safe throughout pregnancy. Ranitidine and omeprazole can be prescribed if symptoms are severe.
Alarm features requiring urgent endoscopy are: dysphagia (difficulty swallowing), haematemesis (vomiting blood), melaena (black tarry stools), unexplained weight loss with heartburn, persistent vomiting, and new onset heartburn in adults over 55. These may indicate oesophageal or gastric cancer.
The most effective lifestyle changes are: losing weight (even 5–10% reduces heartburn significantly), stopping smoking, elevating the head of the bed by 20cm, not eating within 2–3 hours of lying down, eating smaller meals, avoiding fatty foods, alcohol, caffeine, and chocolate.
PPIs are generally safe for long-term use in confirmed GORD or Barrett's oesophagus. Some studies suggest minor risks with long-term use (hypomagnesaemia, B12 deficiency, small fracture risk, and increased C. difficile risk). Always use PPIs at the lowest effective dose. A GP can review the ongoing need annually.
A GP can prescribe PPIs, arrange H. pylori testing and eradication, refer urgently for endoscopy when alarm features are present, and provide lifestyle advice. An online consultation is appropriate for heartburn without alarm features. All heartburn in adults over 55 or with alarm symptoms needs urgent in-person assessment.