Characteristics of Heartburn
Heartburn is a substernal burning sensation in the chest that represents the most commonly recognized manifestation of gastroesophageal reflux disease (GERD), occurring in 44% of U.S. adults at least monthly and 10-20% experiencing symptoms weekly. 1
Primary Clinical Features
Symptom Description and Location
- Heartburn presents as a substernal burning sensation or discomfort in the chest, distinguishing it from other esophageal symptoms 1
- The burning quality is characteristic and helps differentiate it from other chest symptoms 1
- In adults with GERD, heartburn is typically the dominant complaint, often accompanied by regurgitation and bitter/sour taste of gastric content 1
Symptom Triggers and Exacerbating Factors
- Symptoms are characteristically exacerbated after consumption of large meals, rapid eating, acidic foods, and alcohol 1
- Body position changes, particularly lying down or bending over, worsen symptoms 1
- Obesity and tobacco use significantly exacerbate heartburn symptoms 1
- Symptoms typically worsen when lying down within 2-3 hours after meals 1
Characteristics in Overweight and Obese Adults
Increased Prevalence and Severity
- Central obesity is a primary mechanical risk factor that drives pathologic GERD by disrupting the anti-reflux barrier and increasing the intra-abdominal to intra-thoracic pressure gradient 2
- Overweight and obese patients experience more frequent and severe heartburn symptoms compared to normal-weight individuals 1
- Weight loss in overweight or obese patients provides dose-dependent benefits with significant symptom reduction 3, 2
Mechanical Pathophysiology
- The increased intra-abdominal pressure from central obesity compromises the lower esophageal sphincter function 2
- Obesity-related hiatal hernia further compromises the crural diaphragm function and anti-reflux barrier 2
Distinguishing Features from Other Conditions
Differentiation from Eosinophilic Esophagitis (EoE)
- In contrast to EoE, where dysphagia is the dominant symptom, heartburn is the primary complaint in GERD patients 1
- While heartburn may be present in EoE, it characteristically accompanies dysphagia rather than being the dominant symptom 1
- Dysphagia as a dominant symptom is rare in GERD unless a peptic stricture is present 1
Functional Heartburn Considerations
- Approximately 30-50% of patients with nonerosive reflux disease have functional heartburn, where symptoms persist despite normal esophageal acid exposure 4, 5
- Functional heartburn patients demonstrate significantly lower response rates to proton pump inhibitor therapy compared to typical GERD patients 6, 4
- These patients require esophageal pH monitoring to document physiologic acid exposure levels with negative symptom-reflux association 5
Symptom Patterns and Timing
Nocturnal Characteristics
- Nocturnal heartburn symptoms are more troublesome, more difficult to treat, and often manifested by extraesophageal symptoms 7
- Nighttime symptoms significantly impair quality of life in 25-30% of cases 7
- Patients with nocturnal symptoms benefit specifically from elevating the head of the bed by 6-8 inches 1, 3
Frequency and Impact
- Symptoms occurring more than 2-3 times weekly are considered "troublesome" and meet the Montreal definition of GERD requiring treatment 1, 3
- Chronic symptoms and poor sleep impair quality of life in 25-30% of affected individuals 7
- Approximately 70% sensitivity and specificity exists for typical heartburn symptoms in predicting objective GERD 1, 2
Common Pitfalls in Recognition
Misattribution of Symptoms
- Heartburn symptoms alone cannot definitively distinguish between acid reflux, functional heartburn, and other esophageal disorders without objective testing 1, 5
- The moderate correlation between reflux symptoms and esophageal acid exposure means symptom severity doesn't always predict tissue injury 1
- Extraesophageal manifestations (chronic cough, hoarseness, asthma) may occur with or without typical heartburn symptoms 1