Determining Heartburn Cause Is Key

Many people with and without liver disease have signs and symptoms of gastroesophageal reflux or as most people refer to it, heartburn. Heartburn is common and all people at some point in their lives will have an episode of reflux. Typical features of heartburn include a burning sensation in the chest that may or may not be associated with nausea or vomiting. These symptoms are worsened by lying down or bending over after eating. Heartburn can cause bad breath, especially in the morning and it is a common cause of chronic cough leading to it being often misdiagnosed as asthma. Reflux may also be a cause of laryngitis, hiccups or difficulty swallowing.

If heartburn occurs occasionally, there is usually nothing to do except take an over-the-counter antacid and try to determine which foods may have brought it on. Prevention of reflux is the cornerstone of treatment and this requires lifestyle modifications. Avoid large meals, decreasing dietary fat intake and not lying down within three to four hours after eating are important steps that can be taken. Avoiding certain foods that are known to worsen reflux such as citrus and tomato-based products, alcohol, caffeinated beverages, carbonated beverages, chocolate, onions, garlic and peppermint.

Other lifestyle changes that help reduce episodes of reflux include avoid wearing clothing that is tight around the waist, losing weight and stopping cigarette smoking.

There are no specific tests to diagnose reflux or heartburn. The diagnosis is based on symptoms. Unless the heartburn is associated with alarm symptoms such as weight loss, difficulty swallowing, painful swallowing or bleeding, diagnostic tests are usually not indicated and empiric treatment can be started. If any of the above-mentioned alarm symptoms are present, patients should be seen by their gastroenterologist as they may require an upper endoscopy to better assess the esophagus for inflammation, stricture or malignancy.

The initial treatment of heartburn is lifestyle modification. If that does not adequately control the symptoms, then H2 receptor agonists and/or proton pump inhibitors can be started.

Most people with heartburn will become symptomatically controlled if they follow the regimens outlined above. The rare patient who does not improve significantly should be referred to a gastroenterologist for further diagnostic studies and more advanced treatments.

—David Bernstein, MD, MACG, FAASLD, AGAF, FACP