Heartburn is often described as a burning sensation in the chest, typically caused by acid reflux, but there’s more to this condition than stomach acid alone. While acidic reflux is a primary cause, heartburn can also be triggered by non-acidic factors, making it more complex to diagnose and treat. Understanding both acidic and non-acidic causes of heartburn can lead to more effective relief for those who struggle with persistent symptoms.
Acidic Causes: GERD
The most common cause of heartburn is gastroesophageal reflux disease (GERD), where stomach acid flows back into the esophagus. GERD occurs when the lower esophageal sphincter (LES) weakens or relaxes inappropriately, allowing acidic stomach contents to escape into the esophagus. This backflow causes irritation, and the classic burning sensation associated with heartburn. GERD can often be managed with lifestyle changes, diet modifications, and medications like proton pump inhibitors (PPIs), which reduce stomach acid production and relieve symptoms.
Non-Acidic Causes: Bile Acid Reflux, NERD, and Visceral Hypersensitivity
Not all heartburn stems from acid alone. In some cases, heartburn symptoms are triggered by non-acidic factors like bile reflux, non-erosive reflux disease (NERD), and visceral hypersensitivity.
Bile Acid Reflux
Unlike acid reflux, bile acid reflux involves bile, a digestive fluid produced by the liver and stored in the gallbladder. Bile is essential for digesting fats in the small intestine, but if it flows backward into the stomach and esophagus, it can cause significant irritation. Though bile is not acidic, it can produce symptoms similar to acid reflux, including heartburn and a bitter taste. Bile reflux may also occur alongside GERD but is distinct in that it often does not respond to acid-suppressing medications like PPIs. Treatment for bile reflux may include bile acid sequestrants or prokinetic agents, which reduce the backflow of bile rather than targeting acid levels.
Non-Erosive Reflux Disease (NERD)
Another non-acidic contributor to heartburn is non-erosive reflux disease (NERD), which is similar to GERD but without visible esophageal damage. Patients with NERD experience heartburn and other reflux symptoms, but the lack of erosive damage means the condition is often more complex to treat. Standard acid-suppressing treatments like PPIs may be less effective for NERD, as the symptoms are often linked to hypersensitivity to even low levels of acid or other substances in the esophagus. NERD patients may benefit from alternative therapies focused on reducing sensitivity in the esophagus.
Visceral Hypersensitivity
Visceral hypersensitivity is another cause of non-acidic heartburn, where the esophagus becomes overly sensitive to normal stimuli. In individuals with visceral hypersensitivity, even minor pressure or temperature changes in the esophagus can trigger pain or discomfort, mimicking the sensation of heartburn. This heightened sensitivity is thought to involve the nervous system’s response to normal sensations. Treatment for visceral hypersensitivity often involves neuromodulating therapies, such as low-dose antidepressants, which help reduce pain perception rather than targeting acid levels directly.
Managing Heartburn: A Personalized Approach
Diagnosing the specific cause of heartburn is crucial for effective management. For patients with persistent symptoms, diagnostic tests like pH monitoring, EGD with biopsies, checking for the presence of hiatal hernia and impedance testing can help determine whether acid, bile, or non-acidic factors are the root cause. We would also offer a test called HREM ( High resolution esophageal manometry) which gives us an idea about the functioning of esophagus.
Typically, a short course of a regimen of effective acid suppression should be tried
In cases of GERD, acid suppression remains a primary approach, with lifestyle changes to reduce acidic triggers. Patients with bile reflux may benefit from medications that specifically target bile backflow, while those with NERD or visceral hypersensitivity may require pain-modulating treatments to improve quality of life. Dietary modifications, such as avoiding high-fat foods and eating smaller meals, also support symptom relief for both acid and non-acid-related heartburn.
Chronic acid reflux has been identified as a risk factor for esophageal cancer. Typically, in most patient with acid reflux for 5 years or more, we will offer an endoscopy to check the junction of esophagus and stomach to ensure that there is no significant narrowing ( if there is associated symptoms of difficulty swallowing foods), biopsies of the lower esophagus to make sure that there is no early precancerous changes named Barrett’s esophagus.
Once we have clearly identified the cause of a patient’s symptoms we will offer appropriate treatment options based upon the latest data and guidelines which may include lifestyle modification, weight loss up to the point of recommending surgery to repair hiatal hernia if present.