What is heartburn?
Heartburn is a burning sensation in the chest, usually centrally located and sometimes extending as high as the throat. It can vary in intensity from a mild discomfort or ache to severe burning chest pain. Heartburn is often associated with other symptoms like nausea, sometimes vomiting. belching, stomach bloating and/or stomach ache.
Burning Chest Pain
Burning pain in the chest or a burning sensation in the chest may be linked to disorders with the chest wall, organs lying within the thoracic cavity, or referred pain from the abdomen, neck or back. In adults, especially those with risk factors of coronary artery disease, angina or even a heart attack should always be considered.
While these serious cardiac conditions often result in pain that is crushing, tight or stabbing in nature, it may also result in a burning pain. It is not uncommon for heartburn (acid reflux) to be mistaken for cardiac pain and vice versa. Therefore burning pain in the chest requires immediate investigation in order not to miss potentially life threatening cardiovascular conditions.
What causes heartburn?
Most cases of heartburn, whether acute or recurrent, is due to acid reflux. The acidic stomach contents that rise up into the esophagus causes inflammation of the esophageal lining and the typical burning chest pain known as heartburn ensues. Acid reflux, and therefore heartburn, occurs many times in a person’s life – it is temporary and often resolves spontaneously with little or no treatment. In most acute cases, it is a result of overeating, lying flat after a large meal, excessive alcohol consumption and exercising after eating.
Chronic heartburn is most often a result of constant or recurrent acid reflux. This is known as gastroesophageal reflux disease (GERD). While aggravated by the same acute causes, the underlying mechanism of GERD usually involves a dysfunction in the lower esophageal sphincter (LES), a valve-like portion of the esophagus that prevents the backward flow of the stomach contents.
Although acid reflux is the most common cause of heartburn, other conditions may trigger a chest pain that is burning in nature. Of these conditions, cardiac causes of chronic heartburn needs to be seriously considered, especially in high risk patients, and medical treatment sough even if the symptoms are mild.
Conversely, chest pain as a result of acid reflux may not always present as the typical burning pain and could be mistaken for other non-gastrointestinal causes. Due to the life-threatening nature of many cardiovascular conditions that may present similar to heartburn, it is therefore important to distinguish Cardiac and Non-Cardiac Chest Pain.
Causes of Burning Chest Pain
The most common causes of burning pain in the center of the chest includes :
- Gastroesophageal reflux disease (GERD/acid reflux) – heartburn
- Angina – pain is usually crushing and suffocating but can be burning in nature
- Myocardial infarction (heart attack) – similar to angina
- Pulmonary embolism– similar to angina
- Aortic dissection – similar to angina, sharp pain
GERD , angina or heart attack pain are more likely to occur after eating, exercising or stress. GERD is more likely to start of as a burning sensation or discomfort rather than pain, although severe cases can be painful. Esophagitis is often linked to chronic GERD.
With angina, myocardial infarction, pulmonary embolism or aortic dissection, dizziness, shortness of breath and vagal reactions like sweating may also be present. In anxiety, palpitations are a common feature along with shortness of breath and it usually precedes or follows a stressful event. Refer to Stress Chest Pain.
Abnormal breathing sounds and a cough, especially with a history of a respiratory tract infection, is more likely to be tracheitis. Other causes like breastbone pain also need to be considered as well as referred pain from the upper abdominal area. This is further discussed under right upper quadrant abdominal pain, upper middle abdominal pain and left upper quadrant abdominal pain.
The most common causes of burning pain on either side of the chest includes :
- Lung and airway infections like bronchitis, bronchiolitis, pneumonia and pleurisy. Smoke or toxic fume inhalation, bronchiectasis or a collapsed lung also needs to be considered.
- Muscle pain from strain or tears often results in burning pain of varying intensity.
- Nerve pain either from infections like shingles (herpes zoster) or nerve root compression of the intercostal nerve(s).
- Bone, as in rib fractures, and costal cartilages like in costochondritis may also be responsible.
Lung and airway infections are often accompanied by a cough, shortness of breath, difficulty breathing and a fever. Shortness of breath and/or difficulty breathing should raise the concern of non-infectious causes of lung pain. Chest wall pain is often more common, especially in cases of burning pain on the side of the chest. Muscle strain should be considered in cases of pain during and after strenuous exercise, especially activities such as weight lifting.
Pain due to nerve root compression (pinched nerve) may run along the entire course of the affected nerve, just as shingles tends to occur in dermatomes. Bone pain and even pain due to the cartilages is usually preceded by trauma or strain that would have resulted in a fracture of inflammation. Pain upon movement is more likely to be due to muscle strain, bone or cartilage pain.
Causes of Chronic Heartburn
Gastroesophageal Reflux Disease (GERD)
Although this is most prominent after meals (chest pain after eating) and at night when sleeping, heartburn in GERD may arise at any time and can be persistent despite the use of antacids. Other symptoms may include nausea, regurgitation, water brash and throat irritation.
This is the most common cause of GERD and therefore chronic heartburn. Diminished tonicity of the muscles of the lower esophageal sphincter (LES) allows gastric acid to rush up into the esophagus.
Delayed Gastric Emptying
If the exit of the stomach contents into the duodenum is hampered and therefore delayed, the strong muscle contractions of the stomach wall may push acidic contents up into the esophagus. The various causes are discussed under Delayed Gastric Emptying.
Protrusion of a portion of the stomach through the diaphragmatic opening disrupts the pressure gradient between the thoracic and abdominal cavities. Under normal circumstances, this helps to keep the hiatus closed.
Increased intra-abdominal pressure, usually seen with obesity and in the later stages of pregnancy, may cause a retrograde flow of the stomach contents into the esophagus.
Ulceration of the esophageal lining is a common complication of poorly managed GERD. It often presents as a burning chest pain, usually lower down in the chest, and often exacerbates after eating.
These are painful muscle contractions in the wall of esophagus. Most of the symptoms resemble acid reflux, which can also be a cause of the spasms (reflux-induced spasms). Other causes may be due to esophageal motility disorders, neuromuscular diseases or due to unknown causes.
Other Gastrointestinal Causes
Other esophageal conditions, like Barrett’s esophagus and esophageal cancer, may also present with a central chest pain. These conditions are often complications of long standing GERD.
Due to the close proximity of the upper abdominal organs to the chest cavity, and change in position when lying flat, other gastrointestinal conditions may also be mistaken for chronic heartburn.This is more often seen with gastrointestinal conditions like gastritis, peptic ulcer, gallstone pain and pancreatitis. The latter two conditions typically present with a colicky pain but this could be mistaken for severe heartburn.
Chest Wall Pain
Muscular causes of chest pain are fairly common as a result of muscle strain and injury. Other causes may involve the skin, nerves and/or bones. These causes are discussed further under :
Cardiovascular causes often present with a centrally located chest pain that may be sharp, constricting, rubbing, tearing or crushing in nature. However, it is not uncommon for it to also present as the typical burning chest pain seen in heartburn. Cardiovascular conditions are worth mentioning in detail under chronic heartburn due to the life-threatening nature of most of these conditions which may be long-standing and sometimes seem quite innocuous.
Ischemia of the heart muscle (tissue injury) occurs due to limited oxygen availability as a result of restricted blood flow. It is the most prominent symptom of coronary heart disease, and may progress to a myocardial infarction (heart attack).
Death of heart muscle as a result of an insufficient blood supply causes a severe and sudden chest pain, that presents similar to angina and includes shortness of breath, pain that radiates to the left arm, neck, jaw and back, sweating, nausea, dizziness and/or vomiting.
It is important to distinguish between angina and heart attack pain.
Inflammation of the lining surrounding the heart is known as pericarditis. It is usually acute, presenting with severe and sudden pain, but may persist in chronic cases. Other symptoms include shortness of breath, fever (in infectious causes), dry cough, weakness and fatigue.
Collection of blood in the inner lining of the aorta that may rupture. It can be acute or chronic. Other symptoms may resemble both a heart attack and stroke – sweating, dizziness, fainting, weakness, paralysis and shortness of breath.
Other Causes of Heartburn
Most respiratory causes of chest discomfort or a severe burning chest pain are usually acute and this includes a pneumothorax and pulmonary embolism. Other chronic respiratory conditions like laryngitis and tracheitis may also present with a centrally located chest pain but can usually be excluded as a cause of heartburn due to the prominence of respiratory symptoms like a sore throat, hoarse voice, productive cough and difficulty breathing.
Pain may be referred to the center of the chest and present as a burning pain. This may include the other gastrointestinal causes mentioned above – gastritis, peptic ulcer, gallstones or pancreatitis – or arise from other structures like is seen with middle back pain.