Heartburn is a burning feeling in the chest caused by stomach acid travelling up towards the throat (acid reflux). The advantage of the capsule over standard pH testing is that there is no discomfort from a catheter that passes through the throat and nose. Moreover, with the capsule, patients look normal (they don’t have a catheter protruding from their noses) and are more likely to go about their daily activities, for example, go to work, without feeling self-conscious. Because the capsule records for a longer period than the catheter (48 versus 24 hours), more data on acid reflux and symptoms are obtained. Nevertheless, it is not clear whether obtaining additional information is important.
If there are no symptoms or signs of complications and no suspicion of other diseases, a therapeutic trial of acid suppression with H2 antagonists often is used. If H2 antagonists are not adequately effective, a second trial, with the more potent PPIs, can be given. Sometimes, a trial of treatment begins with a PPI and skips the H2 antagonist. If treatment relieves the symptoms completely, no further evaluation may be necessary and the effective drug, the H2 antagonist or PPI, is continued. As discussed previously, however, there are potential problems with this commonly used approach, and some physicians would recommend a further evaluation for almost all patients they see.
As is often the case, the body has ways to protect itself from the harmful effects of reflux and acid. For example, most reflux occurs during the day when individuals are upright. In the upright position, the refluxed liquid is more likely to flow back down into the stomach due to the effect of gravity. In addition, while individuals are awake, they repeatedly swallow, whether or not there more hints is reflux. Each swallow carries any refluxed liquid back into the stomach. Finally, the salivary glands in the mouth produce saliva, which contains bicarbonate. With each swallow, bicarbonate-containing saliva travels down the esophagus. The bicarbonate neutralizes the small amount of acid that remains in the esophagus after gravity and swallowing have removed most of the acidic liquid.
When acid refluxes back into the esophagus in patients with GERD, nerve fibers in the esophagus are stimulated. This nerve stimulation results most commonly in heartburn, the pain that is characteristic of GERD. Heartburn usually is described as a burning pain in the middle of the chest. It may start high in the abdomen or may extend up into the neck. In some patients, however, the pain may be sharp or pressure-like, rather than burning. Such pain can mimic heart pain ( angina ). In other patients, the pain may extend to the back.