Heartburn and GERD: Causes, What Helps and When to See a Doctor

Burning behind the breastbone after a heavy dinner is familiar to almost everyone — occasional reflux occurs in healthy people and is not in itself a disease. The problem begins when episodes recur regularly: that is gastro-oesophageal reflux disease, which not only degrades quality of life but can eventually damage the oesophageal lining. Here is what genuinely helps and what belongs to the category of familiar but useless measures.

How it works#

Between the oesophagus and the stomach sits the lower oesophageal sphincter, a muscular ring that normally opens when you swallow and stays closed the rest of the time. Heartburn occurs when it relaxes outside of swallowing, letting acidic stomach contents into the oesophagus, whose lining has no protection against acid.

That leads to an important point: most people with heartburn have normal gastric acidity. The problem isn't "too much acid" but acid ending up where it shouldn't. Which is why anything that raises pressure in the stomach or relaxes the sphincter affects symptoms more than diet alone.

Factor	What it does	Examples
Sphincter relaxation	Opens the path for reflux	Chocolate, mint, fat, alcohol, nicotine
Raised intra-abdominal pressure	Pushes contents upward	Obesity, pregnancy, tight belts, bending over
Delayed gastric emptying	Keeps volume in the stomach longer	Fatty food, large portions, diabetes
Hiatus hernia	Disrupts the anatomical barrier	A common finding in persistent GERD
Direct mucosal irritation	Increases pain in an already inflamed oesophagus	Citrus, tomatoes, spicy food

What actually helps#

The Norwegian HUNT study and reviews of lifestyle interventions identify a handful of measures with the strongest evidence.

Measure	Evidence	Note
Weight loss if overweight	Strong	Reducing BMI reduces symptoms dose-dependently
No food within 3 hours of bed	Strong	Night-time reflux is the most damaging
Raise the head of the bed 15–20 cm	Moderate	The bed itself, not a stack of pillows, which bends the torso
Sleep on your left side	Moderate	Stomach anatomy reduces reflux episodes
Stop smoking	Moderate	Nicotine relaxes the sphincter
Smaller portions	Moderate	Lowers gastric volume and pressure
Blanket avoidance of the 'trigger list'	Weak	Only works for your personal triggers

The most common mistake is striking the entire classic food list at once. The ACG guideline explicitly notes that blanket restrictions are unsupported and impoverish the diet. It is smarter to keep a short diary for two or three weeks, identify your own two or three triggers, and remove those.

Medications: what does what#

Class	How it works	When to use
Antacids	Neutralise acid within minutes, last 1–2 hours	Occasional episodes, as needed
Alginates	Form a barrier raft on top of stomach contents	Episodes, especially post-meal and in pregnancy
H2 blockers	Reduce secretion for several hours	Night-time symptoms, add-on to PPIs
PPIs	Block the proton pump; full effect by day 3–5	Regular symptoms, erosive oesophagitis; 4–8 week course

PPIs deserve a separate note, because they attract a lot of fear. They are among the best-studied drugs in gastroenterology. Observational studies have linked long-term use to B12 and magnesium deficiency, Clostridioides difficile infection, fractures and kidney disease, but effect sizes are small and causation unproven — people who take PPIs for years differ at baseline from those who don't. The guidelines' position is sensible: prescribe when indicated, use the lowest effective dose, and review the need periodically rather than stopping because of headlines.

One nuance on stopping: after prolonged use there may be rebound acid hypersecretion, a temporary worsening over two to four weeks. PPIs are therefore usually tapered, with alginates or H2 blockers covering the transition.

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Wasted effort#

• Baking soda. It works fast but releases carbon dioxide, distends the stomach and provokes further reflux — and regular use adds sodium.
• Milk for heartburn. Brief relief followed by worsening, thanks to the fat content and stimulated secretion.
• Lying down after eating. Being horizontal removes gravity, the main physical defence of the oesophagus.
• Tight belts and shapewear — a direct increase in intra-abdominal pressure.
• Taking a PPI on demand for a one-off episode — they take days to work; an episode needs an antacid or alginate.

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When endoscopy is needed#

Long-standing GERD can lead to Barrett's oesophagus, in which normal lining is replaced by intestinal-type epithelium. The condition is itself symptomless but raises the risk of oesophageal adenocarcinoma, so screening endoscopy is discussed when risk factors are present — long symptom history, male sex, age over 50, obesity, smoking, family history.

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The bottom line#

Heartburn is not about "extra acid" but about acid reaching the oesophagus. The most effective steps are losing weight if you carry excess, not eating within three hours of bed, raising the head of the bed, and identifying your own food triggers instead of banning everything. Antacids and alginates handle occasional episodes; regular symptoms warrant a PPI course under medical guidance, with periodic review. And dysphagia, weight loss, bleeding or anaemia mean skipping the pharmacy and booking an endoscopy.