In today’s episode, we discuss heartburn, a problem affecting over 60 million Americans.
Dr. Rima Shaposhnikov

Who better to help us better understand this issue than Dr Rima Shaposhnikov. Dr Shaposhnikov is a board certified and licensed Gastroenterologist. She graduated from Yale University and then completed Medical School at the State University of New York in Buffalo. She then completed her residency training in Internal Medicine and a fellowship in Gastroenterology at USC. She is currently an Assistant Clinical Professor at the David Geffen School of Medicine at UCLA.
Better Man Clinics
As a Gastroenterologist, you obviously see your fair share of patients with heartburn. What is heartburn? And why do they call it heartburn.
Dr Shaposhnikov
It is interesting because I’ve tried to do a study in the past trying to figure out if patients can truly describe their experiences with heartburn its really very subjective. People can describe anything from pain in the in the middle area right between their breastbone, any burning sensation that can reach all the way up to your throat, difficulty swallowing, and indigestion. Some of my patients mention that their food tastes different. Others can describe feeling nauseous or queasy. Some patient describe it as any discomfort after eating certain foods. Not everybody has we have classically called heartburn, which is the burning sensation. Really, anytime you’re consuming something and it doesn’t feel right, that most likely could be described as indigestion or heartburn.
Better Man Clinics
The condition is called heartburn but doesn’t really have any relation to the heart aside from the location of the discomfort. Are there any red flags that people should be aware of to differentiate heartburn from real heart problems.
Dr Shaposhnikov
The burning sensation in the chest experienced with heartburn can mimic a heart attack. It is actually very important if somebody does notice that they have severe chest pain, pressure sensation, any shortness of breath, radiation to the left upper arm, tingling in the jaw, or really any movement associated shortness of breath should be seen immediately by a cardiologist. Of course, this is even more pressing in people with a history of heart disease. Also, if the pain persists for a period of time, it could also be a sign of something more serious. Usually, heartburn is experienced after we consume something very acidic, and within 30 to 45 minutes of experiencing that meal. And for some patients, obviously, even earlier, patient may experience the symptoms of even chest pain. But again, if it’s not related to food, we’ll ask them to see their cardiologist and rule heart attack or angina or any other cardiac disease out.
Better Man Clinics
You just mentioned acidic food as potentially triggering heartburn. What actually causes heartburn? What is the underlying problem that’s occurring?
Dr Shaposhnikov
Keep in mind that acid is physiological. So what does that mean? We all need acid that’s made in the stomach to break down our foods. The esophagus is the tube that takes the food from the mouth and dumps it into the stomach. Them, somebody has to play the Iron Chef and chop that food into little pieces before it can actually be taken into the small bowel (the rest of the intestines). Whatever food we’re consuming has to be broken down to the something in size between a quarter to a dime for it to be able to actually get into the small bowel. The stomach will produce the acid to chop food down into smaller pieces and move it forward. So having acid is normal. That said, there are things that can increase the level of acid and therefore be pathological or cause symptoms. Bacteria, for example, can do this. There’s only one bacteria that lives in the stomach. It’s called Helicobacter pylori. So most GI doctors and primary care doctors will check a patient out for that bacteria if they have symptoms of heartburn. Just briefly about that bacteria- it is a considered a carcinogen, which means that if it is present, it can cause not only ulcers, but can even predispose patients to gastric cancer. So very important to check for that. Other things (aside from bacteria) can also cause an abnormal increase in the stomach acid. For example, stress can actually increase acid levels . And as I mentioned before, certain foods are acidic. I use a pneumonic to remember acidic foods. I call it the four C’s. Caffeine can increase your acid as can chocolate. The other C of course, is citrus ( and don’t forget tomatoes are part of that family). Alcohol ( although it doesn’t start with the letter C) – think of champagne, Cabernet, Chardonnay, Corona, Citroen etc. So alcohol. Fatty and greasy foods also increases the acid because you need more acid to break down something heavier and greasier. Finally certain medications can increase the acid, particularly a class of medications called nonsteroidal anti-inflammatories or NSAIDS. These include medications like Ibuprofen, Aleve, and Excedrin. Finally, some prescription blood thinners may also increase symptoms of indigestion and heartburn without necessarily increasing the acid in the stomach.
Better Man Clinics
Does the increase in acid just in the stomach cause heartburn or is it have to actually travel up the esophagus for the heartburn symptoms to occur?
Dr Shaposhnikov
Each person is actually quite different and unique in how they experience the symptoms of heartburn. The acidity level or pH of our stomach is around four(very acidic). The pH of our esophagus is basic (opposite of acidic) and the pH of our small bowel is basic. The acid does not need to move all the way up the esophagus to your vocal cords to get symptoms of heartburn, although that’s where the sensation is. It could actually move only a few centimeters into the esophagus to cause symptoms. It doesn’t have to occur for a long nor does there need to be a huge amount of acid for symptoms will occur.
There is a sphincter between the esophagus and the stomach. That sphincter relaxes in order for food to pass into the stomach from the esophagus and then closes off so that when we’re laying down, the food doesn’t go back into the esophagus. The sphincter relaxes transiently throughout the evening and throughout the day, and that can contribute to patients having acid move up.
Better Man Clinics
So can people without an issue with their sphincter also have heartburn?
Dr Shaposhnikov
For sure. If you have had a heavier meal and went to bed within less than four hours of eating, anyone can experience heartburn.
Better Man Clinics
Are heavier set people more prone to heartburn? And if so why?
Dr Shaposhnikov
Well, part of it is that there’s pressure on the stomach. If there is pressure on the stomach just from the weight pushing on it, that causes a mechanical issue in which you’re getting that acid pushed back into the esophagus. There have been multiple studies looking at gastro esophageal reflux disease (backward movement of acid from the stomach to the esophagus which causes heartburn symptoms) which have demonstrated that weight loss decreases the extent of disease.
Better Man Clinics
Does wearing tight clothing cause the same mechanical pressure that can lead to heartburn?
Dr Shaposhnikov
Not really. I have not seen that.
Better Man Clinics
You had mentioned heartburn occurring when people lay down to quickly after a meal. What is a good rule of thumb about when you can lay down after eating?
Dr Shaposhnikov
We usually recommend four hours between the last meal and laying down. First of all, you want to give your stomach about 45 minutes to break the food down. But you really also want gravity to do its job. And as soon as we lay down, the body goes to rest and the food remains in the stomach instead of being moved forward into the small bowel. People who lay down to sleep quickly after a meal will notice that they will wake up in the middle of a night with symptoms. Sometimes they’ll even describe a choking sensation from acid. And they feel better sometimes sleeping in a sitting position or 15 degree angle. That is why it is a good idea to avoid keeping that stomach full of food upon laying down to sleep.
Better Man Clinics
What types of over the counter medications are available for people to help them manage their symptomatic heartburn?
Dr Shaposhnikov
One very common type of over the counter medication is a histamine 2 (H2) blocker. An example of this is Pepcid, a good medication that works almost within 15 minutes to control the acid, and can control symptoms between six to eight hour. This medication works on the acid pump in the stomach.
That pump can be blocked either irreversibly or reversibly. An h2 blocker like Pepcidt will bind to that acid producing pump and will only bind it for about six to eight hours. Patients can have a return of symptoms after that time when the pump starts working again and producing acid. Another class of medication is the proton pump inhibitor(PPI) and includes medications like Nexium. These medications bind to the pump for a longer period of time. For example, Nexium will bind to the to the pump and the pump will not be effective for supposedly 24 hours. The over the counter version of this medication is just a less potent version of the prescription medication of the same name. Specifically, the over the counter dose is about half of the prescription dose. The label on the over the counter medication will say it is a 14 day medication and to take it and then consult with a physician. If the medication is working and patients don’t have what we call “alarm signs or symptoms”, they’re safe to try any of these products to eliminate their symptoms. But, if they notice that they need it for more than two weeks, or the symptoms are persistent, they should call their physician. These “alarm” signs and symptoms include weight loss, loss of appetite, nausea, vomiting, food getting stuck in the throat, difficulty swallowing, feeling fatigued, any chest pain, shortness of breath, or bleeding from any orifice.
Better Man Clinics
Those alarm symptoms are very useful to know. What are they a sign of? What are we worried about when these symptoms are present?
Dr Shaposhnikov
Aside from the possible cardiac or heart problems that we discussed before, we worry about cancer of the stomach or esophagus when these symptoms are present.
Better Man Clinics
What about people who don’t have any of the alarm symptoms but do have ongoing heartburn for a long period of time that can be managed with over the counter medications? Is there any risk to having intermittent heartburn indefinitely or for long periods of time, even if its mild and manageable?
Dr Shaposhnikov
Yes, especially for your men. Several studies have been done on Caucasian male over the age of 40 with chronic heartburn lasting longer than 5 or 10 years. Camera studies in these men sometimes find a condition called Barrett’s esophagus which is precancerous and can lead to cancer of the esophagus. Unfortunately, up to 50% of patients with this condition may not have chronic symptoms, they may be completely asymptomatic. They don’t have any alarm signs or symptoms, but they may have the silent condition called Barrett’s esophagus. So I would say if you’ve had symptoms of heartburn that occur more than once a week and have persisted for more than few years, it’s probably a good idea just to mention it to your primary care doctor and obviously see a gastroenterologist.
Better Man Clinics
We spoke of over the counter medications that treat heartburn by blocking the acid producing pump in the stomach. What about medications like Tums? How do they work and how do they compare to those other pump based medications we discussed?
Dr Shaposhnikov
They do work differently. Tums has a very short onset. It is a very good medication and does have calcium in addition to it which has some added value. However, while it helps with symptoms of heartburn, it doesn’t actually treat the underlying problem. Pepcid (an h2 blocker) or Nexium (a proton
pump inhibitor) not only treat the symptoms, but actually treat the underlying problem. So if you have to repeatedly rely on Tums for symptomatic relief, its probably time to see a doctor.
Better Man Clinics
Are there any downsides to self-treat with these over the counter medications for the long term?
Dr Shaposhnikov
Studies have shown that longer term use of Nexium can issues of bone loss called osteopenia. Other side effects like kidney failure and dementia have also been reported with long term use. That’s why if symptoms persist after a short (2 week) course of the medications, its probably time to speak with a gastroenterologist. The gastroenterologist may need to do an endoscopy to determine the cause of their symptoms and adjust their weight, their diet, maybe their medication or stress level. For those on medications like Nexium long term, the doctor may check a calcium level and maybe a bone density scan to check for evidence of bone loss.
Better Man Clinics
What should someone going to a gastroenterologist for heart expect during the initial consultation?
Dr Shaposhnikov
First, I think a good starting point would be to actually talk to your primary care doctor or family practitioner to help you better understand what is going on and possibly differentiate heartburn from some of the other conditions we have mentioned. By the time you’re seeing a gastroenterologist, our goal is to narrow down and try to figure out what needs to be done further. During the first visit, we are just meeting the patient, getting a good history from them, and doing a physical examination. Depending on how severe the symptoms are and how concerned we are about what may be going on, the gastroenterologist may recommend a more invasive procedure called an endoscopy. An endoscopy procedure in which a camera tube is passed into the esophagus, stomach and small bowel to actually visually determine what is going and on and potentially causing the symptoms. The patient is asleep during the procedure. Its about a five minute outpatient evaluation- you can go home afterward. That procedure is not done in the doctor’s office and not during the initial consultation. It is usually scheduled in a surgery or procedure center. Not everyone with heartburn requires an endoscopy. But for some people with a long standing problem or with any alarm signs or symptoms, it’s sometimes the next step.
Better Man Clinics
Earlier we talked about some bad things you can find you can find during an endoscopy: a cancer, you an ulcer, a precancerous condition like Barrett’s esophagus. If none of those conditions are present, what else are you potentially finding? What else are you looking for.
Dr Shaposhnikov
Well, first we look at the esophagus and we make sure there’s no mucosal changes (changes seen on the inner lining). We make sure that there is no narrowing as demonstrated by rings or webs. In the stomach, we’re looking at the valve between the esophagus and the stomach to see whether everything closes properly. In the stomach itself we are looking at the folds of the inner lining, making sure there’s no redness or ulcerations. Sometimes we may do a biopsy of a suspicious area or to look for the H pylori bacteria we discussed previously. We will then look into the small bowel and look for any abnormalities.. All in all, its approximately a five to ten minute procedure but it is very useful because it does look at the integrity of the mucosa, it evaluates for any mechanical obstruction, and it assesses for any current and futures risk of malignancy
Better Man Clinics
What role do exams like motility testing or acid probe tests play in the evaluation of heartburn? What other tests may be performed?
Dr Shaposhnikov
The acid probe test is a more specialized test for somebody who may have a completely normal endoscopy but continues to have symptoms, or if we need to differentiate whether they acid is made in the stomach or not. The motility test requires a separate camera or even an attached pill or an attached camera to the esophagus, depending on how we do it. And we’re able to measure the pH of the esophagus. I mentioned earlier that the stomach is very acidic and the esophagus has a very basic pH. And if we leave a little capsule attached to the esophagus for between 40 to 96 hours, we can then determine how much acid leaves the stomach and travels to the esophagus. We can also measure the the squeezing capacity of the esophagus if somebody is having difficulty swallowing, or feels that the food is getting stuck. In those case we may be measuring pressures of the musculature of the esophagus. And we do ask patients to swallow 10 times and we monitor it based on pressures and it’s a color system. We can then look at the sphincter between the esophagus and the stomach and assess if we need to surgically tighten it so that patients are not having symptoms. So these are more specialized procedures. These are not tests that the majority of patients will go through. First, they would get a trial of medications or an endoscopy. If chronic symptoms or unexplained symptoms persist, the doctor may then proceed with these more specialized tests.
Better Man Clinics
Can non invasive tests like a CT scan answer the same questions as some of these more invasive tests?
Dr Shaposhnikov
A CT scan is not the greatest study because that really will not show you. There is a study called barium esophogram. During this test, the patient drinks a solution and imaging is performed that can demonstrate if there’s reflux occurring. I would say that endoscopy is a much better procedures because it not only provides better visualization, but also allows for biopsies of suspicious areas. Also, precancerous lesions like Barret’s Esophagus cannot be diagnosed with imaging.
Better Man Clinics
Assuming that diagnostic tests only demonstrate some reflux, what would be the next step for someone who has mild but persistent heartburn for whom the over the counter medications do not work?
Dr Shaposhnikov
If patients are still having symptoms after we have ruled out bacteria and there are no significant findings on endoscopy such as erosions or cancer, they may benefit from a prescription medication. We usually double the dose of the over the counter medication and monitor patients. They may need three months or longer of prescription medication. Again, depending on their symptoms, we then do discuss the diet again, and any lifestyle modifications that we can make to help patients with symptoms.
Better Man Clinics
How is the H Pylori bacteria treated if it is identified as the cause of the heartburn?
Dr Shaposhnikov
H Pylori can be treated with antibiotics.
Better Man Clinics
Is this a short course or do patients need to be on antibiotics chronically?
Dr Shaposhnikov
It’s usually a two week course of two antibiotics and an antacid.
Better Man Clinics
You had mentioned the three month course of the prescription strength medication. Does that actually usually cure the problem or are other interventions needed?
Dr Shaposhnikov
We still have to figure out the etiology. What caused the acid? Is it that the stressful job? Is it recent weight gain? A change in diet? There has got to be other issues that are contributing to gastroesophageal reflux disease. We don’t want to just throw medication at somebody, but we do use the medication to control the symptoms while we try to identify and address what the underlying issue may be. Some people may only require a few weeks of medication, some may be a little bit longer. Either way, the goal is to find out what is causing the acid reflux. We do spend quite a bit of time on lifestyle modifications to make sure that patients are not on medications long term.
Better Man Clinics
What happens when even the prescription medicine doesn’t help with the symptoms?
Dr Shaposhnikov
It is extremely individualized. Some doctors will add additional medications. We try to avoid surgery, but sometimes it is necessary for specific situations. On such situation is if there is an issue with the valve between the stomach and esophagus. In that case, a surgical option called a Nissen Fundoplication may be an option. Again, that is not for everybody. It is for a very specific subset of patients.
SUMMARY KEYWORDS
Heartburn, acid, esophagus, stomach, medication, reflux, endoscopy, ulcer, bacteria, Nexium, small bowel, food, H Pylori, Pepcid
Disclaimer
The conversation transcribed above is for informational purposes only. It does not represent a medical consultation nor medical advice. Rather, we hope that the information provided empowers men with the knowledge and confidence to address their issues with their health care providers. As with any medical or wellness issues, you should always consult with your health care provider before beginning any type of treatment or preventative intervention.