Heartburn and heart attack may feel the same and it is difficult for even an experienced doctor to differentiate them from the symptoms and examination findings, hence the need for urgent tests to rule out a heart attack. Often, long-standing or recurrent ‘acidity’, ‘gastric’, ‘indigestion’, ‘chest congestion’, bloating, fullness, burping, vomiting sensation, mild stomach pain, burning, or discomfort, is due to causes other than excess acid in the stomach. Mild indigestion can be treated with changes in diet, lifestyle, counselling, and stress reduction, but sometimes it may indicate other health issues requiring diagnostic tests and treatment.
DO NOT IGNORE THESE SYMPTOMS IF
Shortness of breath, sweating, or chest pain radiating to the jaw, neck, or arm is more likely to be an impending heart attack and needs emergency care.
•Severe or constant heartburn or belly pain.
•Unintended weight loss or loss of appetite.
•Fatigue or weakness.
•Vomiting repeatedly or with blood (haematemesis).
•Black, tarry stools (melena).
•Trouble with swallowing (dysphagia).
•A yellowing of the skin or eyes (jaundice).
WHY HAVE ACID IN THE STOMACH?
Fishes (except some that do not have a stomach), amphibians, reptiles, birds (acid in proventriculus), and mammals, with few exceptions, have hydrochloric acid in their stomachs to break down food, absorb nutrients, and kill harmful bacteria. Carnivores (e.g., dogs) and scavengers often have stronger acids to process raw meat and pathogens. Vultures and crocodiles have incredibly high acid levels to digest bones, horns, and rotting meat. The stomach resists its own highly acidic environment (pH 1.5–3.5) with a thick, alkaline mucus barrier that coats the inner lining. Positively charged fats (phospholipids) bind to the mucus, creating a water-repelling (hydrophobic) layer that acts as a barrier against the acid. This barrier, combined with rapid regeneration of the lining and tight cell junctions, prevents hydrochloric acid (HCl) and pepsin (protein-digesting enzyme) from attacking the stomach tissue itself.
HEARTBURN AND GERD
A valve at the entry into the stomach prevents acid in it from flowing backwards (reflux) into the swallowing tube (oesophagus). In GERD (Gastroesophageal Reflux Disease), reflux happens twice a week or more or causes actual damage to the oesophagus (like inflammation or scarring). Reflux and GERD present as heartburn:
•A burning sensation in the chest that may also involve the upper abdomen.
•Usually occurs after eating or while lying down or bending over.
•May disturb sleep, especially when lying down within two hours of a meal.
It may be accompanied by
•Sour taste in the mouth, a sore throat, sensation of a “lump in the throat” (globus), and dental erosion and sensitivity.
•Sinus problems due to the entry of acid into them.
•Chronic cough, wheezing, or asthma-like symptoms caused by acid irritating the airways.
•Sour burps (acid eructation) or some stomach contents returning into the mouth (regurgitation).
•Regurgitation is common in GERD but may also be caused by conditions like achalasia or hiatal hernias that are less responsive or not responsive to acid suppression medications.
•While occasional symptoms are common and relieved by antacids, chronic reflux can damage oesophageal tissues and requires endoscopy and management.
Do not ignore if
•Difficulty or pain when swallowing (dysphagia/odynophagia).
•Unexplained weight loss or loss of appetite.
•Signs of bleeding: Vomiting blood or black, tarry stools.
Management of GERD includes
•Eat healthy, avoid trigger foods like spicy/fatty meals, caffeine, alcohol, citrus, strong spices, and acidic carbonated beverages.
•Eat smaller, more frequent meals and wait at least 3 hours after eating before lying down.
•Wear loose-fitting clothes; pressure on the abdomen (like tight-fitting clothes and tight belts) can force acid upward.
•Elevate the head of the bed by 6–9 inches and sleep on your left side to reduce reflux.
•Maintain a healthy weight and reduce belly fat.
•Antacids, H2 Blockers, or Proton Pump Inhibitors (PPI) drugs, alginates as a floating “raft” like barrier, and prokinetics to aid stomach emptying are used for short-term relief.
•If there is no response to medication or if there are complications like a large hiatal hernia, the top of the stomach is surgically wrapped around the lower oesophagus to strengthen the valve (Laparoscopic Fundoplication). There are other endoscopic options also.
ACIDITY (HYPERACIDITY) AND STOMACH DISCOMFORT (DYSPEPSIA)
The stomach produces too much acid, but it mostly stays in the stomach, unlike in reflux, causing a burning sensation in the upper belly (stomach area), often with bloating or a “too full” feeling, belching, and nausea. It can lead to ulceration of the stomach/duodenum lining (Peptic ulcer disease), inflammation of the stomach lining (Gastritis). Causes include:
•Stress, anxiety, and depression (Functional dyspepsia).
•Lifestyle factors like smoking, obesity, stress, poor sleep, and irregular meals.
•Spicy, oily, fatty foods; caffeine; alcohol; acidic and sour foods like citrus fruits, tomatoes, and carbonated drinks.
•Medications like NSAIDs, antibiotics, antidepressants, and chemotherapy drugs.
•Infection of the stomach lining by Helicobacter pylori bacteria, which produces enzymes that neutralize stomach acid and damage the protective mucous layer of the stomach, leading to ulcers or gastritis. It is transmitted through contaminated food/water or person-to-person spread through contact with saliva, vomit, faecal matter. It is highly contagious and frequently spreads in crowded, unsanitary living conditions.
CONDITIONS WHICH MAY MIMIC ACIDITY AND DYSPEPSIA
Several serious conditions in other organs can mimic the symptoms of acidity because they share common nerve pathways and can easily be mistaken for it.
•Gallstone pain is the most frequent mimic of acidity and is often brushed off as “gas” or “indigestion.” While acidity feels like a burning behind the breastbone, gallstone pain (biliary colic) is usually a sharp, steady ache or squeezing pain in the upper right abdomen or just below the ribs and often travels to the right shoulder or between the shoulder blades. It typically occurs one to two hours after a fatty meal and may last for several hours; unlike acidity, it is not relieved by antacids. Hepatitis and right-sided pneumonia may also present with upper right abdominal ache or pain.
•Peptic ulcers are sores in the stomach or small intestine that can feel like the burning of acid reflux. Ulcer pain often feels like a gnawing or hungry ache in the upper middle abdomen that occurs when the stomach is empty, such as between meals or in the middle of the night. Eating food or taking an antacid may temporarily relieve ulcer pain.
•Heart-related pain (Angina or Heart Attack) can be mistaken for severe acidity because the heart and oesophagus are close together and share nerve supplies. “Heartburn” accompanied by shortness of breath, sweating, or pain radiating to the left arm, jaw, or neck is a medical emergency. Heart-related pain is often triggered by physical exertion, whereas dyspepsia is triggered by lying down, missed meals, or spicy meals.
•Mild pancreatitis may present with upper abdomen pain with spread to the left side of the back. Left-sided pneumonia and spleen problems may also present with left upper abdomen pain.
•Early or mild appendicitis, bowel adhesions, umbilical hernia, small bowel obstruction, or mesenteric ischemia (decreased blood supply to the gut) can present as discomfort or pain around the umbilicus.
•Though less than 2% of those with dyspepsia have gastric (stomach), oesophageal, and rarely colonic cancers, any unexplained weight loss, iron deficiency anaemia, difficulty in swallowing (dysphagia), persistent vomiting, or symptoms persisting despite medication, especially in those above 50 years of age, require urgent investigation.
Symptoms requiring urgent evaluation
•Sudden severe “thunderclap” abdominal pain.
•Chest pain with burning sensation (to rule out heart attack).
•Pain with fever, vomiting blood, black stools, or jaundice.
•Progressive weight loss, anaemia, or difficulty swallowing (to rule out cancer).
•Severe pain in older adults or immunocompromised patients.
BLOATING
It is commonly caused by trapped gas from swallowed air, fizzy carbonated drinks, excessive salt or fibre intake that accumulates water, refined carbohydrates that are quickly fermented by unhealthy bacteria in the small gut (Small Intestinal Bacterial Overgrowth or SIBO), food sensitivities, or constipation with fermentation of the retained faeces releasing foul-smelling gases. Sedentary lifestyle weakens core muscles, which, with excess belly fat and bloating, leads to a protuberant abdomen, the ‘pot belly’. Quick remedies include gentle exercise, sipping peppermint or ginger tea, staying hydrated, and using heating pads on the tummy to reduce cramping and discomfort. Long-term relief involves slow eating and thorough chewing, increasing fibre intake gradually, reducing processed foods, adequate water intake, Simethicone to break up gas bubbles, and Rifaximin to suppress small gut bacteria.
In conclusion, vague symptoms assumed to be due to indigestion may actually be due to a variety of treatable, dangerous conditions that are best recognised and treated early.
Dr. P.S.Venkatesh Rao is a Consultant Surgeon, Former Faculty CMC (Vellore), AIIMS (New Delhi), and a polymath in Bengaluru, drpsvrao.com
