Umapathy Sundaram Explains the Most Common Causes of Chronic Heartburn

Umapathy Sundaram treats chronic heartburn in his patients as a symptom with many possible origins. Millions of people experience the burning sensation behind the breastbone on occasion, but when that discomfort becomes a regular occurrence, it typically signals an underlying disruption in how the digestive system manages stomach acid.

Understanding what drives the disruption has become a central focus for gastroenterologists working to move patients past temporary relief and toward lasting management. Heartburn itself is not a disease but generally a symptom of acid reflux, occurring when digestive contents rise from the stomach into the esophagus and irritate its lining.

When reflux happens with regularity, as in twice a week or more, physicians classify it as gastroesophageal reflux disease (GERD). Roughly fifteen million Americans report experiencing heartburn daily, and understanding its root causes has become essential to effective, long-term treatment.

A Weakened Valve at the Root of the Problem

Most cases of chronic heartburn trace back to a single anatomical structure, the lower esophageal sphincter. The ring of muscle sits at the junction between the esophagus and stomach, opening to allow food to pass through and closing to keep stomach contents where they belong. When that muscle weakens or relaxes at inappropriate times, acid escapes upward and irritates sensitive esophageal tissue.

A variety of factors can compromise the valve’s function, including certain foods, alcohol consumption, and specific medications that reduce muscle tone. Pregnancy hormones and excess abdominal pressure can also interfere with proper closure, contributing to reflux episodes that recur night after night.

Hiatal Hernias and Structural Contributors

Past muscular weakness, structural abnormalities can play a significant role in persistent reflux. A hiatal hernia occurs when a portion of the stomach pushes upward through the diaphragm, disrupting the normal barrier between the stomach and esophagus and making reflux considerably more likely.

Hiatal hernias become more common with age and can exist for years without producing noticeable symptoms until heartburn patterns intensify. Sundaram commonly encounters this particular connection in patients whose reflux resists standard interventions.

“A hiatal hernia changes the mechanics of the entire reflux barrier, and addressing heartburn effectively often requires recognizing that structural piece of the puzzle,” he explains.

Diagnostic imaging and endoscopic evaluation are the most reliable methods for identifying a hiatal hernia, and its presence commonly shapes decisions around whether medication alone will suffice or if more targeted intervention becomes necessary.

Clinicians increasingly view such anatomical assessment as a critical step in evaluating chronic heartburn and its underlying causes, particularly for patients whose symptoms fail to respond to lifestyle changes.

Obesity and Increased Abdominal Pressure

Excess body weight ranks among the most consistently documented risk factors for chronic reflux. Additional abdominal fat increases pressure on the stomach, pushing its contents upward and taxing the lower esophageal sphincter’s ability to maintain a proper seal.

Research examining GERD’s global burden has found that rising obesity rates correlate closely with increasing reflux prevalence across multiple populations, a pattern researchers expect to intensify as global GERD prevalence continues rising through 2035. Weight distribution matters as much as total body weight, with abdominal obesity in particular exerting disproportionate pressure on the gastric region.

Sundaram notes that this relationship regularly gets underappreciated in patients focused solely on dietary triggers.

“Managing body weight frequently produces more durable symptom improvement than eliminating individual foods,” he says. “The mechanical pressure on the stomach matters just as much as what someone eats.”

When appropriate for the individual patient, sustainable weight management has consistently demonstrated measurable reductions in reflux frequency and severity across clinical studies.

Dietary and Lifestyle Triggers

Certain foods and beverages are well established as reflux aggravators, including fatty and fried dishes, caffeine, alcohol, chocolate, and highly acidic items such as citrus and tomato-based products. These substances can relax the lower esophageal sphincter while delaying stomach emptying or directly irritating esophageal tissue already inflamed from prior exposure to acid.

Smoking similarly undermines the body’s natural defenses against reflux, both by weakening sphincter function and by reducing saliva production, which normally helps neutralize acid that reaches the esophagus. Eating large meals, lying down soon after eating, and consuming food late at night all compound the problem by keeping the stomach fuller and more prone to backflow during periods when gravity offers less assistance.

Sundaram is quick to point out that lifestyle modification, while sometimes dismissed as a minor recommendation, forms a genuine foundation for symptom control.

“Small, consistent adjustments in eating patterns and timing often reduce reflux episodes substantially before medication becomes necessary,” he notes.

Medications and Underlying Health Conditions

A range of prescription and over-the-counter medications can contribute to chronic heartburn, including certain blood pressure treatments, sedatives, and nonsteroidal anti-inflammatory drugs. These medications can relax the lower esophageal sphincter or irritate the stomach lining directly, increasing susceptibility to reflux even in patients without other risk factors.

Underlying conditions such as delayed gastric emptying, connective tissue disorders, and certain autoimmune diseases can also predispose patients to persistent reflux by altering digestive motility or esophageal function.

New and developing research has additionally identified associations between chronic GERD and broader systemic effects, including a documented link between GERD and increased cardiovascular risk, supporting that chronic heartburn surpasses simple discomfort and warrants careful clinical attention as opposed to casual self-management.

Recognizing When Heartburn Requires Evaluation

Occasional heartburn seldom signals a serious problem, but frequent or worsening symptoms merit professional evaluation. Persistent reflux can, over time, damage esophageal tissue and increase the risk of complications.

These complications might include strictures and changes to the esophageal lining that require ongoing monitoring. Identifying the specific combination of factors driving an individual’s symptoms allows physicians to move past generic advice and toward a management strategy suited to that patient’s particular anatomy, habits, and health history.

As research continues to clarify the interplay between mechanical, dietary, and physiological contributors to reflux, gastroenterologists are increasingly able to offer patients more precise explanations for symptoms that once seemed unavoidable, along with treatment strategies built around addressing root causes instead of masking discomfort alone.

Umapathy Sundaram is a physician-scientist with a clinical and research focus on gastroenterology, including reflux disease and related digestive conditions. He contributes expert perspective on the biological and lifestyle factors shaping patient care.

Disclaimer: This article is for informational purposes only and does not constitute medical advice. Consult a qualified healthcare provider for diagnosis or treatment of chronic heartburn or GERD.