Heartburn resident survival guide

Heartburn Resident Survival Guide Microchapters
Overview
Definition
Causes
Diagnosis
Treatment
Do's
Don'ts

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: José Eduardo Riceto Loyola Junior, M.D.[2]
Synonyms and keywords: Approach to heartburn, approach to indigestion, approach to acid reflux, approach to gastroesophageal reflux disease, approach to GERD

Overview

Heartburn is the feeling of burning or pressure inside the chest. Due to its location, it can be mistaken by chest pain and presented in life-threatening diseases such as acute coronary syndromes, aortic dissection and pericarditis. The pain can last for several hours and may worsen after food ingestion, in contrast with chest pain due to cardiac reasons which worsen with exercise. Some patients may also have a peculiar acid taste in the back of the throat accompanied with excessive salivation, regurgitating gas and bloating. The most common cause of heartburn is gastroesophageal reflux disease (GERD), in which the lower esophageal sphincter allows for gastric content to reflux into the esophagus. This may also cause atypical symptoms which includes: coughing, wheezing or asthma-like symptoms, hoarseness, sore throat, dental erosion or gum disease, discomfort in the ears and nose. Heartburn is a symptom though, and it can have other causes besides GERD, such as esophagitis (infections, eosinophilic) and esophageal cancer.

Definition

Heartburn is the feeling of burning or pressure inside the chest, normally located behind the breastbone, which can last for several hours and may worsen after food ingestion. Some patients may also have a peculiar acid taste in the back of the throat accompanied with excessive salivation, regurgitating gas and bloating.

Causes

Life Threatening Causes

Heartburn can be expressed by the patient as a type of chest pain. While evaluating heartburn, it is mandatory to differentiate it from cardiac chest pain.

Life-threatening causes include conditions that may result in death or permanent disability within 24 hours if left untreated.

• Acute coronary syndromes
• Aortic dissection
• Pulmonary embolism

Differentiating heartburn from angina

Heartburn (GERD)	Angina or Heart Attack
Burning chest pain, begins at the breastbone	Tightness, pressure, squeezing, stabbing or dull pain, most often in the center
Pain that radiates towards the throat	Pain radiates to the shoulders, neck or arms
Sensation of food coming back to the mouth	Irregular or rapid heartbeat
Acid taste in the back of the throat	Cold sweat or clammy skin
Pain worsens when patient lie down or bend over	Lightheadedness, weakness, dizziness, nausea, indigestion or vomiting
Appears after large or spicy meal	Shortness of breath
	Symptoms appears with physical exertion or extreme stress

Common Causes

• Gastroesophageal reflux disease (GERD)
• Eosinophillic esophagitis
• Malignancy
• Achalasia
• Peptic ulcer disease

Diagnosis

Below is shown a compendium of information summarizing the diagnosis of gastroesophageal reflux disease (GERD) according the the American Journal of Gastroenterology guidelines.

The diagnosis of GERD is made based on:

• Symptom presentation
• Response to antisecretory therapy
• Objective testing with endoscopy
• Ambulatory reflux monitoring

Classic symptoms of GERD (heartburn and regurgitation)

If there are warning signs*: upper endoscopy during the initial evaluation

PPI 8-week trial

If better: GERD probable

If refractory, proceed to refractory GERD algorithm

* Dysphagia, bleeding, anemia, weight loss and recurrent vomiting are considered warning signs and should be investigated with upper endoscopy.

Shown below is an algorithm summarizing the treatment of refractory GERD according the the American Journal of Gastroenterology guidelines.

Treat GERD: Start a 8-week course of PPI

If there are warning signs*: upper endoscopy during the initial evaluation

Refractory GERD

Optimize PPI therapy

No response: Exclude other etiologies

Typical symptoms: Upper endoscopy

Atypical symptoms: Referral to ENT, pulmonary, allergy specialist

Abnormal: (eosinophilic esophagitis, erosive esophagitis, other) Specific treatment

NORMAL

Abnormal: (ENT, pulmonary, or allergic disorder) Specific treatment

REFLUX MONITORING

Low pre test probability of GERD

High pre test probability of GERD

Test off medication with pH or impedance-pH

Test on medication with impedance-pH

• High Risk: Men >50 years with chronic gastroesophageal reflux disease symptoms (>5 years), AND:
  • Nocturnal reflux symptoms
  • Hiatal hernia
  • Elevated body mass index
  • Tobacco use
  • Intra-abdominal distribution of fat

Perform upper endoscopy to detect esophageal adenocarcinoma and Barret’s esophagus. Surveillance examinations should occur not more frequently than once every 3 to 5 years. If the patient presents with Barret's esophagus or dysplasia, more frequent intervals are indicated.

Screening for H. Pylori is not recommended routinely on GERD.

Diagnostic Testing for GERD

Test	Indication	Recommendation
Proton Pump Inhibitor (PPI) trial	Classic symptoms, no warning/alarm symptoms	If negative does not rule out GERD
Barium swallow	Use for evaluating dysphagia	Only useful for complications (stricture, ring)
Endoscopy	Use if alarm symptoms, chest pain or high risk* patients	Consider early for elderly, high risk for Barret’s, non-cardiac chest pain, patients unresponsive to PPI
Esophageal biopsy	Exclude non-GERD causes
Esophageal manometry	Pre operative evaluation for surgery	Rule out achalasia/scleroderma-like esophagus pre-op
Ambulatory reflux monitoring	Preoperatively for non-erosive disease, refractory GERD symptoms or GERD diagnosis in question	Correlate symptoms with reflux, document abnormal acid exposure or reflux frequency

Treatment

Shown below is an algorithm summarizing the treatment of refractory GERD according the the American Journal of Gastroenterology guidelines.

Lifestyle modifications are indicated for all patients and include:

• Dietary changes (reduce ingestion of chocolate, caffeine, alcohol, acidic and/or spicy foods - low degree of evidence, but there are reports of improvements with elimination);
• Weight loss for overweight patients or patients that have had recent weight gain;
• Head of bed elevation and avoidance of meals 2–3 h before bedtime if nocturnal symptoms.

Medications used in GERD

Medication	Indication	Recommendation
PPI therapy	All patients without contraindications	Use the lowest effective dose, safe during pregnancy
H2-receptor antagonist	May be used as a complement to PPIs or as maintenance option in patients without erosive disease	Beware tachyphylaxis after several weeks of usage
Prokinetic therapy and/or baclofen	Used if symptoms do not improve	Undergo diagnostic evaluation first
Sucralfate	Pregnant women	No role in non-pregnant patients

Do's

• Differentiate heartburn from cardiac chest pain.
• Consider a twice daily dosing in patients with night-time symptoms, variable schedules, and/or sleep disturbance.
• Advise the patient to cease eating chocolate, caffeine, spicy foods, citrus or carbonated beverages.
• Strongly recommend weight loss if patient's BMI is higher than 25 or recent weight gain.
• Recommend head of bed elevation if nocturnal GERD.
• Advise against late evening meals.
• Promote alcohol and tobacco cessation.
• If there is an alarm symptom such as dysphagia.
• If there's no response with such measures and initial 8-week PPI treatment, refer patient to a specialist.

Don'ts

• Do not request an upper endoscopy for every patient complaining of GERD.
• Do not request manometry or ambulatory GERD monitoring routinely.