Heartburn resident survival guide: Difference between revisions

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! style="padding: 0 5px; font-size: 85%; background: #A8A8A8" align="center" |{{fontcolor|#2B3B44|Heartburn Resident Survival Guide Microchapters}}
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! style="font-size: 80%; padding: 0 5px; background: #DCDCDC" align="left" |[[Heartburn resident survival guide#Overview|Overview]]
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! style="font-size: 80%; padding: 0 5px; background: #DCDCDC" align="left" |[[Heartburn resident survival guide#Definition|Definition]]
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! style="font-size: 80%; padding: 0 5px; background: #DCDCDC" align="left" |[[Heartburn resident survival guide#Causes|Causes]]
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! style="font-size: 80%; padding: 0 5px; background: #DCDCDC" align="left" |[[Heartburn resident survival guide#Diagnosis|Diagnosis]]
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! style="font-size: 80%; padding: 0 5px; background: #DCDCDC" align="left" |[[Heartburn resident survival guide#Treatment|Treatment]]
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! style="font-size: 80%; padding: 0 5px; background: #DCDCDC" align="left" |[[Heartburn resident survival guide#Do's|Do's]]
|-
! style="font-size: 80%; padding: 0 5px; background: #DCDCDC" align="left" |[[Heartburn resident survival guide#Don'ts|Don'ts]]
|}
__NOTOC__
__NOTOC__
{{Resident survival guide project}}
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{{WikiDoc CMG}}; {{AE}} {{Jose}}<br />
{{WikiDoc CMG}}; {{AE}} {{Jose}}<br />
{{SK}} Approach to heartburn, approach to indigestion, approach to acid reflux, approach to gastroesophageal reflux disease, approach to GERD
==Overview==
==Overview==
[[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]].<ref name="pmid31935049">{{cite journal| author=| title=Gastro-oesophageal reflux disease and dyspepsia in adults: investigation and management | journal=National Institute for Health and Care Excellence: Clinical Guidelines | year= 2019 | volume=  | issue=  | pages=  | pmid=31935049 | doi= | pmc= | url= }} </ref> 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 cause atypical symptoms which includes: [[coughing]], [[wheezing]] or [[asthma]]-like symptoms, [[hoarseness]], [[sore throat]], dental erosions or [[Gingiva|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]]. It can also be mistaken by [[chest pain]] and presented in life-threatening diseases such as [[acute coronary syndromes]], [[aortic dissection]] and [[pericarditis]].
[[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 [[Causes|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 (dental)|erosion]] or [[Gingiva|gum]] [[disease]], [[discomfort]] in the [[ears]] and [[nose]]. [[Heartburn]] is a [[Symptoms|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]].<ref name="pmid31935049">{{cite journal| author=| title=Gastro-oesophageal reflux disease and dyspepsia in adults: investigation and management | journal=National Institute for Health and Care Excellence: Clinical Guidelines | year= 2019 | volume=  | issue=  | pages=  | pmid=31935049 | doi= | pmc= | url= }} </ref>
==Causes==
==Causes==
===Life Threatening 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]].
[[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.
Life-threatening [[causes]] include [[conditions]] that may result in death or permanent [[disability]] within 24 hours if left untreated.


*[[Acute coronary syndromes]]
*[[Acute coronary syndromes]]
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{| class="wikitable"
{| class="wikitable"
|+Differentiating heartburn from angina <ref name="urlHeartburn vs. heart attack - Harvard Health">{{cite web |url=https://www.health.harvard.edu/heart-health/heartburn-vs-heart-attack/heart-health/heartburn-vs-heart-attack/heart-health/heartburn-vs-heart-attack |title=Heartburn vs. heart attack - Harvard Health |format= |work= |accessdate=}}</ref> <ref name="pmid20003376">{{cite journal| author=Bösner S, Haasenritter J, Becker A, Hani MA, Keller H, Sönnichsen AC | display-authors=etal| title=Heartburn or angina? Differentiating gastrointestinal disease in primary care patients presenting with chest pain: a cross sectional diagnostic study. | journal=Int Arch Med | year= 2009 | volume= 2 | issue=  | pages= 40 | pmid=20003376 | doi=10.1186/1755-7682-2-40 | pmc=2799444 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=20003376  }} </ref>
|+Differentiating [[heartburn]] from [[angina]] <ref name="urlHeartburn vs. heart attack - Harvard Health">{{cite web |url=https://www.health.harvard.edu/heart-health/heartburn-vs-heart-attack/heart-health/heartburn-vs-heart-attack/heart-health/heartburn-vs-heart-attack |title=Heartburn vs. heart attack - Harvard Health |format= |work= |accessdate=}}</ref> <ref name="pmid20003376">{{cite journal| author=Bösner S, Haasenritter J, Becker A, Hani MA, Keller H, Sönnichsen AC | display-authors=etal| title=Heartburn or angina? Differentiating gastrointestinal disease in primary care patients presenting with chest pain: a cross sectional diagnostic study. | journal=Int Arch Med | year= 2009 | volume= 2 | issue=  | pages= 40 | pmid=20003376 | doi=10.1186/1755-7682-2-40 | pmc=2799444 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=20003376  }} </ref>
!Heartburn (GERD)
! style="background: #4479BA; color: #FFFFFF " align="center" |Heartburn (GERD)
!Angina or Heart Attack
! style="background: #4479BA; color: #FFFFFF " align="center" |Angina or Heart Attack
|-
|-
|Burning [[chest pain]], begins at the [[breastbone]]
|Burning [[chest pain]], begins at the [[breastbone]]
|Tightness, pressure, squeezing, stabbing or dull pain, most often in the center
|Tightness, pressure, squeezing, stabbing or dull [[pain]], most often in the center
|-
|-
|Pain that radiates towards the [[throat]]
|[[Pain]] that radiates towards the [[throat]]
|Pain radiates to the [[shoulders]], [[neck]] or arms
|[[Pain]] radiates to the [[shoulders]], [[neck]] or arms
|-
|-
|Sensation of food coming back to the [[Mouth (human)|mouth]]
|Sensation of food coming back to the [[Mouth (human)|mouth]]
|Irregular or rapid [[heartbeat]]
|Irregular or rapid [[heartbeat]]
|-
|-
|Acid taste in the back of the [[throat]]
|[[Acid]] taste in the back of the [[throat]]
|Cold [[sweat]] or [[clammy]] skin
|Cold [[sweat]] or [[clammy]] skin
|-
|-
|Pain worsens when patient lie down or bend over
|[[Pain]] worsens when [[patient]] lie down or bend over
|Lightheadedness, [[weakness]], [[dizziness]], [[nausea]], indigestion or vomiting
|[[Lightheadedness]], [[weakness]], [[dizziness]], [[nausea]], [[indigestion]] or [[vomiting]]
|-
|-
|Appears after large or spicy meal
|Appears after large or spicy meal
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|-
|-
|
|
|Symptoms appears with physical exertion or extreme [[stress]]
|[[Symptoms]] appears with physical exertion or extreme [[stress]]
|}
|}


===Common Causes===
===Common Causes===


*[[Gastroesophageal reflux disease]] (GERD)
*[[Gastroesophageal reflux disease]] ([[GERD]])
*Eosinophillic [[esophagitis]]
*Eosinophillic [[esophagitis]]
*[[Malignancy]]
*[[Malignancy]]
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==Diagnosis==
==Diagnosis==
Below is shown a compendium of information summarizing the diagnosis of [[gastroesophageal reflux disease]] (GERD) according the the American Journal of Gastroenterology guidelines.<ref name="pmid23419381">{{cite journal| author=Katz PO, Gerson LB, Vela MF| title=Guidelines for the diagnosis and management of gastroesophageal reflux disease. | journal=Am J Gastroenterol | year= 2013 | volume= 108 | issue= 3 | pages= 308-28; quiz 329 | pmid=23419381 | doi=10.1038/ajg.2012.444 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=23419381  }} </ref>  
Below is shown a compendium of information summarizing the diagnosis of [[gastroesophageal reflux disease]] ([[GERD]]) according the the American Journal of Gastroenterology guidelines.<ref name="pmid23419381">{{cite journal| author=Katz PO, Gerson LB, Vela MF| title=Guidelines for the diagnosis and management of gastroesophageal reflux disease. | journal=Am J Gastroenterol | year= 2013 | volume= 108 | issue= 3 | pages= 308-28; quiz 329 | pmid=23419381 | doi=10.1038/ajg.2012.444 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=23419381  }} </ref>  


The diagnosis of [[GERD]] is made based on:  
The diagnosis of [[GERD]] is made based on:  


* Symptom presentation;
*[[Symptoms|Symptom]] presentation
* Response to antisecretory therapy;
*Response to antisecretory therapy
* Objective testing with [[endoscopy]];
*Objective testing with [[endoscopy]]
* Ambulatory reflux monitoring.<ref name="pmid23419381" />
*Ambulatory [[reflux]] monitoring<ref name="pmid23419381" />


<br>
<br>
{{familytree/start |summary=PE diagnosis Algorithm.}} {{familytree | | | | A01 |~| A02 | A01='''Classic symptoms of GERD''' <br>(heartburn and regurgitation)|A02= If there are '''warning signs*''':<br> upper endoscopy during the initial evaluation}}
{{familytree/start |summary=PE diagnosis Algorithm.}} {{familytree | | | | A01 |~| A02 | A01='''Classic symptoms of GERD''' <br>(heartburn and regurgitation)|A02= If there are '''warning [[signs]]*''':<br> upper [[endoscopy]] during the initial evaluation}}
{{familytree | | | | |!| | | | }}  
{{familytree | | | | |!| | | | }}  
{{familytree | | | | B01 | | | B01= PPI 8-week trial}}  
{{familytree | | | | B01 | | | B01= PPI 8-week trial}}  
{{familytree | | |,|-|^|-|.| | }}
{{familytree | | |,|-|^|-|.| | }}
{{familytree | | C01 | | C02 | C01= If better: GERD probable| C02= If refractory, proceed to refractory GERD algorithm}}  
{{familytree | | C01 | | C02 | C01= If better: [[GERD]] probable| C02= If refractory, proceed to refractory [[GERD]] algorithm}}  
{{familytree/end}}
{{familytree/end}}


<nowiki>*</nowiki> [[Dysphagia]], [[bleeding]], [[anemia]], [[weight loss]] and recurrent [[vomiting]] are considered warning signs and should be investigated with [[upper endoscopy]].
<nowiki>*</nowiki> [[Dysphagia]], [[bleeding]], [[anemia]], [[weight loss]] and recurrent [[vomiting]] are considered warning signs and should be investigated with [[upper endoscopy]].
Line 77: Line 96:


{{familytree/start}}
{{familytree/start}}
{{familytree | | | | | | | Z01 |~| Z02 | |Z01='''Treat GERD:''' <br> '''Start a 8-week course of PPI'''|Z02= If there are '''warning signs*''':<br> upper endoscopy during the initial evaluation}}
{{familytree | | | | | | | Z01 |~| Z02 | |Z01='''Treat [[GERD]]:''' <br> '''Start a 8-week course of [[PPI]]'''|Z02= If there are '''warning [[signs]]*''':<br> upper [[endoscopy]] during the initial evaluation}}
{{familytree | | | | | | | |!| | | | |}}
{{familytree | | | | | | | |!| | | | |}}
{{familytree | | | | | | | A01 | | | |A01='''Refractory GERD'''}}
{{familytree | | | | | | | A01 | | | |A01='''Refractory [[GERD]]'''}}
{{familytree | | | | | | | |!| | | | |}}
{{familytree | | | | | | | |!| | | | |}}
{{familytree | | | | | | | B01 | | | | |B01='''Optimize PPI therapy'''}}
{{familytree | | | | | | | B01 | | | | |B01='''Optimize [[PPI]] therapy'''}}
{{familytree | | | | | | | |!| | | | |}}
{{familytree | | | | | | | |!| | | | |}}
{{familytree | | | | | | | C01 | | | | |C01= '''No response''': <br> Exclude other etiologies}}
{{familytree | | | | | | | C01 | | | | |C01= '''No response''': <br> Exclude other etiologies}}
{{familytree | | | |,|-|-|-|^|-|-|-|.|}}
{{familytree | | | |,|-|-|-|^|-|-|-|.|}}
{{familytree | | | D01 | | | | | | D02 | |D01= '''Typical symptoms''':<BR>Upper endoscopy|D02= '''Atypical symptoms''': <br> Referral to ENT, pulmonary, allergy}}
{{familytree | | | D01 | | | | | | D02 | |D01= '''Typical [[symptoms]]''':<BR>Upper endoscopy|D02= '''Atypical [[symptoms]]''': <br> Referral to [[ENT]], [[pulmonary]], allergy specialist}}
{{familytree | | | |)|-|-|-|v|-|-|-|(| |}}
{{familytree | | | |)|-|-|-|v|-|-|-|(| |}}
{{familytree | | | E01 | | E02 | | E03 | |E01= '''Abnormal''':<br> (eosinophilic esophagitis, erosive esophagitis, other)<br>'''Specific treatment'''|E02= '''NORMAL'''|E03= '''Abnormal''': <br> (ENT, pulmonary, or allergic disorder)<br>'''Specific treatment'''}}
{{familytree | | | E01 | | E02 | | E03 | |E01= '''Abnormal''':<br> ([[eosinophilic esophagitis]], erosive [[esophagitis]], other)<br>'''Specific treatment'''|E02= '''NORMAL'''|E03= '''Abnormal''': <br> (ENT, [[pulmonary]], or [[allergic]] disorder)<br>'''Specific treatment'''}}
{{familytree | | | | | | | |!| | | | | | | | | | |}}
{{familytree | | | | | | | |!| | | | | | | | | | |}}
{{familytree | | | | | | | F01 | | | | | | | | | |F01= '''REFLUX MONITORING'''}}
{{familytree | | | | | | | F01 | | | | | | | | | |F01= '''REFLUX MONITORING'''}}
{{familytree | | | | | |,|-|^|-|.| | | | | | | | |}}
{{familytree | | | | | |,|-|^|-|.| | | | | | | | |}}
{{familytree | | | | | G01 | | G02 | | | | | | | |G01= Low pre test probability of GERD|G02= High pre test probability of GERD}}
{{familytree | | | | | G01 | | G02 | | | | | | | |G01= Low pre test probability of GERD|G02= High pre test probability of [[GERD]]}}
{{familytree | | | | | |!| | | |!| | | | | | | | |}}
{{familytree | | | | | |!| | | |!| | | | | | | | |}}
{{familytree | | | | | H01 | | H02 | | | | |H01=Test off medication with pH or impedance-pH|H02=Test on medication with impedance-pH}}
{{familytree | | | | | H01 | | H02 | | | | |H01=Test off [[medication]] with pH or impedance-pH|H02=Test on [[medication]] with impedance-pH}}
{{familytree/end}}
{{familytree/end}}


* High Risk: Men >50 years with chronic [[gastroesophageal reflux disease]] symptoms (>5 years), AND:  
*High Risk: Men >50 years with chronic [[gastroesophageal reflux disease]] [[symptoms]] (>5 years), AND:  
** Nocturnal reflux symptoms,
**[[Nocturnal]] [[reflux]] [[symptoms]]
**[[Hiatal hernia]],
**[[Hiatal hernia]]
** Elevated body mass index,
**Elevated [[body mass index]]
**[[Tobacco]] use,
**[[Tobacco]] use
** Intra-abdominal distribution of fat.
**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|Barret's]] [[esophagus]] or [[dysplasia]], more frequent intervals are indicated. <ref name="urlwww.worldgastroenterology.org">{{cite web |url=https://www.worldgastroenterology.org/UserFiles/file/WDHD-2015-handbook-final.pdf |title=www.worldgastroenterology.org |format= |work= |accessdate=}}</ref>
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|Barret's]] [[esophagus]] or [[dysplasia]], more frequent intervals are indicated. <ref name="urlwww.worldgastroenterology.org">{{cite web |url=https://www.worldgastroenterology.org/UserFiles/file/WDHD-2015-handbook-final.pdf |title=www.worldgastroenterology.org |format= |work= |accessdate=}}</ref>


Screening for [[H. Pylori]] is not recommended routinely on [[GERD]]. <ref name="urlwww.worldgastroenterology.org">{{cite web |url=https://www.worldgastroenterology.org/UserFiles/file/WDHD-2015-handbook-final.pdf |title=www.worldgastroenterology.org |format= |work= |accessdate=}}</ref>
[[Screening]] for [[H. Pylori]] is not recommended routinely on [[GERD]]. <ref name="urlwww.worldgastroenterology.org">{{cite web |url=https://www.worldgastroenterology.org/UserFiles/file/WDHD-2015-handbook-final.pdf |title=www.worldgastroenterology.org |format= |work= |accessdate=}}</ref>
{| class="wikitable"
{| class="wikitable"
|+Diagnostic Testing for GERD <ref name="pmid23419381">{{cite journal| author=Katz PO, Gerson LB, Vela MF| title=Guidelines for the diagnosis and management of gastroesophageal reflux disease. | journal=Am J Gastroenterol | year= 2013 | volume= 108 | issue= 3 | pages= 308-28; quiz 329 | pmid=23419381 | doi=10.1038/ajg.2012.444 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=23419381  }} </ref> <ref name="pmid28631728">{{cite journal| author=Moayyedi P, Lacy BE, Andrews CN, Enns RA, Howden CW, Vakil N| title=ACG and CAG Clinical Guideline: Management of Dyspepsia. | journal=Am J Gastroenterol | year= 2017 | volume= 112 | issue= 7 | pages= 988-1013 | pmid=28631728 | doi=10.1038/ajg.2017.154 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=28631728  }} </ref>
|+[[Diagnostic]] Testing for [[GERD]] <ref name="pmid23419381">{{cite journal| author=Katz PO, Gerson LB, Vela MF| title=Guidelines for the diagnosis and management of gastroesophageal reflux disease. | journal=Am J Gastroenterol | year= 2013 | volume= 108 | issue= 3 | pages= 308-28; quiz 329 | pmid=23419381 | doi=10.1038/ajg.2012.444 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=23419381  }} </ref> <ref name="pmid28631728">{{cite journal| author=Moayyedi P, Lacy BE, Andrews CN, Enns RA, Howden CW, Vakil N| title=ACG and CAG Clinical Guideline: Management of Dyspepsia. | journal=Am J Gastroenterol | year= 2017 | volume= 112 | issue= 7 | pages= 988-1013 | pmid=28631728 | doi=10.1038/ajg.2017.154 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=28631728  }} </ref>
!Test
! style="background: #4479BA; color: #FFFFFF " align="center" |Test
!Indication
! style="background: #4479BA; color: #FFFFFF " align="center" |Indication
!Recommendation
! style="background: #4479BA; color: #FFFFFF " align="center" |Recommendation
|-
|-
|[[Proton Pump Inhibitor]] ([[PPI]]) trial
|[[Proton Pump Inhibitor]] ([[PPI]]) trial
|Classic symptoms, no warning/alarm symptoms
|Classic [[symptoms]], no warning/alarm [[symptoms]]
|If negative does not rule out [[GERD]]
|If negative does not rule out [[GERD]]
|-
|-
|[[Barium swallow]]
|[[Barium swallow]]
|Use for evaluating [[dysphagia]]
|Use for evaluating [[dysphagia]]
|Only useful for complications ([[stricture]], ring)
|Only useful for [[complications]] ([[stricture]], ring)
|-
|-
|[[Endoscopy]]
|[[Endoscopy]]
|Use if alarm symptoms, chest pain or high risk* patients
|Use if alarm [[symptoms]], [[chest pain]] or high risk* [[patients]]
|Consider early for elderly, high risk for [[Barret’s esophagus|Barret’s,]] non-cardiac [[chest pain]], patients unresponsive to PPI
|Consider early for elderly, high risk for [[Barret’s esophagus|Barret’s,]] non-cardiac [[chest pain]], patients unresponsive to PPI
|-
|-
|Esophageal [[biopsy]]
|[[Esophageal]] [[biopsy]]
|Exclude non-GERD causes
|Exclude non-[[GERD]] causes
|
|
|-
|-
|Esophageal [[manometry]]
|[[Esophageal]] [[manometry]]
|Pre operative evaluation for surgery
|Pre operative evaluation for [[surgery]]
|Rule out [[achalasia]]/[[scleroderma]]-like esophagus pre-op
|Rule out [[achalasia]]/[[scleroderma]]-like esophagus pre-op
|-
|-
|Ambulatory reflux monitoring
|Ambulatory [[reflux]] monitoring
|Preoperatively for non-erosive disease, refractory [[GERD]] symptoms or [[GERD]] diagnosis in question
|Preoperatively for non-erosive disease, refractory [[GERD]] [[symptoms]] or [[GERD]] [[diagnosis]] in question
|Correlate symptoms with reflux, document abnormal acid exposure or reflux frequency
|Correlate [[symptoms]] with reflux, document abnormal [[acid]] exposure or [[reflux]] frequency
|}
|}


==Treatment==
==Treatment==
Shown below is an algorithm summarizing the treatment of refractory [[GERD]] according the the American Journal of Gastroenterology guidelines.<ref name="pmid23419381">{{cite journal| author=Katz PO, Gerson LB, Vela MF| title=Guidelines for the diagnosis and management of gastroesophageal reflux disease. | journal=Am J Gastroenterol | year= 2013 | volume= 108 | issue= 3 | pages= 308-28; quiz 329 | pmid=23419381 | doi=10.1038/ajg.2012.444 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=23419381  }} </ref>
Shown below is an algorithm summarizing the treatment of [[refractory]] [[GERD]] according the the American Journal of Gastroenterology guidelines.<ref name="pmid23419381">{{cite journal| author=Katz PO, Gerson LB, Vela MF| title=Guidelines for the diagnosis and management of gastroesophageal reflux disease. | journal=Am J Gastroenterol | year= 2013 | volume= 108 | issue= 3 | pages= 308-28; quiz 329 | pmid=23419381 | doi=10.1038/ajg.2012.444 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=23419381  }} </ref>


Lifestyle modifications are indicated for all patients and include:
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);
*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;
*[[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.<ref name="pmid23419381" />
*Head of bed elevation and avoidance of meals 2–3 h before bedtime if [[nocturnal]] [[symptoms]].<ref name="pmid23419381" />


{| class="wikitable"
{| class="wikitable"
|+Medications used in GERD
|+[[Medications]] used in [[GERD]]
!Medication
! style="background: #4479BA; color: #FFFFFF " align="center" |Medication
!Indication
! style="background: #4479BA; color: #FFFFFF " align="center" |Indication
!Recommendation
! style="background: #4479BA; color: #FFFFFF " align="center" |Recommendation
|-
|-
|[[Proton pump inhibitor|PPI]] therapy
|[[Proton pump inhibitor|PPI]] therapy
|All patients without contraindications
|All [[patients]] without [[contraindications]]
|Use the lowest effective dose, safe during [[pregnancy]]
|Use the lowest effective dose, safe during [[pregnancy]]
|-
|-
|[[H2-receptor antagonist]]
|[[H2-receptor antagonist]]
|May be used as a complement to PPIs or as maintenance option in patients without erosive disease
|May be used as a complement to [[PPI|PPIs]] or as maintenance option in [[patients]] without erosive [[disease]]
|Beware [[tachyphylaxis]] after several weeks of usage
|Beware [[tachyphylaxis]] after several weeks of usage
|-
|-
|[[Prokinetic]] therapy and/or [[baclofen]]
|[[Prokinetic]] therapy and/or [[baclofen]]
|Used if symptoms do not improve
|Used if [[symptoms]] do not improve
|Undergo diagnostic evaluation first
|Undergo [[diagnostic]] evaluation first
|-
|-
|[[Sucralfate]]
|[[Sucralfate]]
|[[Pregnant]] women
|[[Pregnant]] women
|No role in non-pregnant patients
|No role in non-pregnant [[patients]]
|}
|}
<br />
<br />


== Do's==
==Do's==


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


==Don'ts ==
==Don'ts==


*Do not request an [[upper endoscopy]] for every patient complaining of [[GERD]];
*Do not request an [[upper endoscopy]] for every [[patient]] complaining of [[GERD]].
*Do not request [[manometry]] or ambulatory reflux monitoring routinely.
*Do not request [[manometry]] or ambulatory [[GERD]] monitoring routinely.


==References==
==References==
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{{Reflist|2}}
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Latest revision as of 22:43, 16 September 2021

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.[1]

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.

Differentiating heartburn from angina [2] [3]
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

Diagnosis

Below is shown a compendium of information summarizing the diagnosis of gastroesophageal reflux disease (GERD) according the the American Journal of Gastroenterology guidelines.[4]

The diagnosis of GERD is made based on:


 
 
 
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.[4]

 
 
 
 
 
 
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
 
 
 
 

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. [5]

Screening for H. Pylori is not recommended routinely on GERD. [5]

Diagnostic Testing for GERD [4] [6]
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.[4]

Lifestyle modifications are indicated for all patients and include:

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

Don'ts

References

  1. "Gastro-oesophageal reflux disease and dyspepsia in adults: investigation and management". National Institute for Health and Care Excellence: Clinical Guidelines. 2019. PMID 31935049.
  2. "Heartburn vs. heart attack - Harvard Health".
  3. Bösner S, Haasenritter J, Becker A, Hani MA, Keller H, Sönnichsen AC; et al. (2009). "Heartburn or angina? Differentiating gastrointestinal disease in primary care patients presenting with chest pain: a cross sectional diagnostic study". Int Arch Med. 2: 40. doi:10.1186/1755-7682-2-40. PMC 2799444. PMID 20003376.
  4. 4.0 4.1 4.2 4.3 4.4 4.5 4.6 Katz PO, Gerson LB, Vela MF (2013). "Guidelines for the diagnosis and management of gastroesophageal reflux disease". Am J Gastroenterol. 108 (3): 308–28, quiz 329. doi:10.1038/ajg.2012.444. PMID 23419381.
  5. 5.0 5.1 "www.worldgastroenterology.org" (PDF).
  6. Moayyedi P, Lacy BE, Andrews CN, Enns RA, Howden CW, Vakil N (2017). "ACG and CAG Clinical Guideline: Management of Dyspepsia". Am J Gastroenterol. 112 (7): 988–1013. doi:10.1038/ajg.2017.154. PMID 28631728.