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==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. 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 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]], 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]].(https://www.nice.org.uk/guidance/cg184/ifp/chapter/heartburn-and-reflux). 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]].
==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]]. https://pubmed.ncbi.nlm.nih.gov/23419381/


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.


*[[Life threatening cause 1|Acute coronary syndromes]]
*[[Acute coronary syndromes]]
*[[Life threatening cause 2|Aortic dissection]]
*[[Aortic dissection]]
*Pulmonary embolism
*[[Pulmonary embolism]]
 
{| class="wikitable"
|+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 (human)|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]]
|}
https://www.health.harvard.edu/heart-health/heartburn-vs-heart-attack


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


*[[Common cause 1|Gastroesophageal reflux]]
*[[Gastroesophageal reflux disease]]
*Eosinophillic esophagitis
*Eosinophillic [[esophagitis]]
*[[Common cause 4|Malignancy]]
*[[Malignancy]]
*[[Common cause 5|Achalasia]]
*[[Achalasia]]
*Peptic ulcer disease
*[[Peptic ulcer disease]]<ref name="pmid23419381" />


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


* Symptom presentation;
* Symptom presentation;
* Response to antisecretory therapy;
* Response to antisecretory therapy;
* Objective testing with endoscopy;
* Objective testing with [[endoscopy]];
* Ambulatory reflux monitoring.
* Ambulatory reflux monitoring.<ref name="pmid23419381" />
 
<br>
<br>
{{familytree/start |summary=PE diagnosis Algorithm.}} {{familytree | | | | A01 | | | A01='''Classic symptoms of GERD''' <br>(heartburn and regurgitation) }} {{familytree | | | | |!| | | | }} {{familytree | | | | B01 | | | B01= PPI 8-week trial}} {{familytree | | |,|-|^|-|.| | }}
{{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 | | | | B01 | | | B01= PPI 8-week trial}}  
{{familytree | | |,|-|^|-|.| | }}
{{familytree | | C01 | | C02 | C01= If better: GERD probable| C02= If refractory, proceed to refractory GERD algorithm}}
{{familytree/end}}


{{familytree | | C01 | | C02 | C01= If better: GERD probable| C02= If refractory, proceed to refractory GERD algorithm}} {{familytree/end}}
 
<br>
<nowiki>*</nowiki> [[Dysphagia]], [[bleeding]], [[anemia]], [[weight loss]] and recurrent [[vomiting]] are considered warning signs and should be investigated with [[upper endoscopy]].
* Screening for H. Pylori is not recommended routinely on GERD.


<br>
<br>
Shown below is an algorithm summarizing the treatment of refractory GERD according the the American Journal of Gastroenterology guidelines.  
Shown below is an algorithm summarizing the treatment of refractory [[GERD]] according the the American Journal of Gastroenterology guidelines.  


{{familytree/start}}
{{familytree/start}}
{{familytree | | | | | | | Z01 | | | |Z01='''Treat GERD:''' <br> '''Start a 8-week course of PPI'''}}
{{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'''}}
Line 62: Line 96:


{{familytree/end}}
{{familytree/end}}
https://pubmed.ncbi.nlm.nih.gov/23419381/
* 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|Barret's]] [[esophagus]] or [[dysplasia]], more frequent intervals are indicated.
Screening for [[H. Pylori]] is not recommended routinely on [[GERD]].
https://www.worldgastroenterology.org/UserFiles/file/WDHD-2015-handbook-final.pdf
{| class="wikitable"
{| class="wikitable"
|+Diagnostic Testing for GERD
|+Diagnostic Testing for GERD https://pubmed.ncbi.nlm.nih.gov/23419381/
!Test
!Test
!Indication
!Indication
!Recommendation
!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 Barrett’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.
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:
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.
*Head of bed elevation and avoidance of meals 2–3 h before bedtime if nocturnal symptoms.<ref name="pmid23419381" />


{| class="wikitable"
{| class="wikitable"
Line 108: Line 156:
!Recommendation
!Recommendation
|-
|-
|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 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
|}
|}
Line 129: Line 177:


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


==References==
==References==

Revision as of 15:47, 17 August 2020

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: José Eduardo Riceto Loyola Junior, M.D.[2]

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.(https://www.nice.org.uk/guidance/cg184/ifp/chapter/heartburn-and-reflux). 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 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.

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. https://pubmed.ncbi.nlm.nih.gov/23419381/

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

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

https://www.health.harvard.edu/heart-health/heartburn-vs-heart-attack

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.

The diagnosis of GERD is made based on:

  • Symptom presentation;
  • Response to antisecretory therapy;
  • Objective testing with endoscopy;
  • Ambulatory reflux monitoring.[1]


 
 
 
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
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
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
 
 
 
 

https://pubmed.ncbi.nlm.nih.gov/23419381/

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.

https://www.worldgastroenterology.org/UserFiles/file/WDHD-2015-handbook-final.pdf

Diagnostic Testing for GERD https://pubmed.ncbi.nlm.nih.gov/23419381/
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.[1]
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 >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 reflux monitoring routinely.

References

  1. ↑ 1.0 1.1 1.2


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