Heartburn resident survival guide
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:
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.
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
Common Causes
- Gastroesophageal reflux
- 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) | |||||||||||||||||
| PPI 8-week trial | |||||||||||||||||
| If better: GERD probable | If refractory, proceed to refractory GERD algorithm | ||||||||||||||||
- Screening for H. Pylori is not recommended routinely on GERD.
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 | |||||||||||||||||||||||||||||||||||||
| 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 | ||||||||||||||||||||||||||||||||||||
| 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 Barrett’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.
| 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 or ;
- Do not request manometry or phmetry routinely