Heartburn differential diagnosis
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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 must be differentiated from other diseases that cause chest pain, such as acute coronary syndromes.
- Heartburn may also be differentiated from other diseases that cause dysphagia such as esophageal cancer, achalasia and eosinophilic esophagitis in high risk individuals.
Differentiating Heartburn from other Diseases
- Heartburn must be differentiated from other diseases that cause chest pain, such as acute coronary syndromes.
- Heartburn may also be differentiated from other diseases that cause dysphagia in high risk individuals.
- Cardiac causes must be excluded since they can be life-threatening and may present with similar symptoms. In order to facilitate this, there's a table below which describes the life-threatening causes which must be differentiated:
| 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 |
While evaluating heartburn and considering gastroesophageal reflux disease (GERD) its most probable diagnosis, there's a diagnostic approach that must be performed in order to exclude other causes, especially in high risk patients, according the the American Journal of Gastroenterology guidelines.[3] :
| 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.
| 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
Other causes of heartburn or similar symptoms / associated causes:
Other causes of heartburn include muscular diseases, esophageal diseases, use of medication which may cause inflammation of the esophagus:
- Barrett's esophagus
- Cardiotomy
- Caustic agent ingestion with resultant mucosal injury
- Chagas disease
- Cholelithiasis
- Coronary artery disease
- Coughing
- CREST syndrome (Calcinosis Raynaud's phenomenon Esophagus Sclerodactyly Telangiectasias)
- Direct irritation of esophagus:
- Aspirin
- Cigarette smoke
- Citrus fruits, juice
- Ibuprofen
- Spicy foods
- Tomatoes
- Tomato sauces
- Drugs:
- Esophageal fistula
- Esophageal carcinoma
- Esophageal diverticulum
- Foods:
- Alcohol
- Chocolate
- Coffee
- Fatty foods
- Peppermint
- Soft drinks with caffeine
- Tea
- Fundectomy (postoperative)
- Gastrectomy (postoperative)
- Gastritis
- Gastroesophageal reflux disease (GERD)
- Hiatal hernia
- Infectious esophagitis
- Mallory-Weiss tear
- Motility disorders
- Myasthenia gravis
- Peptic ulcer disease
- Pericardial disease
- Pregnancy
- Pulmonary embolism
- Scleroderma
- Strictures, webs or rings
- Vagotomy (postoperative)
References
- ↑ "Heartburn vs. heart attack - Harvard Health".
- ↑ 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.
- ↑ 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.