Heartburn differential diagnosis

Heartburn Microchapters
Home
Patient Information
Overview
Historical Perspective
Classification
Pathophysiology
Causes
Differentiating Heartburn from other Diseases
Epidemiology and Demographics
Risk Factors
Screening
Natural History, Complications and Prognosis
Diagnosis
Diagnostic Study of Choice
History and Symptoms
Physical Examination
Laboratory Findings
Electrocardiogram
X-ray
Echocardiography and Ultrasound
CT-Scan
MRI
Other Imaging Findings
Other Diagnostic Studies
Treatment
Medical Therapy
Surgery
Primary Prevention
Secondary Prevention
Cost-Effectiveness of Therapy
Future or Investigational Therapies
Case Studies
Case #1
Heartburn differential diagnosis On the Web
Most recent articles
Most cited articles
Review articles
CME Programs
Powerpoint slides
Images
American Roentgen Ray Society Images of Heartburn differential diagnosis All Images X-rays Echo & Ultrasound CT Images MRI
Ongoing Trials at Clinical Trials.gov
US National Guidelines Clearinghouse
NICE Guidance
FDA onHeartburn differential diagnosis
CDC on Heartburn differential diagnosis
Heartburn differential diagnosis in the news
Blogs on Heartburn differential diagnosis
Directions to Hospitals Treating Heartburn
Risk calculators and risk factors for Heartburn differential diagnosis

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:

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

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 :

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. Esophageal cancer, and other severe diseases including esophagitis may be considered, the latter especially in HIV patients.
  

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
• Heartburn must be differentiated from other diseases such as GERD, gastritis, peptic ulcer, crohn's disease, gastric adenocarcinoma, and gastrinoma.

Differential Diagnosis

Disease

Cause

Symptoms

Diagnosis

Other findings

Pain

Nausea & Vomiting

Heartburn

Belching or Bloating

Weight loss

Loss of Appetite

Stools

Endoscopy findings

Location

Aggravating Factors

Alleviating Factors

GERD

Lower esophageal sphincter abnormalities Hiatal hernia Abnormal esophageal contractions Prolonged emptying of stomach Gastrinomas

Epigastric pain

Spicy food Tight fitting clothing

Antacids Head elevation during sleep

✔ (Suspect delayed gastric emptying)

✔

-

-

-

-

Esophagitis Barrette's esophagus Strictures

Other symptoms: Dysphagia Regurgitation Nocturnal cough Hoarseness Complications Esophagitis Strictures Barrette esophagus

Acute gastritis

H. pylori NSAIDS Corticosteroids Alcohol Spicy food Viral infections Crohn's disease Autoimmune diseases Bile reflux Cocaine use Breathing machine or ventilator Ingestion of corrosives

Epigastric pain

Food

Antacids

✔

✔

✔

-

✔

Black stools

Pangastritis or antral gastritis Erosive (Superficial, deep, hemorrhagic) Nonerosive (H. pylori)

-

Chronic gastritis

H. pylori Alcohol Medications Autoimmune diseases Chronic stress

Epigastric pain

Food

Antacids

✔

✔

✔

✔

✔

-

H. pylori gastritis Atrophy Intestinal metaplasia Lymphocytic gastritis Enlarged folds Aphthoid erosions

-

Atrophic gastritis

H. pylori Autoimmune disease

Epigastric pain

-

-

✔

-

✔

✔

-

H. pylori Mucosal atrophy Autoimmune Mucosal atrophy

Iron deficiency anemia Autoimmune gastritis diagnosis includes: Antiparietal and anti-IF antibodies Achlorhydria and hypergastrinemia Low serum cobalamine

Crohn's disease

Autoimmune disease

Abdominal pain

-

-

-

-

-

✔

✔

Chronic diarrhea often bloody with pus or mucus Rectal bleeding

Mucosal nodularity with cobblestoning Multiple aphthous ulcers Linier or serpiginous ulcerations Thickened antral folds Antral narrowing Hypoperistalsis Duodenal strictures

Fever Fatigue Anemia (pernicious anemia)

Peptic ulcer disease

H. pylori Smoking Alcohol Radiation therapy Medications Zollinger-ellison syndrome

Epigastric pain sometimes extending to back Right upper quadrant pain

Duodenal ulcer Pain aggravates with empty stomach Gastric ulcer Pain aggravates with food

Antacids Duodenal ulcer Pain alleviates with food

✔

✔

-

-

-

Black stools

Gastric ulcers Discrete mucosal lesions with a punched-out smooth ulcer base with whitish fibrinoid base Most ulcers are at the junction of fundus and antrum 0.5-2.5cm Duodenal ulcers Well-demarcated break in the mucosa that may extend into the muscularis propria of the duodenum Found in the first part of duodenum <1cm

Other diagnostic tests Serum gastrin levels Secretin stimulation test Biopsy

Gastrinoma

Associated with MEN type 1

Abdominal pain

-

-

✔ (suspect gastric outlet obstruction)

✔

-

-

-

Black stools

Useful in collecting the tissue for biopsy

May present with symptoms of GERD or peptic ulcer disease Associated with MEN type 1 Diagnostic tests Serum gastrin levels Somatostatin receptor scintigraphy CT and MRI

Gastric Adenocarcinoma

H. pylori infection Smoked and salted food

Abdominal pain

-

-

✔

✔

✔

✔

✔

Black stools, or blood in stools

Esophagogastroduodenoscopy Multiple biopsies are taken to establish the diagnosis

Other symptoms Dysphagia Early satiety Frequent burping

Primary gastric lymphoma

H. pylori infection

Abdominal pain Chest pain

-

-

-

-

-

✔

-

-

Useful in collecting the tissue for biopsy

Other symptoms Painless swollen lymph nodes in neck and armpit Night sweats Fatigue Fever Cough or trouble breathing

• GERD must be differentiated from other causes of dysphagia, odynophagia and food regurgitation such as esophageal adenocarcinoma and esophageal stricture.

	Manifestations	Diagnostic tools
Achalasia	Dyspnea Dysphagia for solids and liquids is the most common feature, being seen in 91 % and 85% of patients respectively Regurgitation of undigested food occurs in 76-91% of patients Cough mainly when lying down in 30%	Esophagogastroduodenoscopy findings include a dilated esophagus with residual food fragments, normal mucosa and occasionally candidiasis (due to the prolonged stasis). Barium swallow shows the characteristic bird's beak appearance. Barium swallow showing bird's beak appearance - By Farnoosh Farrokhi, Michael F. Vaezi. - Idiopathic (primary) achalasia. Orphanet Journal of Rare Diseases 2007, 2:38(http://www.pubmedcentral.nih.gov/articlerender.fcgi?artid=2040141), CC BY 2.0, https://commons.wikimedia.org/w/index.php?curid=2950922
GERD	Retrosternal burning chest pain. Cough and hoarseness of voice. May present with complications such as strictures and dysphagia.	Upper GI endoscopy shows the complications such as esophagitis and barret esophagus. Esophageal manometry may show decreased tone of the lower esophageal sphincter. 24-hour esophageal pH monitoring may be done to confirm the diagnosis. Barret's esophagus - By Samir धर्म - taken from patient with permission to place in public domain, Copyrighted free use, https://commons.wikimedia.org/w/index.php?curid=1595945
Esophageal carcinoma	Dysphagia Odynophagia- fluids and soft foods are usually tolerated, while hard or bulky substances (such as bread or meat) cause much more difficulty Weight loss Pain, often of a burning nature, may be severe and worsened by swallowing, and can be spasmodic in character Nausea and vomiting	Upper GI endoscopy and esophageal biopsy the gold standard for the diagnosis of esophageal CC BY-SA 3.0, https://commons.wikimedia.org/w/index.php?curid=2587715
Corckscrew esophagus	Retrosternal chest pain that presents with or without food intake. The condition is not progressive and not causing complications.	Barium swallow shows the characteristic corckscrew appearance of the esophagus. Corckscrew esophagus - Case courtesy of Radswiki, Radiopaedia.org, rID: 11680
Esophageal stricture	Patient may present with the symptoms of the underlying GERD. Dysphagia and odynophagia.	Barium esophagography provides information about the site and the diameter of the stricture before the endoscopic intervention. Peptic stricture - By Samir धर्म - From en.wikipedia.org, Public Domain, https://commons.wikimedia.org/w/index.php?curid=1931423
Plummer-Vinson syndrome	Common symptoms of Plummer-Vinson syndrome include: Difficulty swallowing (more for solids) Weakness Pain Burning sensation in mouth Dry tongue Painful cracks in the angles of a dry mouth Pale color of the skin Less cmmon symptoms Cold intolerance Reduced resistance to infection Altered behavior Craving for for unusual items (such as ice or cold vegetables)	Lab tests are consistent with the diagnosis of iron deficiency anemia. Findings on an x-ray (barium esophagogram) suggestive of esophageal web/strictures associated with Plummer-Vinson syndrome appear as either: Thin projections on the anterior esophageal wall. Multiple upper (cervical) esophageal constrictions consistent with esophageal webs. Plummer-Vinson syndrome (Source: Case courtesy of Dr Hani Salam, <a href="https://radiopaedia.org/">Radiopaedia.org</a>. From the case <a href="https://radiopaedia.org/cases/14029">rID: 14029</a>)