Heartburn differential diagnosis
Jump to navigation
Jump to search
|
Heartburn Microchapters |
|
Diagnosis |
|---|
|
Treatment |
|
Case Studies |
|
Heartburn differential diagnosis On the Web |
|
American Roentgen Ray Society Images of Heartburn differential diagnosis |
|
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:
| 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. 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.[4][5][6][7][8][9][10][11][12]
| 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 |
|
|
|
✔
(Suspect delayed gastric emptying) |
✔ | - | - | - | - | Other symptoms:
Complications
| ||
| Acute gastritis |
|
Food | Antacids | ✔ | ✔ | ✔ | - | ✔ | Black stools |
|
- | |
| Chronic gastritis |
|
Food | Antacids | ✔ | ✔ | ✔ | ✔ | ✔ | - | H. pylori gastritis
Lymphocytic gastritis
|
- | |
| Atrophic gastritis | Epigastric pain | - | - | ✔ | - | ✔ | ✔ | - | H. pylori
|
| ||
| Crohn's disease | - | - | - | - | - | ✔ | ✔ |
|
|
|||
| Peptic ulcer disease |
|
|
|
|
✔ | ✔ | - | - | - | Gastric ulcers
Duodenal ulcers
|
Other diagnostic tests | |
| Gastrinoma |
|
- | - | ✔
(suspect gastric outlet obstruction) |
✔ | - | - | - | Useful in collecting the tissue for biopsy |
Diagnostic tests
| ||
| Gastric Adenocarcinoma |
|
- | - | ✔ | ✔ | ✔ | ✔ | ✔ |
|
Esophagogastroduodenoscopy
|
Other symptoms | |
| Primary gastric lymphoma |
|
- | - | - | - | - | ✔ | - | - | Useful in collecting the tissue for biopsy | Other symptoms
| |
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.
- ↑ Sugimachi K, Inokuchi K, Kuwano H, Ooiwa T (1984). "Acute gastritis clinically classified in accordance with data from both upper GI series and endoscopy". Scand J Gastroenterol. 19 (1): 31–7. PMID 6710074.
- ↑ Sipponen P, Maaroos HI (2015). "Chronic gastritis". Scand J Gastroenterol. 50 (6): 657–67. doi:10.3109/00365521.2015.1019918. PMC 4673514. PMID 25901896.
- ↑ Sartor RB (2006). "Mechanisms of disease: pathogenesis of Crohn's disease and ulcerative colitis". Nat Clin Pract Gastroenterol Hepatol. 3 (7): 390–407. doi:10.1038/ncpgasthep0528. PMID 16819502.
- ↑ Sipponen P (1989). "Atrophic gastritis as a premalignant condition". Ann Med. 21 (4): 287–90. PMID 2789799.
- ↑ Badillo R, Francis D (2014). "Diagnosis and treatment of gastroesophageal reflux disease". World J Gastrointest Pharmacol Ther. 5 (3): 105–12. doi:10.4292/wjgpt.v5.i3.105. PMC 4133436. PMID 25133039.
- ↑ Ramakrishnan K, Salinas RC (2007). "Peptic ulcer disease". Am Fam Physician. 76 (7): 1005–12. PMID 17956071.
- ↑ Banasch M, Schmitz F (2007). "Diagnosis and treatment of gastrinoma in the era of proton pump inhibitors". Wien Klin Wochenschr. 119 (19–20): 573–8. doi:10.1007/s00508-007-0884-2. PMID 17985090.
- ↑ Dicken BJ, Bigam DL, Cass C, Mackey JR, Joy AA, Hamilton SM (2005). "Gastric adenocarcinoma: review and considerations for future directions". Ann Surg. 241 (1): 27–39. PMC 1356843. PMID 15621988.
- ↑ Ghimire P, Wu GY, Zhu L (2011). "Primary gastrointestinal lymphoma". World J Gastroenterol. 17 (6): 697–707. doi:10.3748/wjg.v17.i6.697. PMC 3042647. PMID 21390139.