Heartburn resident survival guide

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Heartburn Resident Survival Guide Microchapters
Overview
Definition
Causes
Diagnosis
Treatment
Do's
Don'ts


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: Approach to heartburn, approach to indigestion, approach to acid reflux, approach to gastroesophageal reflux disease, approach to GERD

Overview

Heartburn is the feeling of burning or pressure inside the chest. Due to its location, it can be mistaken by chest pain and presented in life-threatening diseases such as acute coronary syndromes, aortic dissection and pericarditis. The pain can last for several hours and may worsen after food ingestion, in contrast with chest pain due to cardiac reasons which worsen with exercise. 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 also cause atypical symptoms which includes: coughing, wheezing or asthma-like symptoms, hoarseness, sore throat, dental erosion 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.

Definition

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.[1]

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.

Differentiating heartburn from angina [2] [3]
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

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.[4]

The diagnosis of GERD is made based on:


 
 
 
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.[4]

 
 
 
 
 
 
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
 
 
 
 

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. [5]

Screening for H. Pylori is not recommended routinely on GERD. [5]

Diagnostic Testing for GERD [4] [6]
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.[4]

Lifestyle modifications are indicated for all patients and include:

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

Don'ts

References

  1. "Gastro-oesophageal reflux disease and dyspepsia in adults: investigation and management". National Institute for Health and Care Excellence: Clinical Guidelines. 2019. PMID 31935049.
  2. "Heartburn vs. heart attack - Harvard Health".
  3. 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.
  4. 4.0 4.1 4.2 4.3 4.4 4.5 4.6 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.
  5. 5.0 5.1 "www.worldgastroenterology.org" (PDF).
  6. Moayyedi P, Lacy BE, Andrews CN, Enns RA, Howden CW, Vakil N (2017). "ACG and CAG Clinical Guideline: Management of Dyspepsia". Am J Gastroenterol. 112 (7): 988–1013. doi:10.1038/ajg.2017.154. PMID 28631728.