Recurrent Heartburn
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patient with burning retrosternal discomfort or pain (heartburn)
1
gastro-esophageal reflux disease: titrate PPI therapy
5
alarm features?
2
History and physical examination should look for alarm features suggestive of cancer. This would include evidence of persistent dysphagia, GI bleeding, unintentional weight loss, lymphadenopathy, an epigastric mass, and evidence of anemia.
trial of proton pump inhibitor (PPI)
3
heartburn resolved?
4
upper GI endoscopy ± biopsy
6
functional heartburn
16
any abnormality identified?
7
pH or impedance-pH monitoring (off PPIs)
9
esophageal manometry
13
meets
esophageal motor disorder criteria?
14
LA A-D esophagitis eosinophilic esophagitis
8
abnormal esophageal acid exposure?
10
positive
symptom association probability?
12
achalasia, diffuse esophageal spasm
15
non-erosive reflux disease
11
Case History – Recurrent Hearthburn
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A 34-year old lawyer is referred to a gastroenterologist by her primary care physician because of “therapy-resistant” reflux symptoms. She has suffered for about 5 years with daily episodes of heartburn which has partially responded to treatment with a proton pump inhibitor (PPI), prescribed by her primary care physician. An upper gastrointestinal (GI) endoscopy, carried out 3 years before, had revealed no macroscopic signs of esophagitis and no hiatus hernia.
When the history is taken by the gastroenterologist it becomes clear that the episodes of burning retrosternal pain (Box 1, Fig 1) experienced by the patient last from 10 minutes to some hours, bear no clear temporal relationship to meals, and are not posture-dependent. She does not suffer from regurgitation, or other types of chest pain. There is no dysphagia, odynophagia or other alarm features (Box 2). The use of omeprazole 40 mg daily (Box 3) seems to ameliorate the symptoms somewhat, but the result is described as unsatisfactory, even at a 40mg twice daily dose (Box 4). The patient requests surgical treatment.
The gastroenterologist decides to repeat the upper GI endoscopy (Box 6), after a period of PPI avoidance of 2 weeks. At endoscopy no macroscopic abnormalities are seen (Box 7). No biopsies are taken. 24-hour esophageal pH and impedance monitoring is then undertaken (Box 9). This test is done after the patient discontinues omeprazole for 7 days. Esophageal acid exposure (Box 10) is found to be in the normal range (time with pH < 4: upright 3.2 %, supine 0 %, total 2.3%). During the 24-hour recording 6 symptom episodes are indicated by the patient. None of these are temporally associated with the onset of a reflux episode, neither acid, nor non-acid, leading to a Symptom Association Probability (SAP) of 0% (Box 12). Before placement of the pH/impedance catheter a manometric study was carried out, in order to measure the distance of the lower esophageal sphincter (LES) to the nose (Box 13). During this test, normal esophageal peristalsis and normal LES resting pressure and relaxation were observed (Box 14). A diagnosis of functional heartburn is made (Box 16).