HEARTBURN
HEARTBURN: Excerpt from Differential Diagnosis in Primary Care
True heartburn (see also sections on indigestion, page 271 and anorexia, page 48) may be defined as a burning pain in the substernal area or
midepigastrium, which is usually increased by swallowing and which is almost
invariably due to esophagitis from gastric reflux. There are other causes,
however, and the problem for the diagnostician is how best to recall these
in the clinical situation. From an etiologic standpoint inflammation
is almost invariably the culprit, although myocardial infarction or angina
pectoris are two frequent causes that are not inflammatory.
Anatomically, the best approach is to move in a targetlike fashion from the
intrinsic portion of the esophagus and stomach peripherally. Thus, in the
first zone, one encounters esophagitis, gastritis, and gastric ulcers.
In the second zone, one encounters hiatal hernia (which, of course,
predisposes to esophagitis), pericarditis, mediastinitis, and
gastrojejunostomy complications. In the third zone, one visualizes
cholecystitis (which probably induces a bile esophagitis), pancreatitis,
myocardial infarction or coronary insufficiency, pleurisy, and intestinal
obstruction. In the fourth zone, one recalls systemic diseases such as
uremia, severe emphysema, cirrhosis, and congestive heart failure (CHF)
(which probably causes gastritis or gastric ulcers).
Approach to the Diagnosis
The approach to the diagnosis of heartburn is similar to that of any GI
complaint, but a few clinical tricks will help decide whether it is
intrinsic or extrinsic, especially if the upper GI series is negative.
Always order an esophagram. If the patient has the pain when in your office,
administer a tablespoon or two of lidocaine (xylocaine viscous). If the
patient gets relief in 5 to 10 minutes, the heartburn is probably caused by
esophagitis. Further confirmation can be obtained by a Bernstein test. In
this test, solutions of normal saline and 0.10 normal HCl are administered
by intravenous tubing into the lower esophagus, alternating one with the
other. If the patient invariably experiences pain when the 0.10 normal HCl
is administered, esophagitis is confirmed. Esophagoscopy and gastroscopy
will reveal most intrinsic lesions with certainty, but occasionally they are
normal in esophagitis. Manometric studies of the esophagus are the best way
to diagnose esophageal reflux. If the episodes are frequent but relatively
brief, a trial of nitroglycerin may diagnose angina pectoris. Coronary
insufficiency may also be confirmed by an exercise tolerance test.
Cholecystogram and liver and pancreatic function studies may also be
indicated.
Other Useful Tests
-
Ambulatory pH monitoring (esophageal reflux)
- Gallbladder sonogram (cholecystitis)
- Thallium scan (coronary insufficiency)
- Acid barium swallow (esophagitis)
- Therapeutic trial of nitroglycerin (coronary insufficiency)
- Holter monitoring (coronary insufficiency)
- Coronary angiogram (coronary insufficiency)
CASE PRESENTATION #40
A 48-year-old black man complained of recurrent substernal burning pain
radiating to his jaw for several months. He has a history of smoking 2 packs
of cigarettes a day for 30 years and consumes alcohol in moderation.
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Pictures
Book Source Details
- Book Title: Differential Diagnosis in Primary Care
- Author(s): R. Douglas Collins MD, FACP
- Year of Publication: 2007
- Copyright Details: Differential Diagnosis in Primary Care, Copyright © 2007 Lippincott Williams & Wilkins.
More About Heartburn
More Medical Textbooks Online about Heartburn
Review other book chapters online related to Heartburn:
Medical Books Excerpts
- HEARTBURN
- "Algorithmic Diagnosis of Symptoms and Signs" (2003)
- [ read ]
- HEARTBURN
- "Differential Diagnosis in Primary Care" (2007)
- [ read ]
- Dyspepsia
- "Handbook of Signs & Symptoms (Third Edition)" (2006)
- [ read ]
- Dyspepsia
- "Professional Guide to Signs & Symptoms (Fifth Edition)" (2006)
- [ read ]
- Dyspepsia
- "Signs & Symptoms: A 2-in-1 Reference for Nurses" (2007)
- [ read ]
- Dyspepsia
- "Nursing: Interpreting Signs and Symptoms" (2007)
- [ read ]
- HEARTBURN
- "Differential Diagnosis in Primary Care" (2007)
- [ read ]
Copyright notice for book excerpts: Copyright © 2008 Lippincott Williams & Wilkins. All rights reserved.
» Next page: INDIGESTION (Differential Diagnosis in Primary Care)
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