Heartburn

Heartburn: Excerpt from In a Page: Signs and Symptoms

Heartburn is a term commonly used by patients and must be carefully evaluated to ensure accurate understanding of the symptoms. Typically, the term “heartburn” describes a substernal and/or epigastric burning pain associated with a “sour stomach” sensation and/or a sour, acidic taste in the back of the mouth or throat. Though esophageal pathologies are most common, clinicians must immediately assess the patient for life-threatening conditions, such as myocardial ischemia/infarction, ruptured aortic aneurysm, and perforating peptic ulcer disease.

Differential Diagnosis

• Distinguish between esophageal pain (reflux) and cardiac pain (angina)
• Coronary artery disease
  –Angina/ischemia
  –Myocardial infarction
  –Pericardial disease
• Esophageal pathology
  –Gastroesophageal reflux disease
  –Hiatal hernia
  –Motility disorders with decreased peristaltic clearance (e.g., achalasia)
  –Peptic ulcer disease
  –Gastritis
  –Infectious esophagitis (e.g., Candida, HIV, CMV, HSV): Common in immunosup pressed patients
  –Barrett's esophagus
  –Esophageal carcinoma (commonly squamous cell)
  –Strictures, webs, or rings
  –Esophageal diverticulum
  –Scleroderma
  –Esophageal varices
  –Mallory-Weiss tear
  –Esophageal atresia or fistula
  • Caustic agent ingestion with resultant mucosal injury
  • Myasthenia gravis
  • Chagas’ disease
  • Pulmonary embolism
  • Muscle strain
  • Asthma
  • Pregnancy

  Workup and Diagnosis

  • Distinguish between esophageal pain (reflux) and cardiac pain (angina)
  • History and physical exam often make the diagnosis
  • Be sure to appropriately rule out coronary artery disease in
    unexplained cases of chest pain
    –ECG
    –Cardiac enzymes
    –Stress testing
  • Initial diagnostic test for esophageal etiologies may be a therapeutic challenge with H2 blockers or proton pump inhibitors; further evaluation is indicated only for patients who fail initial therapy or may have serious pathology
  • Endoscopy (with biopsy and Helicobacter pylori testing) will verify reflux esophagitis and other pathology (e.g., stricture) and rule out Barrett's esophagus and esophageal carcinoma
  • Ambulatory esophageal pH monitoring may be used to evaluate patients with atypical reflux symptoms and normal endoscopy
  • Double contrast barium swallow may identify early stages of reflux esophagitis, ulcers, strictures, and folds
  • Esophageal manometry will diagnose motility disorders, decreased peristalsis, and esophageal spasm
  • Biopsy is diagnostic for Barrett's esophagus, carcinoma, sclerosis, and infection

  Treatment

• Lifestyle modification is the initial therapy for most cases of esophageal pathology
  –Elevate head of bed (for nocturnal symptoms)
  –Avoid reflux-inducing foods (e.g., fat, chocolate, caffeine, alcohol, acidic foods)
  –Decrease total caloric intake, smoking, and stress
  –Promote salivation with chewing gum or lozenges
  –Avoid tight-fitting garments
  • Acid suppressive medications are indicated for significant
    reflux and/or failed lifestyle modifications
    –Antacids
    –H2 receptor antagonists (e.g., famotidine)
    –Proton pump inhibitors (e.g., omeprazole)
• Prokinetic medications (e.g., metoclopramide, cisapride) may be used to increase LES pressure and gastric emptying and improve peristalsis; however, significant side effects may occur
• Annual upper GI endoscopy may be indicated to monitor for Barrett's esophagus and carcinoma

Book Source Details

• Book Title: In a Page: Signs and Symptoms
• Author(s): Scott Kahan, Ellen G. Smith
• Year of Publication: 2004
• Copyright Details: In a Page: Signs and Symptoms, Copyright © 2004 Lippincott Williams & Wilkins.

More About Heartburn

• Back to disease: Heartburn: Introduction
• Next Book Extract About Heartburn: HEARTBURN (Differential Diagnosis in Primary Care)
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Copyright notice for book excerpts: Copyright © 2008 Lippincott Williams & Wilkins. All rights reserved.

More About This Book: Title: In a Page: Signs and Symptoms Authors: Scott Kahan, Ellen G. Smith Publisher: Lippincott Williams & Wilkins Copyright: 2004 ISBN: 1-4051-0368-X

 » Next page: HEARTBURN (Differential Diagnosis in Primary Care)

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