Diagnosis of Heartburn
Heartburn Diagnosis: Book Excerpts
Diagnosis of Heartburn: medical news summaries:
The following medical news items
are relevant to diagnosis and misdiagnosis issues for Heartburn:
Diagnostic Tests for Heartburn: Online Medical Books
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for more information about diagnostis of Heartburn.
HEARTBURN:
Ask the Following Questions:
(Algorithmic Diagnosis of Symptoms and Signs)
- Is there frequent regurgitation? If there is frequent regurgitation, the most likely diagnosis is reflux esophagitis and hiatal hernia. Gastritis and a previous gastrectomy will also cause frequent regurgitation.
- Is there recurrent nausea or vomiting? If there is recurrent nausea or vomiting, the most likely diagnosis is cholecystitis and cholelithiasis. Chronic pancreatitis can cause the same symptoms, however.
- Is the heartburn precipitated by exercise and/or relieved by nitroglycerin? These findings suggest coronary insufficiency.
- Is there associated hematemesis or recurrent black stool? The presence of hematemesis or recurrent black stools should suggest a peptic ulcer.
- Is there relief with lidocaine hydrochloride (Xylocaine® Viscous Solution)? The relief of the pain on viscous lidocaine suggests reflux esophagitis, hiatal hernia, and previous gastrectomy with bile esophagitis. Gastritis is not usually relieved by viscous Xylocaine®.
DIAGNOSTIC WORKUP
The workup begins with an upper GI series and esophagogram and stools for occult blood. If there is recurrent vomiting and right upper quadrant pain, a gallbladder ultrasound or cholecystogram should be done. If these are negative, it is best to refer the patient to a gastroenterologist for esophagoscopy and gastroscopy. The gastroenterologist may do a Bernstein test, which will reproduce symptoms by an infusion of dilute hydrochloric acid into the distal esophagus, or perform esophageal manometry or pH monitoring of the distal esophagus. An exercise tolerance test and coronary angiography also have their place in the diagnostic armamentarium.
» READ BOOK EXCERPT ONLINE »
Source: Algorithmic Diagnosis of Symptoms and Signs, 2003
INDIGESTION:
Ask the Following Questions:
(Algorithmic Diagnosis of Symptoms and Signs)
- Is there a history of drug or alcohol ingestion? Alcohol, tobacco, aspirin, other nonsteroidal anti-inflammatory drugs, steroids, caffeine, and antibiotics are just a few of the drugs that may irritate the stomach.
- Is the indigestion brought on by exertion? A history of indigestion brought on by exertion should suggest angina pectoris.
- Is there a loss of appetite and weight? These findings would suggest not only a GI neoplasm but also pernicious anemia, chronic pancreatitis and pyloric obstruction, and chronic gastritis. Chronic organ failure should also be entertained, such as uremia, cirrhosis, or congestive heart failure.
- Is the indigestion or pain relieved by food or antacids? These findings would suggest a duodenal ulcer, hiatal hernia, and esophagitis.
- Is the indigestion or pain brought on by food? These findings would suggest cholecystitis, gastric ulcer, or toxins in food such as monosodium glutamate (MSG) or sulfites.
- Is the indigestion or pain unrelated to meals? These findings would suggest a chronic appendicitis, chronic intestinal obstruction, or tabes dorsalis.
- Is there no pain associated with the indigestion? This finding would suggest functional dyspepsia.
DIAGNOSTIC WORKUP
Routine tests include a CBC, urinalysis, chemistry panel, VDRL test, thyroid profile, serum B
12
and folic acid, an upper GI series, esophagogram, and stools for occult blood and ovum and parasites. The next step is a cholecystogram or gallbladder ultrasound.
If these studies are negative, a gastroenterologist should be consulted. He will do esophagoscopy, gastroscopy, and duodenoscopy. He may also perform esophageal motility studies or esophageal pH monitoring. A Bernstein test may be of value in solving the diagnostic dilemma. He may also want to order a CT scan of the abdomen or a small bowel series.
» READ BOOK EXCERPT ONLINE »
Source: Algorithmic Diagnosis of Symptoms and Signs, 2003
REGURGITATION, ESOPHAGEAL:
Ask the Following Questions:
(Algorithmic Diagnosis of Symptoms and Signs)
- Is there dysphagia? The presence of difficulty swallowing should suggest carcinoma of the esophagus, esophageal strictures, esophageal diverticulum, achalasia, aortic aneurysm, and other mediastinal masses.
- Is there significant weight loss? The presence of significant weight loss suggests carcinoma of the esophagus and esophageal stricture. It is also found in the late stages of achalasia.
- Is there heartburn? Several of the conditions associated with esophageal regurgitation may be accompanied by heartburn, but reflux esophagitis and gastric ulcer are the most common.
DIAGNOSTIC WORKUP
Most disorders will be diagnosed by an upper GI series with an esophagogram and esophagoscopy with a biopsy. A Bernstein test, esophageal pH monitoring, and esophageal manometry may be useful in diagnosing reflux esophagitis. A CBC, serum iron, ferritin, and iron-binding capacity will help diagnose Plummer-Vinson syndrome. An ANA titer and skin biopsy will help diagnose scleroderma. A CT scan of the mediastinum will help diagnose most mediastinal masses, and angiography will be useful in diagnosing an aortic aneurysm.
» READ BOOK EXCERPT ONLINE »
Source: Algorithmic Diagnosis of Symptoms and Signs, 2003
Heartburn:
Differential Diagnosis
(In a Page: Signs and Symptoms)
-
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
» READ BOOK EXCERPT ONLINE »
Source: In a Page: Signs and Symptoms, 2004
HEARTBURN:
Approach to the Diagnosis
(Differential Diagnosis in Primary Care)
The approach to the diagnosis of heartburn is similar to that for any gastrointestinal 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.
» READ BOOK EXCERPT ONLINE »
Source: Differential Diagnosis in Primary Care, 2007
INDIGESTION:
Approach to the Diagnosis
(Differential Diagnosis in Primary Care)
The association of other symptoms and signs is important. If there is relief by antacids, esophagitis, gastritis, or an ulcer may be present. If there is blood in the stool, one should suspect an ulcer or carcinoma. Radiographic studies in the form of an upper GI series and esophagram, cholecystogram, and barium enema are usually indicated. A gastric analysis, esophagoscopy, and gastroscopy often need to be done. Awareness that a systemic disease such as an electrolyte disturbance or uremia may be the cause will suggest the need for other studies, especially if there are systemic symptoms, fever, or shortness of breath.
» READ BOOK EXCERPT ONLINE »
Source: Differential Diagnosis in Primary Care, 2007
Dyspepsia:
History and physical examination
(Handbook of Signs & Symptoms (Third Edition))
If the patient complains of dyspepsia, begin by asking him to describe it in detail. How often and when does it occur, specifically in relation to meals? Do drugs or activities relieve or aggravate it? Has he had nausea, vomiting, melena, hematemesis, a cough, or chest pain? Ask if he's taking prescription drugs and if he has recently had surgery. Does he have a history of renal, cardiovascular, or pulmonary disease? Has he noticed a change in the amount or color of his urine?
Ask the patient if he's experiencing an unusual or overwhelming amount of emotional stress. Determine the patient's coping mechanisms and their effectiveness.
Focus the physical examination on the abdomen. Inspect for distention, ascites, scars, obvious hernias, jaundice, uremic frost, and bruising. Then auscultate for bowel sounds and characterize their motility. Palpate and percuss the abdomen, noting tenderness, pain, organ enlargement, or tympany.
Finally, examine other body systems. Ask about behavior changes, and evaluate the patient's level of consciousness. Auscultate for gallops and crackles. Percuss the lungs to detect consolidation. Note peripheral edema and any swelling of the lymph nodes.
» READ BOOK EXCERPT ONLINE »
Source: Handbook of Signs & Symptoms (Third Edition), 2006
Esophageal diverticula:
Diagnosis
(Professional Guide to Diseases (Eighth Edition))
CONFIRMING DIAGNOSIS X-rays taken following a barium swallow usually confirm the diagnosis by showing characteristic outpouching.
Esophagoscopy can rule out another lesion; however, the procedure risks rupturing the diverticulum by passing the scope into it rather than into the lumen of the esophagus, a special danger with Zenker’s diverticulum.
» READ BOOK EXCERPT ONLINE »
Source: Professional Guide to Diseases (Eighth Edition), 2005
Dyspepsia:
History and physical examination
(Professional Guide to Signs & Symptoms (Fifth Edition))
If the patient complains of dyspepsia, begin by asking him to describe it in detail. How often and when does it occur, specifically in relation to meals? Do any drugs or activities relieve or aggravate it? Has the patient had nausea, vomiting, melena, hematemesis, cough, or chest pain? Ask if he’s taking any prescription drugs and if he has recently had surgery. Does he have a history of renal, cardiovascular, or pulmonary disease? Has he noticed any change in the amount or color of his urine?
Ask the patient if he’s experiencing an unusual or overwhelming amount of emotional stress. Determine the patient’s coping mechanisms and their effectiveness.
Focus the physical examination on the abdomen. Inspect it for distention, ascites, scars, obvious hernias, jaundice, uremic frost, and bruising. Then auscultate it for bowel sounds and characterize their motility. Palpate and percuss the abdomen, noting any tenderness, pain, organ enlargement, or tympany.
Finally, examine other body systems. Ask about behavior changes, and evaluate level of consciousness. Auscultate for gallops and crackles. Percuss the lungs to detect consolidation. Note peripheral edema and any swelling of lymph nodes.
» READ BOOK EXCERPT ONLINE »
Source: Professional Guide to Signs & Symptoms (Fifth Edition), 2006
dysphagia/Heartburn:
Differential Overview
(Field Guide to Bedside Diagnosis)
Dysphagia
❑ Infectious esophagitis
❑ Reflux stricture
❑ Zenker diverticulum
❑ Transfer dysphagia
❑ Diffuse esophageal spasm
❑ Foreign body
❑ Esophageal cancer
❑ Achalasia
❑ External compression
❑ Scleroderma
❑ Myasthenia gravis
❑ Radiation injury
❑ Globus hystericus
❑ Esophageal web
❑ Botulism
Heartburn
❑ Reflux esophagitis
❑ Drugs
❑ Gastritis
❑ Pregnancy
❑ Aerophagia
❑ Infectious esophagitis
❑ Scleroderma
Diagnostic Approach
Dysphagia, a sensation of sticking usually occurs at the level of the obstruction, although distal esophageal obstruction may be referred to the suprasternal notch. Odynophagia (painful swallowing) is usually caused by infectious esophagitis (Candida, HSV, CMV), severe reflux, or pill-induced esophagitis. Phagophobia (fear of swallowing) can occur in patients with hysteria, rabies, tetanus, or pharyngeal paralysis.
Weight loss may occur with dysphagia of any cause, but a major loss disproportionate to the dysphagia suggests cancer. Hoarseness occurring before dysphagia is consistent with a laryngeal lesion. Hoarseness occurring after the onset of dysphagia suggests recurrent laryngeal involvement with esophageal or bronchogenic cancer or laryngitis due to reflux or neuromuscular disease. Hiccups signal a problem in the terminal esophagus (cancer, achalasia, hiatal hernia). Progressive dysphagia is usually caused by cancer or a peptic stricture, while intermittent dysphagia is most often due to a lower esophageal ring. Unilateral wheezing with dysphagia indicates a mediastinal mass involving both the esophagus and bronchus.
History differentiates mechanical obstruction from motor disorders with 80% accuracy.
Heartburn is typically a retrosternal burning, occurring after meals or awakening the patient from sleep. Patients may regurgitate acid and small amounts of undigested food without nausea or retching. Less common symptoms include water brash, a foamy reflex hypersalivation, and globus, the constant sensation of a lump in the throat. The correlation between severity of heartburn and endoscopic grade of esophagitis is poor.
Early evaluation is indicated by coincident symptoms such as dysphagia, severe nausea, vomiting, weight loss or bleeding, lack of response to empiric therapy, or increase in symptoms with exertion (suggesting angina). Heartburn can mimic angina, with chest pressure radiating to the jaw or shoulder. Pain
or difficulty swallowing suggests active inflammation, malignancy, achalasia, or stricture. Nocturnal pain relieved by intake of food, milk, or antacids favors
peptic ulcer disease. Pain increased by meals and not interfering with daily
activities favors nonulcer dyspepsia.
» READ BOOK EXCERPT ONLINE »
Source: Field Guide to Bedside Diagnosis, 2007
Esophageal diverticula:
Diagnosis
(Handbook of Diseases)
A barium esophagogram usually confirms the diagnosis by showing characteristic outpouching. Esophagoscopy isn’t performed because the scope may be passed into the diverticulum and can cause a rupture.
» READ BOOK EXCERPT ONLINE »
Source: Handbook of Diseases, 2003
Dyspepsia:
History
(Signs & Symptoms: A 2-in-1 Reference for Nurses)
If the patient complains of dyspepsia, begin by asking him to describe it in detail. How often and when does it occur, specifically in relation to meals? Do any drugs or activities relieve or aggravate it? Has he had nausea, vomiting, melena, hematemesis, cough, or chest pain? Ask if he’s taking prescription drugs and if he has recently had surgery. Does he have a history of renal, cardiovascular, or pulmonary disease? Has he noticed any change in the amount or color of his urine?
Ask the patient if he’s experiencing an unusual or overwhelming amount of emotional stress. Determine the patient’s coping mechanisms and their effectiveness.
» READ BOOK EXCERPT ONLINE »
Source: Signs & Symptoms: A 2-in-1 Reference for Nurses, 2007
Dyspepsia:
History and physical examination
(Nursing: Interpreting Signs and Symptoms)
If the patient complains of dyspepsia, begin by asking him to describe it in detail. How often and when does it occur, specifically in relation to meals? Do drugs or activities relieve or aggravate it? Has he had nausea, vomiting, melena, hematemesis, a cough, or chest pain? Ask if he's taking prescription drugs and if he has recently had surgery. Does he have a history of renal, cardiovascular, or pulmonary disease? Has he noticed a change in the amount or color of his urine?
Ask the patient if he's experiencing an unusual or overwhelming amount of emotional stress. Determine the patient's coping mechanisms and their effectiveness.
Focus the physical examination on the abdomen. Inspect for distention, ascites, scars, obvious hernias, jaundice, uremic frost, and bruising. Then auscultate for bowel sounds and characterize their motility. Palpate and percuss the abdomen, noting tenderness, pain, organ enlargement, or tympany.
Finally, examine other body systems. Ask about behavior changes, and evaluate the patient's level of consciousness. Auscultate for gallops and crackles. Percuss the lungs to detect consolidation. Note peripheral edema and any swelling of the lymph nodes.
» READ BOOK EXCERPT ONLINE »
Source: Nursing: Interpreting Signs and Symptoms, 2007
HEARTBURN:
Approach to the Diagnosis
(Differential Diagnosis in Primary Care)
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.
» READ BOOK EXCERPT ONLINE »
Source: Differential Diagnosis in Primary Care, 2007
INDIGESTION:
Approach to the Diagnosis
(Differential Diagnosis in Primary Care)
The association of other symptoms and signs is important. If there is
relief by antacids, esophagitis, gastritis, or an ulcer may be present. If
there is blood in the stool, one should suspect an ulcer or carcinoma.
Radiographic studies in the form of an upper GI series, esophagram,
cholecystogram, and barium enema are usually indicated. A gastric analysis,
esophagoscopy, and gastroscopy often need to be done. Awareness that a
systemic disease such as an electrolyte disturbance or uremia may be the
cause will suggest the need for other studies, especially if there are
systemic symptoms, fever, or shortness of breath.
» READ BOOK EXCERPT ONLINE »
Source: Differential Diagnosis in Primary Care, 2007
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