Heartburn

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Heartburn
ICD-10R12
ICD-9787.1
MedlinePlus003114
MeSHD006356
 
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This article is about the medical condition. For the film, see Heartburn (film).
Heartburn
ICD-10R12
ICD-9787.1
MedlinePlus003114
MeSHD006356

Heartburn, also known as pyrosis,[1] cardialgia, or acid indigestion[2] is a burning sensation[3] in the chest, just behind the breastbone or in the epigastrium, the upper central abdomen.[4] The pain often rises in the chest and may radiate to the neck, throat, or angle of the jaw.

Heartburn is usually associated with regurgitation of gastric acid (gastric reflux) which is the major symptom of gastroesophageal reflux disease (GERD).[5] It may also be a symptom of ischemic heart disease, though this is true for only 0.6% of those experiencing heartburn.[6]

Definition[edit]

The terms dyspepsia and indigestion are basically heartburn[citation needed], though some sources emphasize a distinction.[7] Dyspepsia is defined as a combination of epigastric pain and heartburn.[8] Heartburn is commonly used interchangeably with gastroesophageal reflux disease rather than just to describe a symptom of burning in one's chest.[9]

Differential diagnosis[edit]

Cardiac (heart attack) symptoms and esophageal symptoms can be very similar, as the heart and esophagus share the same nerve supply.[6]

Because of the dangers inherent in an overlooked diagnosis of heart attack, cardiac disease is must be considered from the first in patients with unexplained chest pain. Patients with chest pain related to GERD are difficult to distinguish clinically from those with chest pain due to cardiac conditions. Each condition can mimic the signs and symptomatic findings of the other. Further medical investigation, such as imaging, is often necessary and exigent.

Cardiac[edit]

Symptoms of heartburn can be confused with the pain that is a symptom of an acute myocardial infarction and angina.[10] A description of burning or indigestion-like pain increases the risk of acute coronary syndrome, but not to a statistically significant level.[11] In a group of people presenting to a hospital with GERD symptoms, 0.6% may be due to ischemic heart disease.[6]

As many as 30% of chest pain patients undergoing cardiac catheterization have findings which do not account for their chest discomfort, and are often defined as having "atypical chest pain" or chest pain of undetermined origin.[12] According to data recorded in several studies based on ambulatory pH and pressure monitoring, it is estimated that 25% to 50% of these patients have evidence of abnormal GERD.

GERD[edit]

Gastroesophageal reflux disease is the most common cause of heartburn. In this condition acid reflux has led to inflammation of the esophagus.[4]

Functional heartburn[edit]

Functional heartburn is heartburn of unknown cause.[13] It is associated with other functional gastrointestinal disorder like irritable bowel syndrome and is the primary cause of lack of improvement post treatment with proton pump inhibitors (PPIs).[13] PPIs are however still the primary treatment with response rates in about 50% of people.[13] The diagnosis one of elimination, based upon the Rome III criteria: 1) burning retrosternal discomfort; 2) elimination of heart attack and GERD as the cause; and 3) no esophageal motility disorders.[13] It was found to be present in 22.3% of Canadians in one survey.[13]

Diagnostic approach[edit]

Heartburn can be caused by several conditions and a preliminary diagnosis of GERD is based on additional signs and symptoms. The chest pain caused by GERD has a distinct 'burning' sensation, occurs after eating or at night, and worsens when a person lies down or bends over.[14] It also is common in pregnant women, and may be triggered by consuming food in large quantities, or specific foods containing certain spices, high fat content, or high acid content.[14][15] If the chest pain is suspected to be heartburn, patients may undergo an upper GI series to confirm the presence of acid reflux.[15][16] Heartburn or chest pain after eating or drinking and combined with difficulty swallowing may indicate esophageal spasms.[17]

GI cocktail[edit]

Relief of symptoms 5 to 10 minutes after the administration of viscous lidocaine and an antacid increases the suspicion that the pain is esophageal in origin.[18] This however does not rule out a potential cardiac cause[19] as 10% of cases of discomfort due to cardiac causes are improved with antacids.[20]

Biochemical[edit]

Esophageal pH monitoring : a probe can be placed via the nose into the esophagus to record the level of acidity in the lower esophagus. Because some degree of variation in acidity is normal, and small reflux events are relatively common, esophageal pH monitoring can be used to document reflux in real-time.

Mechanical[edit]

Manometry: in this test, a pressure sensor (manometer) is passed through the mouth into the esophagus and measures the pressure of the lower esophageal sphincter directly.

Endoscopy: the esophageal mucosa can be visualized directly by passing a thin, lighted tube with a tiny camera known as an endoscope attached through the mouth to examine the esophagus and stomach. In this way, evidence of esophageal inflammation can be detected, and biopsies taken if necessary. Since an endoscopy allows a doctor to visually inspect the upper digestive tract the procedure may help identify any additional damage to the tract that may not have been detected otherwise.

Biopsy: a small sample of tissue from the esophagus is removed. It is then studied to check for inflammation, cancer, or other problems.

Treatment[edit]

Antacids such as calcium carbonate are often taken to treat the immediate problem,[21] with further treatments depending on the underlying cause. Medicines such as H2 receptor antagonists or proton pump inhibitors are effective for gastritis and GERD, the two most common causes of heartburn. Antibiotics are used if H. pylori is present.

Epidemiology[edit]

About 42% of the United States population has had heartburn at some point.[22]

References[edit]

  1. ^ "Pyrosis definition - Medical Dictionary definitions of popular medical terms easily defined on MedTerms". 
  2. ^ "Heartburn, Gastroesophageal Reflux (GER), and Gastroesophageal Reflux Disease (GERD)". 
  3. ^ "heartburn" at Dorland's Medical Dictionary
  4. ^ a b Differential diagnosis in primary care. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins. 2008. p. 211. ISBN 0-7817-6812-8. 
  5. ^ Heartburn
  6. ^ a b c Kato H, Ishii T, Akimoto T, Urita Y, Sugimoto M (April 2009). "Prevalence of linked angina and gastroesophageal reflux disease in general practice". World J. Gastroenterol. 15 (14): 1764–8. doi:10.3748/wjg.15.1764. PMC 2668783. PMID 19360921. 
  7. ^ Stephen C. Hauser; John J. Poterucha (26 August 2008). Mayo Clinic Gastroenterology and Hepatology Board Review. Third Edition. Informa Health Care. pp. 8–. ISBN 978-1-4200-9223-3. Retrieved 19 May 2010. 
  8. ^ Delaney B, Ford AC, Forman D, Moayyedi P, Qume M (2005). "Initial management strategies for dyspepsia". In Delaney, Brendan. Cochrane Database Syst Rev (4): CD001961. doi:10.1002/14651858.CD001961.pub2. PMID 16235292. 
  9. ^ Sajatovic, Martha; Loue, Sana; Koroukian, Siran M. (2008). Encyclopedia of aging and public health. Berlin: Springer. p. 419. ISBN 0-387-33753-9. 
  10. ^ Waller CG (December 2006). "Understanding prehospital delay behavior in acute myocardial infarction in women". Crit Pathw Cardiol 5 (4): 228–34. doi:10.1097/01.hpc.0000249621.40659.cf. PMID 18340239. 
  11. ^ Woo KM, Schneider JI (November 2009). "High-risk chief complaints I: chest pain--the big three". Emerg. Med. Clin. North Am. 27 (4): 685–712, x. doi:10.1016/j.emc.2009.07.007. PMID 19932401. 
  12. ^ "Heartburn and Regurgitation". Retrieved 2010-06-21. 
  13. ^ a b c d e Fass R (January 2009). "Functional heartburn: what it is and how to treat it". Gastrointest. Endosc. Clin. N. Am. 19 (1): 23–33, v. doi:10.1016/j.giec.2008.12.002. PMID 19232278. 
  14. ^ a b The Mayo Clinic Heartburn page. Accessed May 18, 2010
  15. ^ a b The MedlinePlus Heartburn page. Accessed May 18, 2010
  16. ^ National Digestive Diseases Information Clearinghouse (NDDIC): Upper GI Series. Accessed May 18, 2010
  17. ^ MedlinePlus: Esophageal spasms. Accessed April 18, 2010
  18. ^ Differential diagnosis in primary care. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins. 2008. p. 213. ISBN 0-7817-6812-8. 
  19. ^ Swap CJ, Nagurney JT (November 2005). "Value and limitations of chest pain history in the evaluation of patients with suspected acute coronary syndromes". JAMA 294 (20): 2623–9. doi:10.1001/jama.294.20.2623. PMID 16304077. 
  20. ^ Hanke, Barbara K.; Schwartz, George Robert (1999). Principles and practice of emergency medicine. Baltimore: Williams & Wilkins. p. 656. ISBN 0-683-07646-9. 
  21. ^ http://www.heartburn.com/ReliefAndManagement/Antacids.aspx
  22. ^ Kushner PR (April 2010). "Role of the primary care provider in the diagnosis and management of heartburn". Curr Med Res Opin 26 (4): 759–65. doi:10.1185/03007990903553812. PMID 20095795. 

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