Heartburn

Heartburn

Heartburn, also known as pyrosis  or acid indigestion is a burning sensation in the chest, just behind the breastbone or in the epigastrium. 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). It however may also be a symptom of ischemic heart disease so concluding that it is gastroesophageal reflux disease prematurely may lead to misdiagnosis.

Definition

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

Differential diagnosis

Cardiac and esophageal causes may share similar symptoms as these two structures have the same nerve supply.

Cardiac disease is one of the first conditions that must be excluded in patients with unexplained chest pain given that patients with chest pain related to GERD cannot be distinguished from those with chest pain due to cardiac conditions. 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. 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 / Gastroesophageal reflux disease is the most common cause of heartburn. In this condition acid reflux has led to inflammation of the esophagus.

Functional heartburn

Functional heartburn is heartburn of unknown cause. 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). PPIs are however still the primary treatment with response rates in about 50% of people.

The diagnosis is based upon the Rome III criteria of :

1) burning retrosternal discomfort

2) absence of GERD as the cause

3) no esophageal motility disorders.

Cardiac

Heartburn is recognized as a symptom of an acute myocardial infarction and angina. A description of burning or indigestion like pain non significantly increases the risk of acute coronary syndrome. In a group of people presenting to a hospital with GERD symptoms 0.6% may be due to ischemic heart disease.

Diagnostic approach

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. 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.  If the chest pain is suspected to be heartburn, patients may undergo an upper GI series to confirm the presence of acid reflux. Heartburn or chest pain after eating or drinking and combined with difficulty swallowing may indicate esophageal spasms.