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Summary Article: HEARTBURN
from French's Index of Differential Diagnosis: An A-Z

Retrosternal burning, rising from the epigastrium towards the throat, lies within the spectrum of dyspeptic symptoms. It is commonly ascribed to the reflux of acid or bile into the lower oesophagus secondary to inappropriate relaxation of the lower oesophageal sphincter or mechanical disruption of this mechanism (hiatus hernia, previous surgery or the presence of a stent). There is usually a co-existing element of oesophageal dysmotility impairing acid/bile clearance. Symptoms are classically exacerbated by lying flat or by stooping. Such heartburn may also occur paradoxically in patients with achalasia. Cancer of the gastro-oesophageal junction and gallstones may present with this complaint.

Gastroscopic findings with reflux are usually unremarkable; commonly a normal mucosa is seen. Barrett's oesophagus (intestinal metaplasia of the oesophageal squamous epithelium) is found in approximately 5 per cent of patients complaining of reflux, and is equally as likely to be found in those with epigastric pain alone. The development of such metaplasia may be associated with a disappearance of reflux symptoms, a testament to the protective nature of intestinal-type mucosa. Barrett's oesophagus is of malignant potential, with 0.5 per cent of Barrett's cases developing adenocarcinoma per year; those found to have high-grade dysplasia on biopsy have foci of intramucosal cancer in 50 per cent of cases.

Acid reflux has been implicated in the marked rise in the incidence of adenocarcinoma of the gastro-oesophageal junction reported from developed countries. The majority of people with significant acid reflux, however, do not have any symptoms; those with heartburn are no more likely than those with epigastric pain alone to have acid reflux on investigation. This is of clinical importance in patient management, as targeting those patients with reflux symptoms for cancer prevention would yield little benefit to a population.

A diagnosis of acid/bile reflux and associated dysmotility is made by oesophageal manometry and pH studies. An acid-sensitive oesophagus may also be detected at this test through the blinded introduction of dilute acid (Bernstein test). Patients over the age of 55 years with recent-onset reflux-like symptoms, particularly those with alarm features (dysphagia, odynophagia, anaemia or weight loss), must undergo gastroscopy or barium studies to exclude cancer. A clinical response to medical therapy does not mean that cancer is any less likely to be present.

Patients who display an acid-sensitive oesophagus without detectable gross acid reflux, and those with dysmotility, respond poorly to surgical intervention. Proton-pump inhibitors offer the best initial therapy for reflux, being superior to H2-receptor antagonists, simple antacids or motility agents alone. Lifestyle alterations, including weight reduction, avoidance of alcohol, cigarettes and fatty foods and raising the head of the bed, generally have limited impact in symptom control. There is no definite link between the presence of Helicobacter pylori and reflux; indeed, it has been suggested that eradication of this gastric antrum-dwelling bacterium may induce acid reflux.

Endoscopic treatments for reflux include submucosal injection or insertion of implants at the oesophagogastric junction, application of radiofrequency energy or the suturing/stapling of this area. The results of long-term studies for these techniques are not available.

Guidance on the management of heartburn is offered by many national gastroenterological societies, but must be adapted to take into account local variation in pathology (UK, www.bsg.org; USA, www.gastro.org).

John Meenan
Mark Kinirons
© 2011 Edward Arnold (Publishers) Ltd

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