Diagnosis &Management of Functional Heartburn

Dr. Muhammad AlshekhaniMBChB-CABM-FRCP-EBGH.

Amer JGE 2016

Abstract:• Heartburn is among the most common GI symptoms

presenting to both generalist physicians&gastroenterologists.

• Heartburn that does not respond to traditional acid suppression is a diagnostic & therapeutic dilemma.

• In the era of high utilization of PPIs, a substantial % of patients presenting to the gastroenterologist with chronic symptoms of heartburn do not have a refl ux-mediated disease.

• Subjects without objective evidence of reflux as a cause of their symptoms have “functional heartburn”.

Abstract:• The diagnostic role of endoscopy, reflux&motility testing in (FH) patients

is discussed. • Lifestyle modifi cations,pharmacological interventions& alternative

therapies fare also presented. • Recognition of patients with FH allows earlier assignment of these

patients to different treatment algorithms, which may allow greater likelihood of success of treatment, diminished resource utilization & improved QOL.

• Further data on this large&understudied group of patients is necessary to allow improvement in treatment algorithms and a more evidence-based approach to care of these patients.

Introduction:• Heartburn: retrosternal burning, interferes significantly in

QOL & both medical / lay people easily recognize. • Heartburn affects at some time or another with 10–20% of

patients. • 25–40% complaining of heartburn continue to have

symptoms despite daily PPI. • A substantial proportion with HB symptoms who do not

respond to PPI therapy have normal esophageal acid exposure&no correlation between reflux events &symptoms ,termed “functional heartburn”, to differentiate it from groups in which there is objective evidence of reflux as the etiology of symptoms.

Introduction:• Heartburn may be the presenting symptom of a

heterogeneous group of disorders only some of which are related to (GERD).

• Erosive reflux disease (esophageal mucosal ulceration or erosion on endoscopy) is actually present in only a minority of patients presenting with heartburn.

• NERD is characterized by reflux symptoms in the absence of esophageal mucosal breaks, with objective evidence of pathological levels of gastroesophageal reflux on pH or pH-impedance monitoring.

• Patients with esophageal hypersensitivity have normal eso acid exposures but a positive correlation between reflux events & symptoms, with symptom index >50%&/or a symptom association probability of >95%.

Introduction:• Functional heartburn (FH), heartburn occurs in the setting

of normal endoscopic fndings with no correlation of symptoms with objective testing.

• The Rome III criteria define FH as burning retrosternal discomfort or pain without evidence of GERD for at least 3 of the last 6 months.

• Investigators sometimes describe “endoscopy-negative reflux disease” (ENRD), for any patient with reflux symptoms &without endoscopic stigmata of reflux.

• Some investigators require the presence of HB for inclusion in ENRD,others may include subjects with solely symptoms of regurgitation& other symptoms.

• The differentiation of these conditions must occur in the absence of PPI.

EPIDEMIOLOGY

• FH affects adults of all ages but more commonly >40& women more a reflection of healthcare seeking behaviors than true demography.

• The majority of HB have normal endoscopic exams. • 91% of patients with suspected GERD had a normal

endoscopy & one-third of these patients had a diagnosis of FH when pH testing was used.

• Those with objective evidence of reflux or complications tend to be older, male, smokers,have objective increased prevalence of hiatal hernia&decreased LES tone, in comparison to patients with FH..

EPIDEMIOLOGY

• Increased BMI(>25 kg/m 2 ) is associated with PPI failure in patients with acid reflux compared with those patients with hypersensitive esophagus or FH.

• Understanding the epidemiology/pathogenesis of patients with FH may allow early recognition of these patients&help anticipate/avert therapeutic failure.

PATHOPHYSIOLOGY

• 1.Visceral hypersensitivity.• 2.Esophageal dysmotility: nonspecific manometric findings

in up to 2/3.• 3. A possible manifestation of psychiatric disease: high

rates of anxiety with fewer social support structures,Shared traits with other functional bowel disorders, such as somatization & altered autonomic function.

Clinical presentation&diagnosis:• FH is often suspected by lack of response to aggressive acid

suppresion, usually as twice daily dosing. • Pathologic reflux, motility disorders & structural

abnormalities must be excluded as a prerequisite for a diagnosis of FH.

• Frequency /severity of HB symptoms appear to be stable over time.

• The low QOL scores are similar to patients with ESRD. • 40–80% with ENRD report problems in eating/drinking,

sleeping, energy& anxiety • Demographics & symptoms cannot distinguish bet FH& true

refr HB or FD.

Clinical presentation&diagnosis:• 2/3 of patients with FH endorse other l (GI) symptoms, most

commonly, belching, bloating,postprandial fullness.&higher prevalence of IBS, somatization &dyspeptic symptoms (postprandial fullness, bloating, early satiety,nausea) in FB compared with NERD or hypersensitive esophagus.

• The sensitivity/ specificity of heartburn symptoms for GERD is far from ideal.

• Testing to discern FH from other causes of HB includes (EGD), pH or pH-impedance& motility testing.

• The limitations of these studies& their operating characteristics, must be taken into account when evaluating patients in whom FH is a consideration.

Outcome:

• Reassurance is key, as the diagnosis of FH is associated with a benign course.

• These patients do not have pathologic reflux&unlikely to develop complications but need to be aware of the chronic persistent nature of FH.

• 1 year follow-up data suggest that the majority of patients will continue to have heartburn as a main symptom without significant change over time.

• Although significant decreased QOL may be encountered,there is no evidence that mortality

• Seeking medical care is high, like other functional bowel disorders, >6 visits/ year& higher consultation if present with co-existing FGIDs like FD.

Conclusion:

• Understanding that heartburn is a symptom common to multiple subgroups of patients is key to identifying FH patients.

• FH patients are a subgroup that respond poorly to PPI therapy, have normal esophageal acid exposure&no correlation between symptoms& reflux events. The pathophysiology of FH is unknown but it is often associated with visceral hypersensitivity, nonspecific esophageal dysmotility patterns & shared traits with other functional bowel disorders.

• Endoscopy, motility& pH testing help objectively assess patients with HB, identify potential complications of HB& differentiate FH from other diseases.

Conclusion:

• Making the diagnosis of FH may be the most difficult challenge.

• Owing to the overlap of disease processes & variable definitions for FH, it has been difficult to identify effective treatments specifically targeting FH.

• Lifestyle changes & acid suppression are oft en recommended for FH patients with limited supporting data from well-designed clinical trials.

• Modulation of pain perception & alternative therapies may be potential therapeutic options.

• Because of its chronic nature, reassurance of its benign clinical course is key.

CME:

• 1. A 55-year-old woman with diabetes, hypertension&hyperlipidemia presents to you with heartburn that has been unresponsive to proton pump inhibition twice per day. She takes her acid reflux medication 30 minutes before meals. She has been on this medication for 4 weeks.She denies dysphagia, odynophagia, weight loss, or tobacco use. On physical exam, her body mass index (BMI) is 30 kg/m2 &oropharynx is clear.What is the most likely finding on endoscopy?

• A. Erosive esophagitis• B. Barrett’s esophagus• C. Normal endoscopy• D. Esophageal cancer

CME:

• 2. A 27-year woman with a 2-month H/O HB presents for further evaluation. She currently takes her pantoprazole daily but continues to have daily breakthrough HB. She denies dysphagia, chest pain, or nausea. Her weight has been stable for the last few months, BMI is 24 kg/m2. She does endorse occasional weekend social tobacco & alcohol use. Her physical exam is otherwise unremarkable. Esophagogastroduodenoscopy (EGD) is unremarkable.

• Which one of the following factors plays the most significant role in increasing her risk for having refl ux disease as compared to functional heartburn?

• A. Age• B. Gender• C. Tobacco use D. Weight

CME:

• 3. A patient presents with heartburn and chest pain. He has been on a proton pump inhibitor twice a day. EGD shows a normal esophagus and biopsies are unremarkable. pH testing off medications reveals no significant acid reflux&no symptom correlation. Esophageal motility testing reveals nonspecific motility changes with double peaked waves, a few non-transmitted contractions. His LES resting pressure and residual pressures are normal.Which one of the following diagnoses is most likely?

• A. Functional heartburn• B. Achalasia• C. Esophageal hypersensitivity• D. Gastroesophageal refl ux disease (GERD)

Thank you