Heartburn

Heartburn is a pain or discomfort typically described as burning in nature. Its primary position is usually lower retrosternal, deep to the xiphisternum. Heartburn commonly radiates upwards, retrosternally, occasionally as far as the neck. There may be associated epigastric pain.

The timing of heartburn is characteristic. It occurs intermittently, either postprandially or when the patient bends forward or lies flat in bed, when the gastric contents are level with, or above, the lower end of the oesophagus. When it occurs postprandially, it is most commonly in the early postprandial period, 5 to 30 minutes after a meal. The postural changes that initiate heartburn do so by raising the level of the gastric contents above the level of the gastro-oesophageal junction. The duration of an individual attack, when untreated, rarely exceeds an hour.

Factors that precipitate an attack vary considerably from patient to patient. For some, the size of the meal is important, such that it will occur with large meals but not small meals. For others, particular foodstuffs will precipitate an attack. Foodstuffs more commonly incriminated include curries, garlic, red wine, fatty foods, chocolate and citrus juice. The combination of a meal and lying down can be additive in effect. Some patients will describe waking from sleep with severe heartburn a few hours after retiring to bed, particularly following dietary indiscretions. Attacks may occur when the patient lies on the right side but not on the left side or supine. Exercise, either isometric, including straining, or isotonic, such as brisk walking or running, can trigger heartburn. Retrosternal burning pain that is triggered by exercise needs to be closely scrutinised to ensure that symptoms of coronary ischaemia are not being overlooked.

Response to medication is often predictive of whether the patient’s complaints are secondary to GORD and, therefore, qualify as heartburn. Retrosternal burning pain that is not at least partially relieved by appropriate medication is unlikely to be caused by the reflux of acid into the oesophagus, unless there is some other strong evidence supporting reflux as the cause of the symptom. Heartburn is usually relieved within several minutes by antacids. Discomfort relieved within much shorter periods or after much longer periods is less likely to be secondary to gastro-oesophageal reflux. Similarly, heartburn usually improves with agents that diminish gastric secretion of acid such as H₂-receptor antagonists and proton pump inhibitors, although relief with these agents is not as immediate as the relief produced by antacids.

The time course, severity and frequency of heartburn will vary considerably from patient to patient. Some patients have the recent onset of symptoms, while others will have symptoms dating back over many years; some describe symptoms as occasional only, while others are inconvenienced many times a day. It is important to ask about nocturnal symptoms since those patients may have more severe mucosal disease, a poorer health-related quality of life and more difficult to treat disease. Heartburn is very common, reported by one-third of the population at least once a month; 10% have daily heartburn. Only a minority of those with reflux symptoms present for medical care.

Regurgitation

Regurgitation is the second ‘typical’ symptom of GORD. Patients with regurgitation often, but not always, also have heartburn. Although the two symptoms can be closely linked temporally, heartburn tends to be more frequent.

Regurgitation describes the intermittent, sudden and often spontaneous sensation of material moving from the stomach proximally towards the oesophagus and throat. Individual patients tend to regurgitate about the same volume of bolus each time. The usual precipitants of heartburn for a particular patient are also the precipitants of acid regurgitation. They include meals (especially larger meals), assumption of a horizontal posture, rises in intraabdominal pressure, and belching. Food regurgitation is described as the predominant form of regurgitation by some patients. This will obviously occur mostly after eating. Regurgitation occurring within the first 30–60 minutes after a meal usually will not be acidic in character, while regurgitation occurring more distant in time from a meal will usually be acidic. Regurgitation may persist in a treated patient even if the heartburn has resolved with acid suppression.

‘Waterbrash’ is a term used to describe the sudden appearance of a volume of salty or tasteless fluid in the mouth. It is the result of salivary gland stimulation in response to gastro-oesophageal reflux or peptic ulcer disease. At times, it is difficult to distinguish from regurgitation, but since both are reflux symptoms, that distinction is not always critical. There are several other symptoms that can be confused with regurgitation. Rumination is the effortless return of food into the oesophagus or mouth. This usually occurs during meals and the food is often reswallowed. Patients with bulimia are also occasionally misdiagnosed as having GORD. Finally, burping and belching involve the ‘reflux’ of air, not liquids, and can also be confused with regurgitation. Patients with rumination, bulimia and aerophagia (excessive belching and burping) can usually be diagnosed with a carefully taken history and will, at times, have false positive ambulatory reflux testing.

Complications of acid regurgitation

Severe acid regurgitation can be associated with other problematic symptoms including choking attacks, cough, asthma, hoarseness of voice, a foul taste in the mouth in the morning, bad breath, a sore tongue, dental caries and nasal aspiration. Some patients complain of waking up episodically with a sensation of choking such that they will cough vigorously, but rarely produce sputum, get up out of bed and even go to an open window to catch their breath. These symptoms subside fairly rapidly. For some, the history suggesting episodic tracheal aspiration will be less dramatic. They may describe a chronic cough, perhaps worse in the morning, but without sudden exacerbations. When that is the case, other causes of cough will need to be considered and excluded as part of a respiratory work-up. Asthma usually has an allergic basis but, occasionally, can be precipitated by gastro-oesophageal reflux. Such patients may present later in life without any obvious cause for obstructive airways disease. In these patients, the symptoms of gastro-oesophageal reflux are commonly not severe. Acid regurgitation can result in a chemical laryngitis and cause hoarseness of voice. Usually the regurgitation occurs at night so hoarseness is most evident in the morning, and gradually settles as the day passes. Similarly, waking up with a foul taste in the mouth or bad breath can be attributed to nocturnal gastro-oesophageal reflux. Nasal aspiration is a particularly unpleasant consequence of regurgitation, again usually occurring at night.

Problems with swallowing

Upper gastrointestinal endoscopy

The finding of peptic oesophagitis at endoscopy confirms that symptoms of heartburn and regurgitation are due to GORD. On the other hand the absence of oesophagitis in no way excludes GORD. Patients with typical symptoms that occur occasionally and that are completely controlled by simple measures, such as attention to lifestyle (see below) or antacids, do not need upper endoscopy. On the other hand, patients with reflux symptoms and alarm features (such as vomiting, bleeding, weight loss or dysphagia) should always be investigated. In addition, certain patients (particularly older patients with chronic symptoms) should undergo endoscopy to screen for Barrett’s oesophagus.

The characteristic endoscopic signs of reflux oesophagitis are shown in Table 1.1 and Figure 1.1. As mentioned above, there is only a weak correlation between the severity of oesophageal acidification and the degree of peptic oesophagitis. On the other hand, it is clear that more severe grades of esophagitis are more difficult to heal. Oesophagitis should never be diagnosed based on anything short of mucosal erosion and never should be based on erythema of the distal oesophagus. The diagnostic endoscopic examination is always carried as far as the first part of the duodenum looking for incidental pathology. The finding of a chronic duodenal ulcer is significant as this may be the underlying cause of gastro-oesophageal reflux symptoms (see Ch 5).

Table 1.1 Classification of reflux at endoscopy (Los Angeles—LA—System)

Figure 1.1 Endoscopic view of linear erosive peptic oesophagitis (Grade D) of the distal oesophagus.

From plate 20-4 of the online edition of the Merck Manual, with permission from Dr D Martin.

Oesophageal biopsy at upper gastrointestinal endoscopy

Biopsy of a normal-appearing oesophagus was once suggested to aid in the diagnosis of GORD, but is not advocated by most experts in adult GORD. Microscopic changes suggestive of GORD include:

These microscopic findings can be relatively difficult to quantify on routine biopsy specimens and the diagnostic value of these findings continues to be disputed, so biopsy is not recommended routinely. Recently, some experts have suggested obtaining midoesophageal biopsies in patients with any unexplained oesophageal symptom (especially dysphagia) to search for histological evidence of eosinophilic oesophagitis (Ch 2).

Upper gastrointestinal radiology

Before the establishment of flexible upper gastrointestinal endoscopy, upper gastrointestinal contrast radiology with barium was the initial investigation for dyspepsia and reflux symptoms. It has been downgraded to a second-line investigation, mainly because it is not a sensitive detector of oesophageal mucosal damage. It does, however, offer complementary information, which is sometimes useful. Some advocate routine radiological testing in any patient with dysphagia. It also allows better definition of the presence and size of a hiatus hernia, which may be important if surgery for reflux is contemplated. The demonstration of barium refluxing into the oesophagus is neither specific nor sensitive for the presence of pathological acid reflux.