Heartburn

The most common symptom for a heart attack is chest pain.[12] However, as many as 30% of chest pain patients undergoing cardiac catheterization have findings that do not account for their chest discomfort. These are often defined as having "atypical chest pain" or chest pain of undetermined origin.[13] Women experiencing heart attacks may also deny classic signs and symptoms[14] and instead complain of GI symptoms.[12][15][16] One article estimates that ischemic heart disease may appear to be GERD in 0.6% of people.[11]

• GERD (most common cause of heartburn) occurs when acid refluxes from the stomach and inflames the esophagus.[4]
• Esophageal spasms typically occur after eating or drinking and may be combined with difficulty swallowing.[17]
• Esophageal strictures
• Esophageal cancers

• GERD
• Eosinophilic esophagitis – a disease commonly associated with other atopic diseases such as asthma, food allergies, seasonal allergies, and atopic skin disease
• Mallory-Weis tears – tears of the superficial mucosa of the esophagus that are subsequently exposed to gastric acid commonly due to vomiting and/or retching
• Chemical esophagitis – related to the intake of caustic substances, excessive amounts of hot liquids, alcohol, or tobacco smoke
• Infections may explain heartburn symptoms. These especially include CMV and certain fungal infections, most common in immunocompromised persons

• Peptic ulcer disease[19] – can be secondary to H. Pylori infection or heavy NSAID use that weakens stomach mucosal layer. Pain often worsens with eating.
• Stomach cancer

• Intestinal ulcers – generally secondary to other conditions such as H. Pylori infection or cancers of the GI tract. Pain often improves with eating.
• Duodenitis – inflammation of the small intestine. May be the result of several conditions

• Gallstones

• Pancreatitis – can be autoimmune, due to a gallstone obstructing the lumen, related to alcohol consumption.

• Pernicious anemia – can be autoimmune, due to atrophic gastritis.[20]

Heartburn is common during pregnancy having been reported in as high as 80% of pregnancies.[21] It is most often due to GERD and results from relaxation of the lower esophageal sphincter (LES), changes in gastric motility, and/or increasing intra-abdominal pressure.[22][21] The onset of symptoms can be during any trimester of pregnancy.

• Hormonal – related to the increasing amounts of estrogen and progesterone and their effect on the LES
• Mechanical – the enlarging uterus increasing intra-abdominal pressure, inducing reflux of gastric acid
• Behavioral – as with other instances of heartburn, behavioral modifications can exacerbate or alleviate symptoms

Functional heartburn is heartburn of unknown cause.[23] It is commonly associated with psychiatric conditions like depression, anxiety, and panic attacks. It is also seen with other functional gastrointestinal disorders like irritable bowel syndrome and is the primary cause of lack of improvement post treatment with proton pump inhibitors (PPIs).[23] Despite this, PPIs are still the primary treatment with response rates in about 50% of people.[23] The diagnosis is one of elimination, based upon the Rome III criteria. It was found to be present in 22.3% of Canadians in one survey.[23]

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.[28] This however does not rule out a potential cardiac cause[29] as 10% of cases of discomfort due to cardiac causes are improved with antacids.[30]

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.[31] Patients are able to record symptom onset to correlate lower esophageal pH with time of symptom onset.

Manometry: in this test, a pressure sensor (manometer) is passed via the mouth into the esophagus and measures the pressure of the LES directly.[32]

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 oesophagus 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.[33]

Biopsy: a small sample of tissue from the oesophagus is removed. It is then studied to check for inflammation, cancer, or other problems.[32]

• Antacids (i.e. calcium carbonate) are often taken to treat the immediate problem[34]
• H2 receptor antagonists or proton pump inhibitors are effective for the two most common causes of heartburn (e.g. gastritis and GERD)
• Antibiotics are used if H. pylori is present.

• Taking medications 30–45 minutes before eating suppresses the stomach's acid generating response to food
• Avoiding spicy foods, foods high in fats, peppermint, and chocolate
• Avoiding reclining 2.5–3.5 hours after a meal to prevent the reflux of stomach's contents

• Early studies show that diets that are high in fiber may show evidence in decreasing symptoms of dyspepsia.[35]
• Weight loss can decrease abdominal pressure that both delays gastric emptying and increases gastric acid reflux into the esophagus

Symptoms of heartburn may not always be the result of an organic cause. Patients may respond better to therapies targeting anxiety and symptoms of hyper-vigilance, through medications aimed towards a psychiatric etiology, osteopathic manipulation and acupuncture.[23]

• Psychotherapy may show a positive role in treatment of heartburn and the reduction of distress experienced during symptoms.[23]
• Acupuncture - in cases of functional heartburn (e.g. heartburn of unknown origin) acupuncture may be as effective if not more than PPIs alone.[36]

In the case of GERD causing heartburn symptoms, surgery may be required if PPI is not effective.[37] Surgery is not undergone if functional heartburn is the leading diagnosis.[38]