The Family Practitioner’s Approach to Heartburn Pali Hungin MD FRCP FRCGP Professor of General Practice and Primary Care School of Medicine, Pharmacy and Health Durham University, Queen’s Campus Stockton on Tees, United Kingdom Family Practitioners or Primary Care Physicians (PCPs) are used to dealing with symptoms and are not always as enthusiastic as gastroenterologists in providing diagnostic labels. Thus, Gastro- Oesophageal Reflux Disease (GORD or GERD), a label beloved of gastroenterologists, is not necessarily as well recognized in primary care practice even though heartburn, reflux and other upper abdominal and chest symptoms are commonly seen and dealt with. The concept of “GORD” 1 is in any case a bit of a problem – the traditional perception has been that this is essentially an acid-related disorder, possibly related to “excessive” acid in the esophagus, together with a picture of a failing gastro-esophageal valve, with or without impaired gastric emptying. This is handy for providing an explanation to the patient but none of these concepts is completely true in GORD. It is hardly surprising that many PCPs are confused about the true cause and nature of symptoms such as heartburn. The situation has been compounded by the assumption that acid suppression would resolve these symptoms and it has been a problem that a large proportion of patients do not actually benefit from this. A common experience in primary care is the variable response of GORD symptoms, including heartburn, to proton pump inhibitors (PPI). It was initially assumed that this was due to therapy adherence shortcomings and inadequate or badly timed dosing but adjustments here have provided only marginal improvements. Indeed, in primary care practice, the majority of patients on long-term acid suppression continue to suffer moderate to severe symptoms 2. This experience is mirrored in secondary care where the more symptom-resistant patients are likely to be seen. In a seminal study on patients on high dose PPIs for GORD, Mainie et al 3 discovered that 86% had continuing symptoms and, with esophageal pH measurements, they deduced that only 8% of them had acid reflux, 35% had non-acid reflux and that in 57% their symptoms did not appear to be related to reflux at all. This challenges the Montreal Consensus on GORD 1 which described this as “a condition that develops when the reflux of stomach contents causes troublesome symptoms and/or complications”. PCPs, at the sharp end of clinical practice, have long been aware of our inadequacies in managing GORD symptoms effectively. The value and meaning of symptoms themselves is confusing. In the Diamond study 4 the researchers critically assessed the value of symptoms in patients judged as having GORD, through independent assessment and investigations. GORD was considered to be present in only 65% of those diagnosed initially and only 49% of patients selected heartburn or regurgitation, the so called cardinal symptoms, as their most troublesome symptom. The value of these, essentially clinician-led descriptors, has been further questioned in a large international study across 13 countries 5 where sufferers used a far wider variety of descriptors and where our traditionally used clinical terms did not tally with their experiences. In short, people presenting in primary care do not necessarily present using terms such as “heartburn” and it is more likely that these are categorized as such by the clinician. Even those saying they have “heartburn” might actually have some other meaning in mind. Incorrectly interpreting the symptoms can present a nightmare scenario – getting it wrong can be dangerous – for the PCP who has to be on the lookout for cardiac problems, amongst other things. With their innately holistic approach to patients’ problems, PCPs are also aware of the overlap of symptoms from different causes, including the functional disorders. The label of functional heartburn is only sparsely used in primary care but associations with IBS and with other non-GI functional disorders, such as fibromyalgia and non-cardiac chest pain are common. In the possible presence of circumstantial psychological stress, anxiety and depression in the patient, the PCP has to grapple with a multiplicity of problems. Specific, single symptoms such as heartburn are sometimes relegated to a lower order of priority. Meanwhile, and this impacts heavily on primary care, the prevalence of GORD is increasing. The Norwegian HUNT Research Centre 6 reported a 31% increase in the prevalence of gastroesophageal symptoms over ten years to 2009 with a corresponding 47% increase in the frequency of symptoms. Startlingly, the increase was most strongly marked in those over 60 years, a stage at which the possibility of cancer becomes a greater issue. Thus, the size of the problem as well as the need for vigilance in the older age group, is important for PCPs. In terms of investigations, in the UK, priority in gastroenterology resources and effort has shifted to colonoscopy for the earlier detection of lower GI cancer. This has reduced the emphasis on gastroscopy. Gastroscopy is now reserved, essentially, for those in high-risk groups, such as those with red flag symptoms or older patients and is not recommended for the investigation of GORD symptoms in younger people. Although PCPs, as in many other western countries, have the right of direct access to gastroscopy they are subject to review and possible sanction from their Clinical Commissioning Groups (CCGs), the purchasers of clinical services on their behalf. Trends in gastroscopy numbers are, therefore, downwards compared with previous years and the approach to management is based on an empirical approach rather than on initial investigation. The mainstay of treatment of heartburn (or GORD in the wider sense) amongst PCPs, following advice and initiatives towards lifestyle measures and antacids and alginates, remains acid suppression therapy. Most consulters are at the stage where they are seeking active treatment. PPIs remain the mainstay of acid suppression therapy, despite the difficulties outlined above in relation to limited success. In previous years, debate around the management of World Digestive Health Day WDHD May 29, 2015 WGO HANDBOOK HEARTBURN: A GLOBAL PERSPECTIVE 17
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