Differential Diagnosis of Heartburn, continued. are unclear, since triggering by any form of reflux events rules out the diagnosis of functional heartburn. The treatment of functional heartburn remains largely empirical, and an individualized approach is therefore recommended. The clinician should provide reassurance and refrain from performing repeated invasive procedures. Since the pathophysiology of functional heartburn mainly involves visceral hypersensitivity, use of pain modulators like low dose tricyclic antidepressants and possibly selective serotonin reuptake inhibitors is reasonable. Table - Differential diagnosis of heartburn as a gastro-esophageal reflux symptom Epigastric pain Sore throat Eosinophilic esophagitis Esophageal motility disorders (incl. achalasia of the cardia) Reflux hypersensitivity (hypersensitive esophagus) Functional heartburn References 1. Carlsson R, Dent J, Bolling-Sternevald E, et al. The usefulness of a structured questionnaire in the assessment of symptomatic gastroesophageal reflux disease. Scand J Gastroenterol 1998;33:1023-9. 2. Vaezi MF, Richter JE, Stasney CR, et al. Treatment of chronic posterior laryngitis with esomeprazole. Laryngoscope 2006;116:254-60. 3. Dickman R, Boaz M, Aizic S, et al. Comparison of clinical characteristics of patients with gastroesophageal reflux disease who failed proton pump inhibitor therapy versus those who fully responded. J Neurogastroenterol Motil 2011;17:387-94. 4. Hatlebakk JG, Katz PO, Camacho-Lobato L, et al. Proton pump inhibitors: better acid suppression when taken before a meal than without a meal. Aliment Pharmacol Ther 2000;14:1267-72. 5. Poh CH, Gasiorowska A, Navarro-Rodriguez T, et al. Upper GI tract findings in patients with heartburn in whom proton pump inhibitor treatment failed versus those not receiving antireflux treatment. Gastrointest Endosc 2010;71:28-34. 6. Dellon ES, Gonsalves N, Hirano I, et al. ACG Clinical Guideline: Evidenced Based Approach to the Diagnosis and Management of Esophageal Eosinophilia and Eosinophilic Esophagitis (EoE). Am J Gastroenterol 2013;108:679-92. 7. Garcia-Compean D, Gonzalez Gonzalez JA, Marrufo Garcia CA, et al. Prevalence of eosinophilic esophagitis in patients with refractory gastroesophageal reflux disease symptoms: A prospective study. Dig Liver Dis 2011;43:204-8. 8. Sa CC, Kishi HS, Silva-Werneck AL, et al. Eosinophilic esophagitis in patients with typical gastroesophageal reflux disease symptoms refractory to proton pump inhibitor. Clinics (Sao Paulo) 2011;66:557-61. 9. Zerbib F, Omari T. Oesophageal dysphagia: manifestations and diagnosis. Nat Rev Gastroenterol Hepatol 2014. 10. Ponce J, Ortiz V, Maroto N, et al. High prevalence of heartburn and low acid sensitivity in patients with idiopathic achalasia. Dig Dis Sci 2011;56:773-6. 11. Richter JE. How to manage refractory GERD. Nat Clin Pract Gastroenterol Hepatol 2007;4:658-64. 12. Sifrim D, Zerbib F. Diagnosis and management of patients with reflux symptoms refractory to proton pump inhibitors. Gut 2012;61:1340-54. 13. Martinez SD, Malagon IB, Garewal HS, et al. Non-erosive reflux disease (NERD)--acid reflux and symptom patterns. Aliment Pharmacol Ther 2003;17:537-45. 14. Zerbib F, Belhocine K, Simon M, et al. Clinical, but not oesophageal pH-impedance, profiles predict response to proton pump inhibitors in gastro-oesophageal reflux disease. Gut 2012;61:501-6. World Digestive Health Day WDHD May 29, 2015 WGO HANDBOOK HEARTBURN: A GLOBAL PERSPECTIVE 32
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