Dr. Falchuk explains the that determining if a patient’s condition is heartburn or gastric reflux depends different symptoms such as the timing of the incident, trigger of the heartburn, and if it was associated with nausea.
Kenneth Falchuk, MD: Heartburn is a common symptom. The greatest concern that we as physicians have, not just gastroenterologists, any physician who deals with a patient who complains of heartburn is, is this symptom an indication of reflux disease, what we call gastroesophageal reflux disease (GERD), or could it be something else?
For the most part, heartburn is a burning sensation. Some people call it bitter sensation in the chest that could go all the way up to your throat. It can occur lying down after eating a large meal, after eating something delicious, rich such as a fatty meal, and delicious pastry with a lot of goodies build into it, eating spicy food, garlic, drinking a lot of liquor, two pieces of chocolate, so there are different food products or deli things that we do in society to enjoy ourselves that can trigger heartburn.
Now heartburn is not usually triggered by exercise, it can, sometimes if you bend forward, if you do push-ups but if you are walking on a treadmill or going up a set of stairs or flight of stairs, you should not have heartburn.Be careful about that symptom, they may not be something as simple as gastroesophageal reflux but indicative of something more serious that can be originating not in the esophagus but rather in the heart.
To evaluate the symptom further, one has to ask the patient about other symptoms. When does it occur? What did they do when this happened? Were they on any types of drugs that sometimes can also trigger heartburn or uncover something that is associated with heartburn, such as increased acid production? Was it related to exertion? Was it associated with some nausea or difficulty swallowing? Did it happen after meals? If it is associated with a meal or as nausea, then more likely or not one is dealing with a condition that originates in the stomach and esophagus were acid is regurgitating, refluxing into the esophagus.
So, depending on the age of the patient, they are ways to approach these dietary changes. If the symptoms do not improve or they are persistent and they go more than a few weeks or associated with these red flags as I said before such as difficulty swallowing, persistent vomiting, severe chest pain, the physician must evaluate the patient further or if the patient does not have a physician he or she must see their doctor.
Now, who do we evaluate heartburn? We do your history in some areas or centers or doctors’ offices, you can do an x-ray to see if there is evidence of reflux or a barrier back into the esophagus.
If someone is over 50, that is a warning sign because as we get older and if we have had some so called subclinical reflux for a while their conditions, it could be pre-malignant that should be evaluated, something called Barrett’s, which is a tissue in the lining of the esophagus, it can be premalignant.
Now to be definitive, one has to measure acid production. How much acid is going back into the esophagus, refluxing? Now a test that accomplish that is something called capsule bravo technique in which you can place a little capsule in the esophagus, send the patient home with a recorder for two days or so and determine how much acid goes back from the esophagus. There are other ways to do it with something called impedance, which is somewhat invasive as a capsule but these are more definitive testing whereby the physician can quantify how much acid, how many hours a day, what else occurs of that type and therefore give the physician a more specific evaluation. When an endoscopy is done, samples are taken to look at the tissue under microscope. If the tissue has been injured by reflux, there will be changes there to support that.
Now it is important therefore to differentiate heartburn due to reflux from heartburn associated with chest pain of cardiac origin, so it is non-GI chest pain. The cardiologist usually likes to say non-cardiac chest pain but in someone who is their 50s or so with risk factors or overweight, high cholesterol, family history of heart disease, one should not just say this is reflux, do not worry about it, take this, go home and I will see you in a few months. So if there is the lack of true confirmation of reflux, a cardiac evaluation must be done as well so one physician needs to work closely with another, be their general physicians, gastroenterologist or cardiologist as well.
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