pyrosis (heartburn)

Introduction

The sense of substernal warmth, burning or searing. It may occur in waves with a tendency to ascend from the subxiphoid area towards the neck.

Etiology

• gastroesophageal reflux disease (GERD)
• infection &/or inflammation
  • esophagus
  • stomach
  • duodenum
• esophageal dysmotility
• esophageal malignancy
• reflux secondary to pregnancy
• predisposing/aggravating factors
  • foods: tomatoes, citrus fruits, chocolate, onions, fats, sugars, spicy foods, peppermint
  • large meals, eating late at night
  • tobacco
  • alcohol
  • coffee
  • pharmacologic agents
    • anticholinergic agents
    • NSAIDs
    • calcium channel blockers
    • nitrates
    • progesterone
  • increased abdominal pressure: bending over, lifting, tight-fitting clothes, straining on defecation, exercise

Epidemiology

• occurs daily in 7-10% of the population
• occurs monthly in 45% of the population

Pathology

• reflux of gastric contents into the esophagus, oral cavity or airway

Clinical manifestations

• 'red flags'
  • anemia or occult gastrointestinal bleeding
  • dysphagia
  • weight loss
    • new onset dyspepsia age > 55 years

Diagnostic procedures

• ECG exercise stress test to rule out cardiac etiology
• esophagogastroduodenoscopy (EGD)
• 24 hour ambulatory pH monitoring
• Bernstein test

Management

• do not test
  • treat empirically. proton pump inhibitor 1st line
  • testing reserved for red flags & empiric treatment failure
• H2-receptor antagonists
  • cimetidine (Tagamet)
  • ranitidine (Zantac)
  • famotidine (Pepcid)
  • nizatidine (Axid)
  • roxatidine
• antacids
  • absorbable CaCO3 or NaHCO3
    • Tums, Titralac, Rolaids
  • nonabsorbable Al(OH)3, Mg(OH)2 +/- simethicone for gas
    • Maalox, Mylanta, Riopan, Gelusil, Amphojel, Basajel
    • Camalox
  • Gaviscon tablets
    • antacid plus algginic acid
    • forms a foam that floats on gastric contents
    • lessens effects of refluxed material into esophagus
• proton pump inhibitors
  • omeprazole (Prilosec)
  • lansoprazole
• mucosal coating agents - sucralfate
• promotility agents
  • metoclopramide (Reglan)
  • cisapride (Propulsid)
• life-style modification
  • tobacco cessation
  • weight loss/food restriction
  • avoidance of eating 2-3 hours before bedtime
  • alcohol avoidance
  • avoidance of aggravating foods
  • elevating head of bed

More general terms

• dyspepsia (indigestion)

Additional terms

• Bernstein test
• gastroesophageal reflux disease (GERD)

Patient information

pyrosis (heartburn) patient information