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Functional heartburn: An underrecognized cause of PPI-refractory symptoms
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Scott Gabbard, MD
Sonya Vijayvargiya

A 44-year-old woman presents with an 8-year history of intermittent heartburn, and in the past year she has been experiencing her symptoms daily. She says the heartburn is constant and is worse immediately after eating spicy or acidic foods. She says she has had no dysphagia, weight loss, or vomiting. Her symptoms have persisted despite taking a histamine (H)2-receptor antagonist twice daily plus a proton pump inhibitor (PPI) before breakfast and dinner for more than 3 months.

She has undergone upper endoscopy 3 times in the past 8 years. Each time, the esophagus was normal with a regular Z-line and normal biopsy results from the proximal and distal esophagus.

The patient believes she has severe gastroesophageal reflux disease (GERD) and asks if she is a candidate for fundoplication surgery.

HEARTBURN IS A SYMPTOM; GERD IS A CONDITION

A distinction should be made between heartburn—the symptom of persistent retrosternal burning and discomfort—and gastroesophageal reflux disease—the condition in which reflux of stomach contents causes troublesome symptoms or complications.1 While many clinicians initially diagnose patients who have heartburn as having GERD, there are many other potential causes of their symptoms.

For patients with persistent heartburn, an empiric trial of a once-daily PPI is usually effective, but one-third of patients continue to have heartburn.2,3 The most common cause of this PPI-refractory heartburn is functional heartburn, a functional or hypersensitivity disorder of the esophagus.4

PATHOPHYSIOLOGY IS POORLY UNDERSTOOD

800fig1.jpg
%3Cp%3EFigure%201.%20Conceptual%20pathophysiologic%20basis%20of%20functional%20heartburn.%3C%2Fp%3E
Functional heartburn is defined as retrosternal burning in the absence of objective evidence of GERD, mucosal abnormality (ie, erosive esophagitis), or major motility disorder.5 The symptoms are theorized to result from hypersensitivity of the visceral nerves of the esophagus, which may be exacerbated by central sensitization, hypervigilance, stress, and anxiety.6 The pathogenesis is poorly understood, but it may involve activation of inflammatory mediators in the esophagus, alterations in esophageal mucosal integrity, increased chemical and pressure sensation in the esophagus, and both peripheral and central sensitization (Figure 1).7

DIAGNOSTIC EVALUATION

801tbl1.jpg
When evaluating patients with heartburn symptoms refractory to PPI therapy, the differential diagnosis is broad and includes GERD, eosinophilic esophagitis, infectious esophagitis, pill-induced esophagitis, esophageal motility disorder, and functional heartburn (Table 1). Of these, functional heartburn is the most common, accounting for more than 50% of cases of PPI-refractory heartburn.8

Clinicians have several tests available for diagnosing these conditions.

Upper endoscopy

Upper endoscopy is recommended for patients with heartburn that does not respond to a 3-month trial of a PPI.9 Endoscopy is also indicated in any patient who has any of the following “alarm symptoms” that could be due to malignancy or peptic ulcer:

  • Dysphagia
  • Odynophagia
  • Vomiting
  • Unexplained weight loss or anemia
  • Signs of gastrointestinal bleeding
  • Anorexia
  • New onset of dyspepsia in a patient over age 60.

During upper endoscopy, the esophagus is evaluated for reflux esophagitis, Barrett esophagus, and other inflammatory disorders such as infectious esophagitis. But even if the esophageal mucosa appears normal, the proximal and distal esophagus should be biopsied to rule out an inflammatory disorder such as eosinophilic or lymphocytic esophagitis.

 

 

Esophageal manometry

If endoscopic and esophageal biopsy results are inconclusive, a workup for an esophageal motility disorder is the next step. Dysphagia is the most common symptom of these disorders, although the initial presenting symptom may be heartburn or regurgitation that persists despite PPI therapy.

Manometry is used to test for motility disorders such as achalasia and esophageal spasm.10 After applying a local anesthetic inside the nares, the clinician inserts a flexible catheter (about 4 mm in diameter) with 36 pressure sensors spaced at 1-cm intervals into the nares and passes it through the esophagus and lower esophageal sphincter. The patient then swallows liquid, and the sensors relay the esophageal response, creating a topographic plot that shows esophageal peristalsis and lower esophageal sphincter relaxation.

Achalasia is identified by incomplete lower esophageal sphincter relaxation combined with 100% failed peristalsis in the body of the esophagus. Esophageal spasms are identified by a shortened distal latency, which corresponds to premature contraction of the esophagus during peristalsis.11

Esophageal pH testing

Measuring esophageal pH levels is an important step to quantify gastroesophageal reflux and determine if symptoms occur during reflux events. According to the updated Porto GERD consensus group recommendations,12 a pH test is positive if the acid exposure time is greater than 6% of the testing period. Testing the pH differentiates between GERD (abnormal acid exposure), reflux hypersensitivity (normal acid exposure, strong correlation between symptoms and reflux events), and functional heartburn (normal acid exposure, negative correlation between reflux events and symptoms).5 For this test, a pH probe is placed in the esophagus transnasally or endoscopically. The probe records esophageal pH levels for 24 to 96 hours in an outpatient setting. Antisecretory therapy needs to be withheld for 7 to 10 days before the test.

Transnasal pH probe. For this approach, a thin catheter is inserted through the nares and advanced until the tip is 5 cm proximal to the lower esophageal sphincter. (The placement is guided by the results of esophageal manometry, which is done immediately before pH catheter placement.) The tube is secured with clear tape on the side of the patient’s face, and the end is connected to a portable recorder that compiles the data. The patient pushes a button on the recorder when experiencing heartburn symptoms. (A nurse instructs the patient on proper procedure.) After 24 hours, the patient either removes the catheter or has the clinic remove it. The pH and symptom data are downloaded and analyzed.

Transnasal pH testing can be combined with impedance measurement, which can detect nonacid reflux or weakly acid reflux. However, the clinical significance of this measurement is unclear, as multiple studies have found total acid exposure time to be a better predictor of response to therapy than weakly acid or nonacid reflux.12

Wireless pH probe. This method uses a disposable, catheter-free, capsule device to measure esophageal pH. The capsule, about the size of a gel capsule or pencil eraser, is attached to the patient’s esophageal lining, usually during upper endoscopy. The capsule records pH levels in the lower esophagus for 48 to 96 hours and transmits the data wirelessly to a receiver the patient wears. The patient pushes buttons on the receiver to record symptom-specific data when experiencing heartburn, chest pain, regurgitation, or cough. The capsule detaches from the esophagus spontaneously, generally within 7 days, and is passed out of the body through a bowel movement.

Diagnosing functional heartburn

802fig2.jpg
%3Cp%3EFigure%202.%20High-resolution%20esophageal%20manometry%20in%20our%20patient%20shows%20normal%20esophageal%20resting%20pressure%20and%20relaxation%2C%20and%20a%20distal%20latency%20of%207.5%20seconds%2C%20indicating%20normal%20peristalsis.%20It%20also%20shows%20a%20distal%20contractile%20integral%20of%202%2C368%20mm%20Hg-sec-cm%2C%20a%20measure%20of%20the%20pressure%2C%20duration%2C%20and%20vertical%20length%20of%20the%20distal%20esophageal%20contraction.%20The%20vertical%20axis%20shows%20the%20length%20along%20the%20esophagus%20from%20upper%20to%20lower%2C%20and%20the%20horizontal%20axis%20shows%20time.%20The%20color%20depicts%20pressure%20from%20low%20(blue)%20to%20high%20(red)%3B%20note%20how%20the%20waves%20of%20contraction%20(high%20pressure)%20proceed%20from%20proximal%20(top)%20to%20distal%20(bottom).%3C%2Fp%3E
The Rome IV diagnostic criteria for functional heartburn5 require that a patient experience retrosternal burning, discomfort, or pain at least twice a week for at least 6 months. By definition, the symptoms have not responded to antisecretory drugs (an H2-receptor antagonist or PPI) in optimal doses. Also, inflammatory disorders such as erosive esophagitis and eosinophilic esophagitis and motility disorders such as achalasia (Table 1) need to be ruled out.

CASE CONTINUED: NORMAL RESULTS ON TESTING

803fig3.jpg
%3Cp%3EFigure%203.%20In%20our%20patient%20with%20functional%20heartburn%2C%2024-hour%20wireless%20esophageal%20pH%20testing%20showed%20a%20pH%20greater%20than%204%20(the%20conventional%20cutoff%20in%20esophageal%20pH%20testing)%20for%20most%20of%20the%20test.%20During%20the%20test%2C%20the%20patient%20recorded%20experiencing%20heartburn%2067%20times%20(gray%20diamonds)%3B%20her%20esophageal%20pH%20was%20below%204%20for%20just%203%20of%20the%2067%20events.%20This%20pH%20test%20is%20consistent%20with%20a%20diagnosis%20of%20functional%20heartburn.%20The%20vertical%20axis%20shows%20the%20pH%20from%200%20to%208%2C%20with%20a%20midline%20at%204.%20The%20horizontal%20axis%20shows%20a%2024-hour%20period%20from%20noon%20to%20noon.%3C%2Fp%3E
The patient undergoes esophageal manometry and esophagogastro-duodenoscopy with placement of a wireless pH probe. Results of esophageal manometry are normal. She has normal lower esophageal resting pressure and relaxation and normal peristalsis in the esophagus body (Figure 2). Wireless pH testing shows a total acid exposure time of 1.7% and a strongly negative symptom association with heartburn, chest pain, and regurgitation (Figure 3).

Based on these results, her condition is diagnosed as functional heartburn, consistent with the Rome IV criteria.5

 

 

TREATMENT

Patient education is key

Patient education about the pathogenesis, natural history, and treatment options is the most important aspect of treating any functional gastrointestinal disorder. This includes the “brain-gut connection” and potential mechanisms of dysregulation. Patient education along with assessment of symptoms should be part of every visit, especially before discussing treatment options.

Patients whose condition is diagnosed as functional heartburn need reassurance that the condition is benign and, in particular, that the risk of progression to esophageal adenocarcinoma is minimal in the absence of Barrett esophagus.13 Also important to point out is that the disorder may spontaneously resolve: resolution rates of up to 40% have been reported for other functional gastrointestinal disorders.14

Antisecretory medications may work for some

A PPI or H2-receptor antagonist is the most common first-line treatment for heartburn symptoms. Although most patients with functional heartburn experience no improvement in symptoms with an antisecretory agent, a small number report some relief, which suggests that acid-suppression therapy may have an indirect impact on pain modulation in the esophagus.15 In patients who report symptom relief with an antisecretory agent, we suggest continuing the medication tapered to the lowest effective dose, with repeated reassurance that the medication can be discontinued safely at any time.

Antireflux surgery should be avoided

Antireflux surgery should be avoided in patients with normal pH testing and no objective finding of reflux, as this is associated with worse subjective outcomes than in patients with abnormal pH test results.16

Neuromodulators

804tbl2.jpg
No drug has yet been approved by the US Food and Drug Administration to treat functional heartburn, and clinical evidence for treating this condition is minimal. Using neuromodulators to reduce pain perception is the mainstay of treatment for functional gastrointestinal disorders, including functional heartburn. Table 2 lists neuromodulators used to treat functional esophageal disorders, with recommended dosing intervals.

It is important to discuss with patients the concept of neuromodulation, including the fact that antidepressants are often used because of their effects on serotonin and norepinephrine, which decrease visceral hypersensitivity.

The selective serotonin reuptake inhibitor citalopram has been shown to reduce esophageal hypersensitivity,17 and a tricyclic antidepressant has been shown to improve quality of life.18 These results have led experts to recommend a trial of a low dose of either type of medication.19 The dose of tricyclic antidepressant often needs to be increased sequentially every 2 to 4 weeks.

Interestingly, melatonin 6 mg at bedtime has also shown efficacy for functional heartburn, potentially due to its antinociceptive properties.20

Alternative and complementary therapies

Many esophageal centers use cognitive behavioral therapy and hypnotherapy as first-line treatment for functional esophageal disorders. Here again, it is important for the patient to understand the rationale of therapy for functional gastrointestinal disorders, given the stigma in the general population regarding psychotherapy.

Cognitive behavioral therapy has been used for functional gastrointestinal disorders for many years, as it has been shown to modulate visceral perception.21 Although published studies are limited, research regarding other functional esophageal disorders suggests that patients who commit to long-term behavioral therapy have had a significant improvement in symptoms.22

The goal of esophageal-directed behavioral therapy is to promote focused relaxation using deep breathing techniques, which can help patients manage esophageal hypervigilance, especially if symptoms continue despite neuromodulator therapy. Specifically, hypnotherapy has been shown to modulate functional chest pain through the visceral sensory pathway and also to suppress gastric acid secretion.21,23 A study of a 7-week hypnotherapy program reported significant benefits in heartburn relief and improved quality of life in patients with functional heartburn.24 The data support the use of behavioral therapies as first-line therapy or as adjunctive therapy for patients already taking a neuromodulator.

CASE FOLLOW-UP: IMPROVEMENT WITH TREATMENT

During a follow-up visit, the patient is given several printed resources, including the Rome Foundation article on functional heartburn.5 We again emphasize the benign nature of functional heartburn, noting the minimal risk of progression to esophageal adenocarcinoma, as she had no evidence of Barrett esophagus on endoscopy. And we discuss the natural course of functional heartburn, including the spontaneous resolution rate of about 40%.

For treatment, we present her the rationale for using neuromodulators and reassure her that these medications are for treatment of visceral hypersensitivity, not for anxiety or depression. After the discussion, the patient opts to start amitriptyline therapy at 10 mg every night at bedtime, increasing the dose by 10 mg every 2 weeks until symptoms improve, up to 75–100 mg every day.

After 3 months, the patient reports a 90% improvement in symptoms while on amitriptyline 30 mg every night. She is also able to taper her antisecretory medications once symptoms are controlled. We plan to continue amitriptyline at the current dose for 6 to 12 months, then discuss a slow taper to see if her symptoms spontaneously resolve.

References
  1. Vakil N, van Zanten SV, Kahrilas P, Dent J, Jones R; Global Consensus Group. The Montreal definition and classification of gastroesophageal reflux disease: a global evidence-based consensus. Am J Gastroenterol 2006; 101(8):1900–1920.
  2. Dean BB, Gano AD Jr, Knight K, Ofman JJ, Fass R. Effectiveness of proton pump inhibitors in nonerosive reflux disease. Clin Gastroenterol Hepatol 2004; 2(8):656–664. pmid:15290657
  3. Hachem C, Shaheen NJ. Diagnosis and management of functional heartburn. Am J Gastroenterol 2016; 111(1):53–61. doi:10.1038/ajg.2015.376
  4. Fass R, Sifrim D. Management of heartburn not responding to proton pump inhibitors. Gut 2009; 58(2):295–309. doi:10.1136/gut.2007.145581
  5. Aziz Q, Fass R, Gyawali CP, Miwa H, Pandolfino JE, Zerbib F. Esophageal disorders. Gastroenterology 2016; 150(6):1368-1379. doi:10.1053/j.gastro.2016.02.012
  6. Kondo T, Miwa H. The role of esophageal hypersensitivity in functional heartburn. J Clin Gastroenterol 2017; 51(7):571–578. doi:10.1097/MCG.0000000000000885
  7. Farmer AD, Ruffle JK, Aziz Q. The role of esophageal hypersensitivity in functional esophageal disorders. J Clin Gastroenterol 2017; 51(2):91–99. doi:10.1097/MCG.0000000000000757
  8. Mainie I, Tutuian R, Shay S, et al. Acid and non-acid reflux in patients with persistent symptoms despite acid suppressive therapy: a multicentre study using combined ambulatory impedance-pH monitoring. Gut 2006; 55(10):1398–1402. doi:10.1136/gut.2005.087668
  9. Katz PO, Gerson LB, Vela MF. Guidelines for the diagnosis and management of gastroesophageal reflux disease. Am J Gastroenterol 2013; 108(3):308–328. doi:10.1038/ajg.2012.444
  10. Kahrilas PJ, Bredenoord AJ, Fox M, et al; International High Resolution Manometry Working Group. The Chicago classification of esophageal motility disorders, v3.0. Neurogastroenterol Motil 2015; 27(2):160–174. doi:10.1111/nmo.12477
  11. Kichler AJ, Gabbard S. A man with progressive dysphagia. Cleve Clin J Med 2017; 84(6):443–449. doi:10.3949/ccjm.84a.16055
  12. Roman S, Gyawali CP, Savarino E, et al; GERD consensus group. Ambulatory reflux monitoring for diagnosis of gastro-esophageal reflux disease: update of the Porto consensus and recommendations from an international consensus group. Neurogastroenterol Motil 2017; 29(10):1–15. doi:10.1111/nmo.13067
  13. Shaheen NJ, Falk GW, Iyer PG, Gerson LB; American College of Gastroenterology. ACG clinical guideline: diagnosis and management of Barrett’s esophagus. Am J Gastroenterol 2016; 111(1):30–50. doi:10.1038/ajg.2015.322
  14. Halder SL, Locke GR 3rd, Schleck CD, Zinsmeister AR, Melton LJ 3rd, Talley NJ. Natural history of functional gastrointestinal disorders: a 12-year longitudinal population-based study. Gastroenterology 2007; 133(3):799–807. doi:10.1053/j.gastro.2007.06.010
  15. Park EY, Choi MG, Baeg M, et al. The value of early wireless esophageal pH monitoring in diagnosing functional heartburn in refractory gastroesophageal reflux disease. Dig Dis Sci 2013; 58(10):2933–2939. doi:10.1007/s10620-013-2728-4
  16. Khajanchee YS, Hong D, Hansen PD, Swanström LL. Outcomes of antireflux surgery in patients with normal preoperative 24-hour pH test results. Am J Surg 2004; 187(5):599–603. doi:10.1016/j.amjsurg.2004.01.010
  17. Viazis N, Keyoglou A, Kanellopoulos AK, et al. Selective serotonin reuptake inhibitors for the treatment of hypersensitive esophagus: a randomized, double-blind, placebo-controlled study. Am J Gastroenterol 2012; 107(11):1662–1667. doi:10.1038/ajg.2011.179
  18. Limsrivilai J, Charatcharoenwitthaya P, Pausawasdi N, Leelakusolvong S. Imipramine for treatment of esophageal hypersensitivity and functional heartburn: a randomized placebo-controlled trial. Am J Gastroenterol 2016; 111(2):217–224. doi:10.1038/ajg.2015.413
  19. Keefer L, Kahrilas PJ. Low-dose tricyclics for esophageal hypersensitivity: is it all placebo effect? Am J Gastroenterol 2016; 111(2):225–227. doi:10.1038/ajg.2016.13
  20. Basu PP, Hempole H, Krishnaswamy N, Shah NJ, Aloysius, M. The effect of melatonin in functional heartburn: a randomized, placebo-controlled clinical trial. Open J Gastroenterol 2014; 4(2):56–61. doi:10.4236/ojgas.2014.42010
  21. Watanabe S, Hattori T, Kanazawa M, Kano M, Fukudo S. Role of histaminergic neurons in hypnotic modulation of brain processing of visceral perception. Neurogastroenterol Motil 2007; 19(10):831–838. doi:10.1111/j.1365-2982.2007.00959.x
  22. Riehl ME, Kinsinger S, Kahrilas PJ, Pandolfino JE, Keefer L. Role of a health psychologist in the management of functional esophageal complaints. Dis Esophagus 2015; 28(5):428–436. doi:10.1111/dote.12219
  23. Klein KB, Spiegel D. Modulation of gastric acid secretion by hypnosis. Gastroenterology 1989; 96(6):1383–1387. pmid:2714570
  24. Riehl ME, Pandolfino JE, Palsson OS, Keefer L. Feasibility and acceptability of esophageal-directed hypnotherapy for functional heartburn. Dis Esophagus 2016; 29(5):490–496. doi:10.1111/dote.12353
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Department of Gastroenterology, Hepatology & Nutrition, Cleveland Clinic; Assistant Professor, Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland, OH

Sonya Vijayvargiya
Emory University, Atlanta, GA

Address: Scott Gabbard, MD, Department of Gastroenterology and Hepatology, A31, Cleveland Clinic, 9500 Euclid Avenue, Cleveland, OH 44195; gabbars@ccf.org

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functional heartburn, proton pump inhibitor, PPI, gastroesophageal reflux disease, esophagus, upper endoscopy, biopsy, esophageal manometry, pH monitoring, cognitive behavioral therapy, hypnotherapy, Rome IV criteria, histamine-2 receptor antagonist, retrosternal pain, brain-gut connection, tricyclic antidepressants, selective serotonin reuptake inhibitors, SSRIs, trazodone, serotonin and norepinephrine reuptake inhibitors, SNRIs, alternative and complementary therapies, Scott Gabbard, Sonya Vijayvargiya
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Scott Gabbard, MD
Department of Gastroenterology, Hepatology & Nutrition, Cleveland Clinic; Assistant Professor, Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland, OH

Sonya Vijayvargiya
Emory University, Atlanta, GA

Address: Scott Gabbard, MD, Department of Gastroenterology and Hepatology, A31, Cleveland Clinic, 9500 Euclid Avenue, Cleveland, OH 44195; gabbars@ccf.org

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Department of Gastroenterology, Hepatology & Nutrition, Cleveland Clinic; Assistant Professor, Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland, OH

Sonya Vijayvargiya
Emory University, Atlanta, GA

Address: Scott Gabbard, MD, Department of Gastroenterology and Hepatology, A31, Cleveland Clinic, 9500 Euclid Avenue, Cleveland, OH 44195; gabbars@ccf.org

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Related Articles
GERD: Diagnosing and treating the burn
A man with progressive dysphagia

A 44-year-old woman presents with an 8-year history of intermittent heartburn, and in the past year she has been experiencing her symptoms daily. She says the heartburn is constant and is worse immediately after eating spicy or acidic foods. She says she has had no dysphagia, weight loss, or vomiting. Her symptoms have persisted despite taking a histamine (H)2-receptor antagonist twice daily plus a proton pump inhibitor (PPI) before breakfast and dinner for more than 3 months.

She has undergone upper endoscopy 3 times in the past 8 years. Each time, the esophagus was normal with a regular Z-line and normal biopsy results from the proximal and distal esophagus.

The patient believes she has severe gastroesophageal reflux disease (GERD) and asks if she is a candidate for fundoplication surgery.

HEARTBURN IS A SYMPTOM; GERD IS A CONDITION

A distinction should be made between heartburn—the symptom of persistent retrosternal burning and discomfort—and gastroesophageal reflux disease—the condition in which reflux of stomach contents causes troublesome symptoms or complications.1 While many clinicians initially diagnose patients who have heartburn as having GERD, there are many other potential causes of their symptoms.

For patients with persistent heartburn, an empiric trial of a once-daily PPI is usually effective, but one-third of patients continue to have heartburn.2,3 The most common cause of this PPI-refractory heartburn is functional heartburn, a functional or hypersensitivity disorder of the esophagus.4

PATHOPHYSIOLOGY IS POORLY UNDERSTOOD

800fig1.jpg
%3Cp%3EFigure%201.%20Conceptual%20pathophysiologic%20basis%20of%20functional%20heartburn.%3C%2Fp%3E
Functional heartburn is defined as retrosternal burning in the absence of objective evidence of GERD, mucosal abnormality (ie, erosive esophagitis), or major motility disorder.5 The symptoms are theorized to result from hypersensitivity of the visceral nerves of the esophagus, which may be exacerbated by central sensitization, hypervigilance, stress, and anxiety.6 The pathogenesis is poorly understood, but it may involve activation of inflammatory mediators in the esophagus, alterations in esophageal mucosal integrity, increased chemical and pressure sensation in the esophagus, and both peripheral and central sensitization (Figure 1).7

DIAGNOSTIC EVALUATION

801tbl1.jpg
When evaluating patients with heartburn symptoms refractory to PPI therapy, the differential diagnosis is broad and includes GERD, eosinophilic esophagitis, infectious esophagitis, pill-induced esophagitis, esophageal motility disorder, and functional heartburn (Table 1). Of these, functional heartburn is the most common, accounting for more than 50% of cases of PPI-refractory heartburn.8

Clinicians have several tests available for diagnosing these conditions.

Upper endoscopy

Upper endoscopy is recommended for patients with heartburn that does not respond to a 3-month trial of a PPI.9 Endoscopy is also indicated in any patient who has any of the following “alarm symptoms” that could be due to malignancy or peptic ulcer:

  • Dysphagia
  • Odynophagia
  • Vomiting
  • Unexplained weight loss or anemia
  • Signs of gastrointestinal bleeding
  • Anorexia
  • New onset of dyspepsia in a patient over age 60.

During upper endoscopy, the esophagus is evaluated for reflux esophagitis, Barrett esophagus, and other inflammatory disorders such as infectious esophagitis. But even if the esophageal mucosa appears normal, the proximal and distal esophagus should be biopsied to rule out an inflammatory disorder such as eosinophilic or lymphocytic esophagitis.

 

 

Esophageal manometry

If endoscopic and esophageal biopsy results are inconclusive, a workup for an esophageal motility disorder is the next step. Dysphagia is the most common symptom of these disorders, although the initial presenting symptom may be heartburn or regurgitation that persists despite PPI therapy.

Manometry is used to test for motility disorders such as achalasia and esophageal spasm.10 After applying a local anesthetic inside the nares, the clinician inserts a flexible catheter (about 4 mm in diameter) with 36 pressure sensors spaced at 1-cm intervals into the nares and passes it through the esophagus and lower esophageal sphincter. The patient then swallows liquid, and the sensors relay the esophageal response, creating a topographic plot that shows esophageal peristalsis and lower esophageal sphincter relaxation.

Achalasia is identified by incomplete lower esophageal sphincter relaxation combined with 100% failed peristalsis in the body of the esophagus. Esophageal spasms are identified by a shortened distal latency, which corresponds to premature contraction of the esophagus during peristalsis.11

Esophageal pH testing

Measuring esophageal pH levels is an important step to quantify gastroesophageal reflux and determine if symptoms occur during reflux events. According to the updated Porto GERD consensus group recommendations,12 a pH test is positive if the acid exposure time is greater than 6% of the testing period. Testing the pH differentiates between GERD (abnormal acid exposure), reflux hypersensitivity (normal acid exposure, strong correlation between symptoms and reflux events), and functional heartburn (normal acid exposure, negative correlation between reflux events and symptoms).5 For this test, a pH probe is placed in the esophagus transnasally or endoscopically. The probe records esophageal pH levels for 24 to 96 hours in an outpatient setting. Antisecretory therapy needs to be withheld for 7 to 10 days before the test.

Transnasal pH probe. For this approach, a thin catheter is inserted through the nares and advanced until the tip is 5 cm proximal to the lower esophageal sphincter. (The placement is guided by the results of esophageal manometry, which is done immediately before pH catheter placement.) The tube is secured with clear tape on the side of the patient’s face, and the end is connected to a portable recorder that compiles the data. The patient pushes a button on the recorder when experiencing heartburn symptoms. (A nurse instructs the patient on proper procedure.) After 24 hours, the patient either removes the catheter or has the clinic remove it. The pH and symptom data are downloaded and analyzed.

Transnasal pH testing can be combined with impedance measurement, which can detect nonacid reflux or weakly acid reflux. However, the clinical significance of this measurement is unclear, as multiple studies have found total acid exposure time to be a better predictor of response to therapy than weakly acid or nonacid reflux.12

Wireless pH probe. This method uses a disposable, catheter-free, capsule device to measure esophageal pH. The capsule, about the size of a gel capsule or pencil eraser, is attached to the patient’s esophageal lining, usually during upper endoscopy. The capsule records pH levels in the lower esophagus for 48 to 96 hours and transmits the data wirelessly to a receiver the patient wears. The patient pushes buttons on the receiver to record symptom-specific data when experiencing heartburn, chest pain, regurgitation, or cough. The capsule detaches from the esophagus spontaneously, generally within 7 days, and is passed out of the body through a bowel movement.

Diagnosing functional heartburn

802fig2.jpg
%3Cp%3EFigure%202.%20High-resolution%20esophageal%20manometry%20in%20our%20patient%20shows%20normal%20esophageal%20resting%20pressure%20and%20relaxation%2C%20and%20a%20distal%20latency%20of%207.5%20seconds%2C%20indicating%20normal%20peristalsis.%20It%20also%20shows%20a%20distal%20contractile%20integral%20of%202%2C368%20mm%20Hg-sec-cm%2C%20a%20measure%20of%20the%20pressure%2C%20duration%2C%20and%20vertical%20length%20of%20the%20distal%20esophageal%20contraction.%20The%20vertical%20axis%20shows%20the%20length%20along%20the%20esophagus%20from%20upper%20to%20lower%2C%20and%20the%20horizontal%20axis%20shows%20time.%20The%20color%20depicts%20pressure%20from%20low%20(blue)%20to%20high%20(red)%3B%20note%20how%20the%20waves%20of%20contraction%20(high%20pressure)%20proceed%20from%20proximal%20(top)%20to%20distal%20(bottom).%3C%2Fp%3E
The Rome IV diagnostic criteria for functional heartburn5 require that a patient experience retrosternal burning, discomfort, or pain at least twice a week for at least 6 months. By definition, the symptoms have not responded to antisecretory drugs (an H2-receptor antagonist or PPI) in optimal doses. Also, inflammatory disorders such as erosive esophagitis and eosinophilic esophagitis and motility disorders such as achalasia (Table 1) need to be ruled out.

CASE CONTINUED: NORMAL RESULTS ON TESTING

803fig3.jpg
%3Cp%3EFigure%203.%20In%20our%20patient%20with%20functional%20heartburn%2C%2024-hour%20wireless%20esophageal%20pH%20testing%20showed%20a%20pH%20greater%20than%204%20(the%20conventional%20cutoff%20in%20esophageal%20pH%20testing)%20for%20most%20of%20the%20test.%20During%20the%20test%2C%20the%20patient%20recorded%20experiencing%20heartburn%2067%20times%20(gray%20diamonds)%3B%20her%20esophageal%20pH%20was%20below%204%20for%20just%203%20of%20the%2067%20events.%20This%20pH%20test%20is%20consistent%20with%20a%20diagnosis%20of%20functional%20heartburn.%20The%20vertical%20axis%20shows%20the%20pH%20from%200%20to%208%2C%20with%20a%20midline%20at%204.%20The%20horizontal%20axis%20shows%20a%2024-hour%20period%20from%20noon%20to%20noon.%3C%2Fp%3E
The patient undergoes esophageal manometry and esophagogastro-duodenoscopy with placement of a wireless pH probe. Results of esophageal manometry are normal. She has normal lower esophageal resting pressure and relaxation and normal peristalsis in the esophagus body (Figure 2). Wireless pH testing shows a total acid exposure time of 1.7% and a strongly negative symptom association with heartburn, chest pain, and regurgitation (Figure 3).

Based on these results, her condition is diagnosed as functional heartburn, consistent with the Rome IV criteria.5

 

 

TREATMENT

Patient education is key

Patient education about the pathogenesis, natural history, and treatment options is the most important aspect of treating any functional gastrointestinal disorder. This includes the “brain-gut connection” and potential mechanisms of dysregulation. Patient education along with assessment of symptoms should be part of every visit, especially before discussing treatment options.

Patients whose condition is diagnosed as functional heartburn need reassurance that the condition is benign and, in particular, that the risk of progression to esophageal adenocarcinoma is minimal in the absence of Barrett esophagus.13 Also important to point out is that the disorder may spontaneously resolve: resolution rates of up to 40% have been reported for other functional gastrointestinal disorders.14

Antisecretory medications may work for some

A PPI or H2-receptor antagonist is the most common first-line treatment for heartburn symptoms. Although most patients with functional heartburn experience no improvement in symptoms with an antisecretory agent, a small number report some relief, which suggests that acid-suppression therapy may have an indirect impact on pain modulation in the esophagus.15 In patients who report symptom relief with an antisecretory agent, we suggest continuing the medication tapered to the lowest effective dose, with repeated reassurance that the medication can be discontinued safely at any time.

Antireflux surgery should be avoided

Antireflux surgery should be avoided in patients with normal pH testing and no objective finding of reflux, as this is associated with worse subjective outcomes than in patients with abnormal pH test results.16

Neuromodulators

804tbl2.jpg
No drug has yet been approved by the US Food and Drug Administration to treat functional heartburn, and clinical evidence for treating this condition is minimal. Using neuromodulators to reduce pain perception is the mainstay of treatment for functional gastrointestinal disorders, including functional heartburn. Table 2 lists neuromodulators used to treat functional esophageal disorders, with recommended dosing intervals.

It is important to discuss with patients the concept of neuromodulation, including the fact that antidepressants are often used because of their effects on serotonin and norepinephrine, which decrease visceral hypersensitivity.

The selective serotonin reuptake inhibitor citalopram has been shown to reduce esophageal hypersensitivity,17 and a tricyclic antidepressant has been shown to improve quality of life.18 These results have led experts to recommend a trial of a low dose of either type of medication.19 The dose of tricyclic antidepressant often needs to be increased sequentially every 2 to 4 weeks.

Interestingly, melatonin 6 mg at bedtime has also shown efficacy for functional heartburn, potentially due to its antinociceptive properties.20

Alternative and complementary therapies

Many esophageal centers use cognitive behavioral therapy and hypnotherapy as first-line treatment for functional esophageal disorders. Here again, it is important for the patient to understand the rationale of therapy for functional gastrointestinal disorders, given the stigma in the general population regarding psychotherapy.

Cognitive behavioral therapy has been used for functional gastrointestinal disorders for many years, as it has been shown to modulate visceral perception.21 Although published studies are limited, research regarding other functional esophageal disorders suggests that patients who commit to long-term behavioral therapy have had a significant improvement in symptoms.22

The goal of esophageal-directed behavioral therapy is to promote focused relaxation using deep breathing techniques, which can help patients manage esophageal hypervigilance, especially if symptoms continue despite neuromodulator therapy. Specifically, hypnotherapy has been shown to modulate functional chest pain through the visceral sensory pathway and also to suppress gastric acid secretion.21,23 A study of a 7-week hypnotherapy program reported significant benefits in heartburn relief and improved quality of life in patients with functional heartburn.24 The data support the use of behavioral therapies as first-line therapy or as adjunctive therapy for patients already taking a neuromodulator.

CASE FOLLOW-UP: IMPROVEMENT WITH TREATMENT

During a follow-up visit, the patient is given several printed resources, including the Rome Foundation article on functional heartburn.5 We again emphasize the benign nature of functional heartburn, noting the minimal risk of progression to esophageal adenocarcinoma, as she had no evidence of Barrett esophagus on endoscopy. And we discuss the natural course of functional heartburn, including the spontaneous resolution rate of about 40%.

For treatment, we present her the rationale for using neuromodulators and reassure her that these medications are for treatment of visceral hypersensitivity, not for anxiety or depression. After the discussion, the patient opts to start amitriptyline therapy at 10 mg every night at bedtime, increasing the dose by 10 mg every 2 weeks until symptoms improve, up to 75–100 mg every day.

After 3 months, the patient reports a 90% improvement in symptoms while on amitriptyline 30 mg every night. She is also able to taper her antisecretory medications once symptoms are controlled. We plan to continue amitriptyline at the current dose for 6 to 12 months, then discuss a slow taper to see if her symptoms spontaneously resolve.

A 44-year-old woman presents with an 8-year history of intermittent heartburn, and in the past year she has been experiencing her symptoms daily. She says the heartburn is constant and is worse immediately after eating spicy or acidic foods. She says she has had no dysphagia, weight loss, or vomiting. Her symptoms have persisted despite taking a histamine (H)2-receptor antagonist twice daily plus a proton pump inhibitor (PPI) before breakfast and dinner for more than 3 months.

She has undergone upper endoscopy 3 times in the past 8 years. Each time, the esophagus was normal with a regular Z-line and normal biopsy results from the proximal and distal esophagus.

The patient believes she has severe gastroesophageal reflux disease (GERD) and asks if she is a candidate for fundoplication surgery.

HEARTBURN IS A SYMPTOM; GERD IS A CONDITION

A distinction should be made between heartburn—the symptom of persistent retrosternal burning and discomfort—and gastroesophageal reflux disease—the condition in which reflux of stomach contents causes troublesome symptoms or complications.1 While many clinicians initially diagnose patients who have heartburn as having GERD, there are many other potential causes of their symptoms.

For patients with persistent heartburn, an empiric trial of a once-daily PPI is usually effective, but one-third of patients continue to have heartburn.2,3 The most common cause of this PPI-refractory heartburn is functional heartburn, a functional or hypersensitivity disorder of the esophagus.4

PATHOPHYSIOLOGY IS POORLY UNDERSTOOD

800fig1.jpg
%3Cp%3EFigure%201.%20Conceptual%20pathophysiologic%20basis%20of%20functional%20heartburn.%3C%2Fp%3E
Functional heartburn is defined as retrosternal burning in the absence of objective evidence of GERD, mucosal abnormality (ie, erosive esophagitis), or major motility disorder.5 The symptoms are theorized to result from hypersensitivity of the visceral nerves of the esophagus, which may be exacerbated by central sensitization, hypervigilance, stress, and anxiety.6 The pathogenesis is poorly understood, but it may involve activation of inflammatory mediators in the esophagus, alterations in esophageal mucosal integrity, increased chemical and pressure sensation in the esophagus, and both peripheral and central sensitization (Figure 1).7

DIAGNOSTIC EVALUATION

801tbl1.jpg
When evaluating patients with heartburn symptoms refractory to PPI therapy, the differential diagnosis is broad and includes GERD, eosinophilic esophagitis, infectious esophagitis, pill-induced esophagitis, esophageal motility disorder, and functional heartburn (Table 1). Of these, functional heartburn is the most common, accounting for more than 50% of cases of PPI-refractory heartburn.8

Clinicians have several tests available for diagnosing these conditions.

Upper endoscopy

Upper endoscopy is recommended for patients with heartburn that does not respond to a 3-month trial of a PPI.9 Endoscopy is also indicated in any patient who has any of the following “alarm symptoms” that could be due to malignancy or peptic ulcer:

  • Dysphagia
  • Odynophagia
  • Vomiting
  • Unexplained weight loss or anemia
  • Signs of gastrointestinal bleeding
  • Anorexia
  • New onset of dyspepsia in a patient over age 60.

During upper endoscopy, the esophagus is evaluated for reflux esophagitis, Barrett esophagus, and other inflammatory disorders such as infectious esophagitis. But even if the esophageal mucosa appears normal, the proximal and distal esophagus should be biopsied to rule out an inflammatory disorder such as eosinophilic or lymphocytic esophagitis.

 

 

Esophageal manometry

If endoscopic and esophageal biopsy results are inconclusive, a workup for an esophageal motility disorder is the next step. Dysphagia is the most common symptom of these disorders, although the initial presenting symptom may be heartburn or regurgitation that persists despite PPI therapy.

Manometry is used to test for motility disorders such as achalasia and esophageal spasm.10 After applying a local anesthetic inside the nares, the clinician inserts a flexible catheter (about 4 mm in diameter) with 36 pressure sensors spaced at 1-cm intervals into the nares and passes it through the esophagus and lower esophageal sphincter. The patient then swallows liquid, and the sensors relay the esophageal response, creating a topographic plot that shows esophageal peristalsis and lower esophageal sphincter relaxation.

Achalasia is identified by incomplete lower esophageal sphincter relaxation combined with 100% failed peristalsis in the body of the esophagus. Esophageal spasms are identified by a shortened distal latency, which corresponds to premature contraction of the esophagus during peristalsis.11

Esophageal pH testing

Measuring esophageal pH levels is an important step to quantify gastroesophageal reflux and determine if symptoms occur during reflux events. According to the updated Porto GERD consensus group recommendations,12 a pH test is positive if the acid exposure time is greater than 6% of the testing period. Testing the pH differentiates between GERD (abnormal acid exposure), reflux hypersensitivity (normal acid exposure, strong correlation between symptoms and reflux events), and functional heartburn (normal acid exposure, negative correlation between reflux events and symptoms).5 For this test, a pH probe is placed in the esophagus transnasally or endoscopically. The probe records esophageal pH levels for 24 to 96 hours in an outpatient setting. Antisecretory therapy needs to be withheld for 7 to 10 days before the test.

Transnasal pH probe. For this approach, a thin catheter is inserted through the nares and advanced until the tip is 5 cm proximal to the lower esophageal sphincter. (The placement is guided by the results of esophageal manometry, which is done immediately before pH catheter placement.) The tube is secured with clear tape on the side of the patient’s face, and the end is connected to a portable recorder that compiles the data. The patient pushes a button on the recorder when experiencing heartburn symptoms. (A nurse instructs the patient on proper procedure.) After 24 hours, the patient either removes the catheter or has the clinic remove it. The pH and symptom data are downloaded and analyzed.

Transnasal pH testing can be combined with impedance measurement, which can detect nonacid reflux or weakly acid reflux. However, the clinical significance of this measurement is unclear, as multiple studies have found total acid exposure time to be a better predictor of response to therapy than weakly acid or nonacid reflux.12

Wireless pH probe. This method uses a disposable, catheter-free, capsule device to measure esophageal pH. The capsule, about the size of a gel capsule or pencil eraser, is attached to the patient’s esophageal lining, usually during upper endoscopy. The capsule records pH levels in the lower esophagus for 48 to 96 hours and transmits the data wirelessly to a receiver the patient wears. The patient pushes buttons on the receiver to record symptom-specific data when experiencing heartburn, chest pain, regurgitation, or cough. The capsule detaches from the esophagus spontaneously, generally within 7 days, and is passed out of the body through a bowel movement.

Diagnosing functional heartburn

802fig2.jpg
%3Cp%3EFigure%202.%20High-resolution%20esophageal%20manometry%20in%20our%20patient%20shows%20normal%20esophageal%20resting%20pressure%20and%20relaxation%2C%20and%20a%20distal%20latency%20of%207.5%20seconds%2C%20indicating%20normal%20peristalsis.%20It%20also%20shows%20a%20distal%20contractile%20integral%20of%202%2C368%20mm%20Hg-sec-cm%2C%20a%20measure%20of%20the%20pressure%2C%20duration%2C%20and%20vertical%20length%20of%20the%20distal%20esophageal%20contraction.%20The%20vertical%20axis%20shows%20the%20length%20along%20the%20esophagus%20from%20upper%20to%20lower%2C%20and%20the%20horizontal%20axis%20shows%20time.%20The%20color%20depicts%20pressure%20from%20low%20(blue)%20to%20high%20(red)%3B%20note%20how%20the%20waves%20of%20contraction%20(high%20pressure)%20proceed%20from%20proximal%20(top)%20to%20distal%20(bottom).%3C%2Fp%3E
The Rome IV diagnostic criteria for functional heartburn5 require that a patient experience retrosternal burning, discomfort, or pain at least twice a week for at least 6 months. By definition, the symptoms have not responded to antisecretory drugs (an H2-receptor antagonist or PPI) in optimal doses. Also, inflammatory disorders such as erosive esophagitis and eosinophilic esophagitis and motility disorders such as achalasia (Table 1) need to be ruled out.

CASE CONTINUED: NORMAL RESULTS ON TESTING

803fig3.jpg
%3Cp%3EFigure%203.%20In%20our%20patient%20with%20functional%20heartburn%2C%2024-hour%20wireless%20esophageal%20pH%20testing%20showed%20a%20pH%20greater%20than%204%20(the%20conventional%20cutoff%20in%20esophageal%20pH%20testing)%20for%20most%20of%20the%20test.%20During%20the%20test%2C%20the%20patient%20recorded%20experiencing%20heartburn%2067%20times%20(gray%20diamonds)%3B%20her%20esophageal%20pH%20was%20below%204%20for%20just%203%20of%20the%2067%20events.%20This%20pH%20test%20is%20consistent%20with%20a%20diagnosis%20of%20functional%20heartburn.%20The%20vertical%20axis%20shows%20the%20pH%20from%200%20to%208%2C%20with%20a%20midline%20at%204.%20The%20horizontal%20axis%20shows%20a%2024-hour%20period%20from%20noon%20to%20noon.%3C%2Fp%3E
The patient undergoes esophageal manometry and esophagogastro-duodenoscopy with placement of a wireless pH probe. Results of esophageal manometry are normal. She has normal lower esophageal resting pressure and relaxation and normal peristalsis in the esophagus body (Figure 2). Wireless pH testing shows a total acid exposure time of 1.7% and a strongly negative symptom association with heartburn, chest pain, and regurgitation (Figure 3).

Based on these results, her condition is diagnosed as functional heartburn, consistent with the Rome IV criteria.5

 

 

TREATMENT

Patient education is key

Patient education about the pathogenesis, natural history, and treatment options is the most important aspect of treating any functional gastrointestinal disorder. This includes the “brain-gut connection” and potential mechanisms of dysregulation. Patient education along with assessment of symptoms should be part of every visit, especially before discussing treatment options.

Patients whose condition is diagnosed as functional heartburn need reassurance that the condition is benign and, in particular, that the risk of progression to esophageal adenocarcinoma is minimal in the absence of Barrett esophagus.13 Also important to point out is that the disorder may spontaneously resolve: resolution rates of up to 40% have been reported for other functional gastrointestinal disorders.14

Antisecretory medications may work for some

A PPI or H2-receptor antagonist is the most common first-line treatment for heartburn symptoms. Although most patients with functional heartburn experience no improvement in symptoms with an antisecretory agent, a small number report some relief, which suggests that acid-suppression therapy may have an indirect impact on pain modulation in the esophagus.15 In patients who report symptom relief with an antisecretory agent, we suggest continuing the medication tapered to the lowest effective dose, with repeated reassurance that the medication can be discontinued safely at any time.

Antireflux surgery should be avoided

Antireflux surgery should be avoided in patients with normal pH testing and no objective finding of reflux, as this is associated with worse subjective outcomes than in patients with abnormal pH test results.16

Neuromodulators

804tbl2.jpg
No drug has yet been approved by the US Food and Drug Administration to treat functional heartburn, and clinical evidence for treating this condition is minimal. Using neuromodulators to reduce pain perception is the mainstay of treatment for functional gastrointestinal disorders, including functional heartburn. Table 2 lists neuromodulators used to treat functional esophageal disorders, with recommended dosing intervals.

It is important to discuss with patients the concept of neuromodulation, including the fact that antidepressants are often used because of their effects on serotonin and norepinephrine, which decrease visceral hypersensitivity.

The selective serotonin reuptake inhibitor citalopram has been shown to reduce esophageal hypersensitivity,17 and a tricyclic antidepressant has been shown to improve quality of life.18 These results have led experts to recommend a trial of a low dose of either type of medication.19 The dose of tricyclic antidepressant often needs to be increased sequentially every 2 to 4 weeks.

Interestingly, melatonin 6 mg at bedtime has also shown efficacy for functional heartburn, potentially due to its antinociceptive properties.20

Alternative and complementary therapies

Many esophageal centers use cognitive behavioral therapy and hypnotherapy as first-line treatment for functional esophageal disorders. Here again, it is important for the patient to understand the rationale of therapy for functional gastrointestinal disorders, given the stigma in the general population regarding psychotherapy.

Cognitive behavioral therapy has been used for functional gastrointestinal disorders for many years, as it has been shown to modulate visceral perception.21 Although published studies are limited, research regarding other functional esophageal disorders suggests that patients who commit to long-term behavioral therapy have had a significant improvement in symptoms.22

The goal of esophageal-directed behavioral therapy is to promote focused relaxation using deep breathing techniques, which can help patients manage esophageal hypervigilance, especially if symptoms continue despite neuromodulator therapy. Specifically, hypnotherapy has been shown to modulate functional chest pain through the visceral sensory pathway and also to suppress gastric acid secretion.21,23 A study of a 7-week hypnotherapy program reported significant benefits in heartburn relief and improved quality of life in patients with functional heartburn.24 The data support the use of behavioral therapies as first-line therapy or as adjunctive therapy for patients already taking a neuromodulator.

CASE FOLLOW-UP: IMPROVEMENT WITH TREATMENT

During a follow-up visit, the patient is given several printed resources, including the Rome Foundation article on functional heartburn.5 We again emphasize the benign nature of functional heartburn, noting the minimal risk of progression to esophageal adenocarcinoma, as she had no evidence of Barrett esophagus on endoscopy. And we discuss the natural course of functional heartburn, including the spontaneous resolution rate of about 40%.

For treatment, we present her the rationale for using neuromodulators and reassure her that these medications are for treatment of visceral hypersensitivity, not for anxiety or depression. After the discussion, the patient opts to start amitriptyline therapy at 10 mg every night at bedtime, increasing the dose by 10 mg every 2 weeks until symptoms improve, up to 75–100 mg every day.

After 3 months, the patient reports a 90% improvement in symptoms while on amitriptyline 30 mg every night. She is also able to taper her antisecretory medications once symptoms are controlled. We plan to continue amitriptyline at the current dose for 6 to 12 months, then discuss a slow taper to see if her symptoms spontaneously resolve.

References
  1. Vakil N, van Zanten SV, Kahrilas P, Dent J, Jones R; Global Consensus Group. The Montreal definition and classification of gastroesophageal reflux disease: a global evidence-based consensus. Am J Gastroenterol 2006; 101(8):1900–1920.
  2. Dean BB, Gano AD Jr, Knight K, Ofman JJ, Fass R. Effectiveness of proton pump inhibitors in nonerosive reflux disease. Clin Gastroenterol Hepatol 2004; 2(8):656–664. pmid:15290657
  3. Hachem C, Shaheen NJ. Diagnosis and management of functional heartburn. Am J Gastroenterol 2016; 111(1):53–61. doi:10.1038/ajg.2015.376
  4. Fass R, Sifrim D. Management of heartburn not responding to proton pump inhibitors. Gut 2009; 58(2):295–309. doi:10.1136/gut.2007.145581
  5. Aziz Q, Fass R, Gyawali CP, Miwa H, Pandolfino JE, Zerbib F. Esophageal disorders. Gastroenterology 2016; 150(6):1368-1379. doi:10.1053/j.gastro.2016.02.012
  6. Kondo T, Miwa H. The role of esophageal hypersensitivity in functional heartburn. J Clin Gastroenterol 2017; 51(7):571–578. doi:10.1097/MCG.0000000000000885
  7. Farmer AD, Ruffle JK, Aziz Q. The role of esophageal hypersensitivity in functional esophageal disorders. J Clin Gastroenterol 2017; 51(2):91–99. doi:10.1097/MCG.0000000000000757
  8. Mainie I, Tutuian R, Shay S, et al. Acid and non-acid reflux in patients with persistent symptoms despite acid suppressive therapy: a multicentre study using combined ambulatory impedance-pH monitoring. Gut 2006; 55(10):1398–1402. doi:10.1136/gut.2005.087668
  9. Katz PO, Gerson LB, Vela MF. Guidelines for the diagnosis and management of gastroesophageal reflux disease. Am J Gastroenterol 2013; 108(3):308–328. doi:10.1038/ajg.2012.444
  10. Kahrilas PJ, Bredenoord AJ, Fox M, et al; International High Resolution Manometry Working Group. The Chicago classification of esophageal motility disorders, v3.0. Neurogastroenterol Motil 2015; 27(2):160–174. doi:10.1111/nmo.12477
  11. Kichler AJ, Gabbard S. A man with progressive dysphagia. Cleve Clin J Med 2017; 84(6):443–449. doi:10.3949/ccjm.84a.16055
  12. Roman S, Gyawali CP, Savarino E, et al; GERD consensus group. Ambulatory reflux monitoring for diagnosis of gastro-esophageal reflux disease: update of the Porto consensus and recommendations from an international consensus group. Neurogastroenterol Motil 2017; 29(10):1–15. doi:10.1111/nmo.13067
  13. Shaheen NJ, Falk GW, Iyer PG, Gerson LB; American College of Gastroenterology. ACG clinical guideline: diagnosis and management of Barrett’s esophagus. Am J Gastroenterol 2016; 111(1):30–50. doi:10.1038/ajg.2015.322
  14. Halder SL, Locke GR 3rd, Schleck CD, Zinsmeister AR, Melton LJ 3rd, Talley NJ. Natural history of functional gastrointestinal disorders: a 12-year longitudinal population-based study. Gastroenterology 2007; 133(3):799–807. doi:10.1053/j.gastro.2007.06.010
  15. Park EY, Choi MG, Baeg M, et al. The value of early wireless esophageal pH monitoring in diagnosing functional heartburn in refractory gastroesophageal reflux disease. Dig Dis Sci 2013; 58(10):2933–2939. doi:10.1007/s10620-013-2728-4
  16. Khajanchee YS, Hong D, Hansen PD, Swanström LL. Outcomes of antireflux surgery in patients with normal preoperative 24-hour pH test results. Am J Surg 2004; 187(5):599–603. doi:10.1016/j.amjsurg.2004.01.010
  17. Viazis N, Keyoglou A, Kanellopoulos AK, et al. Selective serotonin reuptake inhibitors for the treatment of hypersensitive esophagus: a randomized, double-blind, placebo-controlled study. Am J Gastroenterol 2012; 107(11):1662–1667. doi:10.1038/ajg.2011.179
  18. Limsrivilai J, Charatcharoenwitthaya P, Pausawasdi N, Leelakusolvong S. Imipramine for treatment of esophageal hypersensitivity and functional heartburn: a randomized placebo-controlled trial. Am J Gastroenterol 2016; 111(2):217–224. doi:10.1038/ajg.2015.413
  19. Keefer L, Kahrilas PJ. Low-dose tricyclics for esophageal hypersensitivity: is it all placebo effect? Am J Gastroenterol 2016; 111(2):225–227. doi:10.1038/ajg.2016.13
  20. Basu PP, Hempole H, Krishnaswamy N, Shah NJ, Aloysius, M. The effect of melatonin in functional heartburn: a randomized, placebo-controlled clinical trial. Open J Gastroenterol 2014; 4(2):56–61. doi:10.4236/ojgas.2014.42010
  21. Watanabe S, Hattori T, Kanazawa M, Kano M, Fukudo S. Role of histaminergic neurons in hypnotic modulation of brain processing of visceral perception. Neurogastroenterol Motil 2007; 19(10):831–838. doi:10.1111/j.1365-2982.2007.00959.x
  22. Riehl ME, Kinsinger S, Kahrilas PJ, Pandolfino JE, Keefer L. Role of a health psychologist in the management of functional esophageal complaints. Dis Esophagus 2015; 28(5):428–436. doi:10.1111/dote.12219
  23. Klein KB, Spiegel D. Modulation of gastric acid secretion by hypnosis. Gastroenterology 1989; 96(6):1383–1387. pmid:2714570
  24. Riehl ME, Pandolfino JE, Palsson OS, Keefer L. Feasibility and acceptability of esophageal-directed hypnotherapy for functional heartburn. Dis Esophagus 2016; 29(5):490–496. doi:10.1111/dote.12353
References
  1. Vakil N, van Zanten SV, Kahrilas P, Dent J, Jones R; Global Consensus Group. The Montreal definition and classification of gastroesophageal reflux disease: a global evidence-based consensus. Am J Gastroenterol 2006; 101(8):1900–1920.
  2. Dean BB, Gano AD Jr, Knight K, Ofman JJ, Fass R. Effectiveness of proton pump inhibitors in nonerosive reflux disease. Clin Gastroenterol Hepatol 2004; 2(8):656–664. pmid:15290657
  3. Hachem C, Shaheen NJ. Diagnosis and management of functional heartburn. Am J Gastroenterol 2016; 111(1):53–61. doi:10.1038/ajg.2015.376
  4. Fass R, Sifrim D. Management of heartburn not responding to proton pump inhibitors. Gut 2009; 58(2):295–309. doi:10.1136/gut.2007.145581
  5. Aziz Q, Fass R, Gyawali CP, Miwa H, Pandolfino JE, Zerbib F. Esophageal disorders. Gastroenterology 2016; 150(6):1368-1379. doi:10.1053/j.gastro.2016.02.012
  6. Kondo T, Miwa H. The role of esophageal hypersensitivity in functional heartburn. J Clin Gastroenterol 2017; 51(7):571–578. doi:10.1097/MCG.0000000000000885
  7. Farmer AD, Ruffle JK, Aziz Q. The role of esophageal hypersensitivity in functional esophageal disorders. J Clin Gastroenterol 2017; 51(2):91–99. doi:10.1097/MCG.0000000000000757
  8. Mainie I, Tutuian R, Shay S, et al. Acid and non-acid reflux in patients with persistent symptoms despite acid suppressive therapy: a multicentre study using combined ambulatory impedance-pH monitoring. Gut 2006; 55(10):1398–1402. doi:10.1136/gut.2005.087668
  9. Katz PO, Gerson LB, Vela MF. Guidelines for the diagnosis and management of gastroesophageal reflux disease. Am J Gastroenterol 2013; 108(3):308–328. doi:10.1038/ajg.2012.444
  10. Kahrilas PJ, Bredenoord AJ, Fox M, et al; International High Resolution Manometry Working Group. The Chicago classification of esophageal motility disorders, v3.0. Neurogastroenterol Motil 2015; 27(2):160–174. doi:10.1111/nmo.12477
  11. Kichler AJ, Gabbard S. A man with progressive dysphagia. Cleve Clin J Med 2017; 84(6):443–449. doi:10.3949/ccjm.84a.16055
  12. Roman S, Gyawali CP, Savarino E, et al; GERD consensus group. Ambulatory reflux monitoring for diagnosis of gastro-esophageal reflux disease: update of the Porto consensus and recommendations from an international consensus group. Neurogastroenterol Motil 2017; 29(10):1–15. doi:10.1111/nmo.13067
  13. Shaheen NJ, Falk GW, Iyer PG, Gerson LB; American College of Gastroenterology. ACG clinical guideline: diagnosis and management of Barrett’s esophagus. Am J Gastroenterol 2016; 111(1):30–50. doi:10.1038/ajg.2015.322
  14. Halder SL, Locke GR 3rd, Schleck CD, Zinsmeister AR, Melton LJ 3rd, Talley NJ. Natural history of functional gastrointestinal disorders: a 12-year longitudinal population-based study. Gastroenterology 2007; 133(3):799–807. doi:10.1053/j.gastro.2007.06.010
  15. Park EY, Choi MG, Baeg M, et al. The value of early wireless esophageal pH monitoring in diagnosing functional heartburn in refractory gastroesophageal reflux disease. Dig Dis Sci 2013; 58(10):2933–2939. doi:10.1007/s10620-013-2728-4
  16. Khajanchee YS, Hong D, Hansen PD, Swanström LL. Outcomes of antireflux surgery in patients with normal preoperative 24-hour pH test results. Am J Surg 2004; 187(5):599–603. doi:10.1016/j.amjsurg.2004.01.010
  17. Viazis N, Keyoglou A, Kanellopoulos AK, et al. Selective serotonin reuptake inhibitors for the treatment of hypersensitive esophagus: a randomized, double-blind, placebo-controlled study. Am J Gastroenterol 2012; 107(11):1662–1667. doi:10.1038/ajg.2011.179
  18. Limsrivilai J, Charatcharoenwitthaya P, Pausawasdi N, Leelakusolvong S. Imipramine for treatment of esophageal hypersensitivity and functional heartburn: a randomized placebo-controlled trial. Am J Gastroenterol 2016; 111(2):217–224. doi:10.1038/ajg.2015.413
  19. Keefer L, Kahrilas PJ. Low-dose tricyclics for esophageal hypersensitivity: is it all placebo effect? Am J Gastroenterol 2016; 111(2):225–227. doi:10.1038/ajg.2016.13
  20. Basu PP, Hempole H, Krishnaswamy N, Shah NJ, Aloysius, M. The effect of melatonin in functional heartburn: a randomized, placebo-controlled clinical trial. Open J Gastroenterol 2014; 4(2):56–61. doi:10.4236/ojgas.2014.42010
  21. Watanabe S, Hattori T, Kanazawa M, Kano M, Fukudo S. Role of histaminergic neurons in hypnotic modulation of brain processing of visceral perception. Neurogastroenterol Motil 2007; 19(10):831–838. doi:10.1111/j.1365-2982.2007.00959.x
  22. Riehl ME, Kinsinger S, Kahrilas PJ, Pandolfino JE, Keefer L. Role of a health psychologist in the management of functional esophageal complaints. Dis Esophagus 2015; 28(5):428–436. doi:10.1111/dote.12219
  23. Klein KB, Spiegel D. Modulation of gastric acid secretion by hypnosis. Gastroenterology 1989; 96(6):1383–1387. pmid:2714570
  24. Riehl ME, Pandolfino JE, Palsson OS, Keefer L. Feasibility and acceptability of esophageal-directed hypnotherapy for functional heartburn. Dis Esophagus 2016; 29(5):490–496. doi:10.1111/dote.12353
Issue
Cleveland Clinic Journal of Medicine - 86(12)
Issue
Cleveland Clinic Journal of Medicine - 86(12)
Page Number
799-806
Page Number
799-806
Publications
Cleveland Clinic Journal of Medicine
Publications
Cleveland Clinic Journal of Medicine
Topics
Gastroenterology
Pain
Drug Therapy
Mental Health
Article Type
Article
Display Headline
Functional heartburn: An underrecognized cause of PPI-refractory symptoms
Display Headline
Functional heartburn: An underrecognized cause of PPI-refractory symptoms
Legacy Keywords
functional heartburn, proton pump inhibitor, PPI, gastroesophageal reflux disease, esophagus, upper endoscopy, biopsy, esophageal manometry, pH monitoring, cognitive behavioral therapy, hypnotherapy, Rome IV criteria, histamine-2 receptor antagonist, retrosternal pain, brain-gut connection, tricyclic antidepressants, selective serotonin reuptake inhibitors, SSRIs, trazodone, serotonin and norepinephrine reuptake inhibitors, SNRIs, alternative and complementary therapies, Scott Gabbard, Sonya Vijayvargiya
Legacy Keywords
functional heartburn, proton pump inhibitor, PPI, gastroesophageal reflux disease, esophagus, upper endoscopy, biopsy, esophageal manometry, pH monitoring, cognitive behavioral therapy, hypnotherapy, Rome IV criteria, histamine-2 receptor antagonist, retrosternal pain, brain-gut connection, tricyclic antidepressants, selective serotonin reuptake inhibitors, SSRIs, trazodone, serotonin and norepinephrine reuptake inhibitors, SNRIs, alternative and complementary therapies, Scott Gabbard, Sonya Vijayvargiya
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KEY POINTS

  • Functional heartburn accounts for more than half of all referrals for PPI-refractory GERD.
  • Diagnostic criteria require at least 3 months of symptoms in the 6 months before presentation.
  • Results of upper endoscopy with biopsy, esophageal manometry, and esophageal pH monitoring must be normal.
  • Patient education is key, with reassurance that the risk of progression to malignancy is low in the absence of Barrett esophagus, and that the condition remits spontaneously in up to 40% of cases.
  • Neuromodulators to reduce pain perception are the mainstay of treatment for functional gastrointestinal disorders such as functional heartburn. Cognitive behavioral therapy and hypnotherapy are also used as first-line treatment.
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