The basics - The causes of heartburn

A variety of GI disorders present with heartburn. Dr Taqi Hashmi explains the common diagnoses.

Heartburn is a substernal pain or burning sensation usually associated with the regurgitation of gastric juice into the oesophagus.

Depending on how strictly the term is defined it is either synonymous with dyspepsia or a distinct entity.

Dyspepsia has no universally agreed definition. It includes nearly any symptom of the upper GI tract including: pain, discomfort, heartburn, acid reflux, nausea or vomiting. This can occur in up to 40 per cent of patients presenting to their GP.


Barium X-ray may demonstrate the presence of a gastric cancer

Red flags in heartburn

  • Chronic GI bleeding
  • Iron deficiency anaemia
  • Unintentional weight loss
  • Progressive dysphagia
  • Epigastric mass
  • Patients >55 years with unexplained or recent-onset symptoms

The clinical relevance of upper GI symptoms is limited by their lack of predictive power. The positive predictive value of various criteria that have attempted to predict endoscopic findings from the clinical presentation are poor. They range from 25 to around 50 per cent.

If patients presenting with symptoms of heartburn and/or dyspepsia undergo endoscopic investigation they fall into three main categories: GORD, peptic ulcer or non-ulcer dyspepsia.

Other findings include gastric cancer, oesophageal cancer, Barrett's oesophagus and hiatus hernia.

GORD is defined as evidence of gastric reflux resulting in oesophagitis on endoscopic examination. The majority of the oesophagus lies in the intra-thoracic cavity where the pressure is lower than abdomen. If no sphincter was present gastric contents would reflux.

The acidic gastric juices are kept in the stomach by the action of the lower oesophageal sphincter (LOS). The sphincter is physiological and is a function of its intra-abdominal length, resting pressure (15-35mmHg), overall length and adequate frequency of waves of relaxation.

Adequate gastric emptying and salivary neutralisation also play a part. A disturbance in the balance of these will result in GORD. Hiatus hernia may disrupt the LOS mechanism, while drugs such as beta-blockers and calcium-channel blockers may lower LOS pressure.

Barrett's oesophagus
Chronic exposure to gastric secretions can lead to metaplastic change of the oesophageal squamous epithelium into a columnar epithelium known as Barrett's oesophagus.

This is present in 8-15 per cent of patients with GORD and may progress to adenocarcinoma. The association is strongest if the length of distal oesophagus involved is more than 3cm.

The gender ratio for GORD is equal but oesophagitis and Barrett's are more common in men.

Peptic ulcer
Peptic ulcer, another endoscopic entity, is defined as the presence of an ulcer due to the action of pepsin (hence the term peptic) anywhere in the GI tract, mostly in the duodenum and stomach.

Duodenal ulcers are twice as common in men and have a peak age of incidence from 45 to 64 years, whereas gastric ulcers are equally common in men and women and show an increasing frequency with age.

Peptic ulcers occur when there is an imbalance of the protective mechanisms that resist the action of gastric juice.

Presentation can either be acute or chronic.

Acute ulcers present over a short period of time, with severe dyspepsia, epigastric pain and GI haemorrhage and warrant immediate referral for endoscopy. Where the mucosal wall has been perforated peritonitis will result.

Chronic ulcers run a more indolent course and can be either asymptomatic or dyspeptic. The natural course of ulcers is remitting and relapsing and the same complications as in acute peptic ulcer disease can occur. Gradual GI blood loss presents as iron deficiency anaemia.

H pylori
Most duodenal ulcers and 80 per cent of gastric ulcers are associated with the presence of Helicobacter pylori. There is substantial evidence to suggest peptic ulcer disease may be cured by the eradication of H pylori.

Most other cases show a strong association with NSAIDs, although the absolute risk of an ulcer in those who are not at risk is low (one symptomatic ulcer per 100 patient-years of NSAID use). The risks are considered high in patients with previous ulcer history, elderly and those using concurrent medication harmful to the gastric mucosa (such as steroids).

Non-ulcer dyspepsia
Non-ulcer dyspepsia - an endoscopic diagnosis of exclusion - is the presence of dyspepsia without any positive endoscopic findings. This is the most common finding on endoscopy accounting for around 60 per cent of cases. It is likely that a number of these patients actually have other dyspepsia aetiologies and studies show that, with repeat endoscopies, their diagnosis can change.

Other causes include gastric cancer (on the decline) and oesophageal cancer, which is increasing in incidence. Gastric neoplasia is strongly associated with the presence of H pylori.

The prevalence of H pylori varies across the world and can range from 20 to 80 per cent of the population (UK 40 per cent). Given its presence in so many asymptomatic individuals and the low absolute incidence of gastric cancer, it is unlikely to be the only cause.

It has been speculated that H pylori eradication treatment is a reason for the declining incidence of gastric carcinoma.

Given the poor predictive value of clinical symptoms, a balance has to be struck between aggressive investigation and symptomatic therapy. NICE in its 2004 guidance recommended an empirical approach for treating uninvestigated dyspepsia with a stepwise approach starting with lifestyle interventions.

The evidence for lifestyle interventions is limited, contradictory and if present shows a weak association such as obesity. Suggested interventions include reducing smoking, coffee, chocolate, fat and raising the head of the bed in an effort to increase LOS pressure or gastric emptying.

The next steps are full-dose PPI, test and treat for H pylori and finally pro-motility agents (metoclopramide and domperidone).

Further investigation and referral are indicated if alarm symptoms are present (see box above). PPI or H2 antagonists taken within two weeks prior to endoscopy can mask and delay detection of malignant lesions.

The treatment of GORD and peptic ulcer are based on the same principles with differences in the duration of therapy and the possibility of surgical intervention.

  • Dr Hashmi is a former GP in London working as a consultant in family medicine in Jeddah, Saudi Arabia

Learning points

  • Dyspepsia is a common problem (40% prevalence).
  • Endoscopy is required for a definitive diagnosis.
  • Common diagnoses are: GORD, peptic ulcer or non-ulcer dyspepsia.
  • Clinical tools cannot be used to predict endoscopic findings.
  • NICE recommend an empirical stepwise approach in uninvestigated cases.
  • Evidence for lifestyle interventions is poor.

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