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pyrosis (heartburn)

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: 1) gastroesophageal reflux disease (GERD) 2) infection &/or inflammation a) esophagus b) stomach c) duodenum 3) esophageal dysmotility 4) esophageal malignancy 5) reflux secondary to pregnancy 6) predisposing/aggravating factors a) foods: tomatoes, citrus fruits, chocolate, onions, fats, sugars, spicy foods, peppermint b) large meals, eating late at night b) tobacco c) alcohol d) coffee e) pharmacologic agents 1] anticholinergic agents 2] NSAIDs 3] calcium channel blockers 4] nitrates 5] progesterone f) increased abdominal pressure: bending over, lifting, tight-fitting clothes, straining on defecation, exercise Epidemiology: 1) occurs daily in 7-10% of the population 2) occurs monthly in 45% of the population [2] 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 Special laboratory: 1) ECG exercise stress test to rule out cardiac etiology [4] 2) esophagogastroduodenoscopy (EGD) 3) 24 hour ambulatory pH monitoring 4) Bernstein test Management: 1) do not test - treat empirically. proton pump inhibitor 1st line [4] - testing reserved for red flags & empiric treatment failure 2) H2-receptor antagonists a) cimetidine (Tagamet) b) ranitidine (Zantac) c) famotidine (Pepcid) d) nizatidine (Axid) e) roxatidine 3) antacids a) absorbable CaCO3 or NaHCO3 - Tums, Titralac, Rolaids b) nonabsorbable Al(OH)3, Mg(OH)2 +/- simethicone for gas - Maalox, Mylanta, Riopan, Gelusil, Amphojel, Basajel - Camalox c) Gaviscon tablets - antacid plus algginic acid - forms a foam that floats on gastric contents - lessens effects of refluxed material into esophagus 4) proton pump inhibitors a) omeprazole (Prilosec) b) lansoprazole 5) mucosal coating agents - sucralfate 6) promotility agents a) metoclopramide (Reglan) b) cisapride (Propulsid) 7) life-style modification a) tobacco cessation b) weight loss/food restriction c) avoidance of eating 2-3 hours before bedtime d) alcohol avoidance e) avoidance of aggravating foods f) elevating head of bed

Related

Bernstein test gastroesophageal reflux disease (GERD)

General

dyspepsia (indigestion)

References

  1. Saunders Manual of Medical Practice, Rakel (ed), WB Saunders, Philadelphia, 1996, pg 297-300
  2. Geriatrics Review Syllabus, American Geriatrics Society, 5th edition, 2002-2004
  3. NIDDK: Acid Reflux (GER & GERD) in Adults https://www.niddk.nih.gov/health-information/digestive-diseases/acid-reflux-ger-gerd-adult
  4. Medical Knowledge Self Assessment Program (MKSAP) 15, 16, 17. American College of Physicians, Philadelphia 2009, 2012, 2014