How to Diagnose Heartburn

Heartburn is most likely from GERD, which requires a formal evaluation

Odds are you have experienced heartburn at some time in your life. In most cases, the discomfort you feel in your upper chest is fleeting and may even be accompanied by an acid taste in your mouth, medically referred to as water brash. These symptoms may go away on their own or with a simple over-the-counter medication.

When symptoms become more chronic or occur two or more times per week, however, you may have gastroesophageal reflux disease (GERD), which may require a more formal evaluation of clinical symptoms, lab tests, and imaging.

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Clinical Symptoms

The diagnosis of GERD is usually based on clinical symptoms. Do not be surprised if your doctor asks you to complete a questionnaire. The ​Gastroesophageal Reflux Disease Questionnaire (GERD-Q) is a validated test that has been shown in clinical studies to help make the diagnosis with an accuracy rate of 89 percent.

The GERD-Q asks six simple questions about the frequency of symptoms and your need for over-the-counter treatments like antacids. Each question is scored on a 0 (0 days per week) to three-point scale (four to seven days per week). Scores of nine or greater are consistent with a diagnosis of GERD.

Diagnostic Treatment Trial

The next step in your evaluation is often not a test at all. Unless your symptoms raise concern for a more serious condition, it is most likely that your doctor will recommend a treatment trial.

In this case, your doctor will prescribe a proton pump inhibitor (PPI) for you to take over four to eight weeks. PPIs work by suppressing acid production in the stomach. If your symptoms improve when acid levels are decreased, this is often sufficient to confirm the diagnosis. Medications in this category include esomeprazole (Nexium), omeprazole (Prilosec), pantoprazole (Prevacid), or rabeprazole (AcipHex). Many of these medications are now available over the counter.

Labs and Tests

A common misconception is that H. pylori, a bacteria associated with peptic ulcer disease, also causes GERD. Research has not shown this to be true and screening is generally not recommended. In practice, treatment of H. pylori infection does little to improve GERD symptoms.

That is not the case for dyspepsia. While GERD is usually limited to heartburn and water brash, dyspepsia is a broader clinical syndrome. It includes other gastrointestinal symptoms like upper abdominal pain, bloating, nausea, and early satiety, even with small amounts of food. Evaluation for H. pylori should be considered for this cases.

Testing for H. pylori infection can be done in one of three ways.

  • Urea breath test: The test relies on the fact that H. pylori bacteria breaks urea down into carbon dioxide and ammonia. At a laboratory facility, you will ingest a sample of urea, either as a liquid or a tablet, that has trace amounts of a radioactive carbon isotope attached to it. You will then breathe into a container where your carbon dioxide level is measured. If H. pylori is present, the isotope will be detected in the sample.
  • Stool antigen assay: If you are infected with H. pylori, proteins from the bacteria will be excreted in your stool. Enzyme immunoassays can detect whether or not you are infected by testing your stool sample with antibodies that bind to those antigens.
  • Serology testing: Your immune system makes antibodies against H. pylori if you have been infected. Unfortunately, it is not always easy to interpret serology results. IgM antibodies in the blood may indicate active infection but IgG antibiotics could represent either active or old infection.

The urea breath test and the stool antigen assay are the preferred tests for active infection. Because PPIs, bismuth subsalicylate (Pepto-Bismol), and antibiotics can interfere with the accuracy of the results, it is recommended you not take these medications for at least two weeks before your test. The laboratory facility will provide you with instructions on how to best prepare.

Imaging

If you have failed a diagnostic treatment trial, meaning that you still have symptoms, you may need further evaluation. It could be that you have a more aggressive case of GERD, complications from GERD, or another cause for your heartburn symptoms altogether. At this point, your doctor will want to get a closer look at your esophagus and how well it works.

Upper Endoscopy

The most common imaging study is an upper endoscopy, also referred to as an esophagogastroduodenoscopy (EGD). The study is performed under sedation.

A thin flexible scope with a camera and light source at the end is inserted into your mouth and guided down the esophagus into the stomach and into the upper part of the duodenum, the first part of the small intestine. This allows the doctor, most often a gastroenterologist, to directly visualize the inside of these organs and to take biopsies or perform procedures as needed based on his findings. Tissue samples can also be collected for H. pylori testing.

The test is most helpful in diagnosing complications from too much acid exposure.​ Esophagitis (inflammation of the esophagus) and esophageal strictures (narrowing of the esophagus) can develop, leading to persistent heartburn and other symptoms. Barrett's esophagus, a condition that increases your risk for esophageal cancer, is another, albeit less common, complication.

Complications from the upper endoscopy itself are rare but do occur. Thankfully, this only happens 0.15 percent of the time. The more common complication is a tear in the esophagus but it is more likely to occur when a procedure, like esophageal dilation, is also performed. Other complications to consider are infections from the endoscope or bleeding that can occur at biopsy sites.

Esophageal pH Monitoring and Impedance Testing

The gold standard for diagnosing GERD is esophageal pH monitoring. The problem is it can be time-consuming and inconvenient. No wonder it is not used as a first-line diagnostic tool. Instead, it is performed when the other studies mentioned above are negative and the doctor needs to confirm that there is an acid reflux problem causing your symptoms.

This study measures how much acid gets into the esophagus. It relies on a thin catheter with a pH sensor at one end and a recording device on the other. The catheter is placed through the nose and guided into the esophagus so that it sits above the lower esophageal sphincter (LES). Anatomically, the LES separates the esophagus from the stomach.

The catheter is left in place for 24 hours. It measures the pH level at the LES over time. It also can measure the amount of food and other gastric contents that reflux into the esophagus in what is known as impedance testing. During this time, you are asked to keep a diary of your symptoms and food intake. Once time is up, data is collected from the sensor and correlated with your diary.

Acid is defined by pH less than 7.0. For diagnostic purposes, a pH less than 4 percent confirms a diagnosis of GERD if it occurs 4.3 percent or more of the time. This is, at least, the case if you are not taking a PPI. If you are taking a PPI, your test is considered abnormal when your pH is in this range 1.3 percent of the time.

There is also a capsule version of pH monitoring, although impedance testing is not an option with this method. The capsule is attached to the esophagus during an upper endoscopy and the data is collected wirelessly. Acid levels are measured over 48 to 96 hours. There is no need to have another endoscopy to remove the capsule. Within a week's time, the device falls off the esophagus and is excreted in the stool. While the test is more accurate than traditional catheter pH testing, it is also more invasive and considerably more expensive.

Esophageal Manometry

Your doctor may suspect that an esophageal motility disorder is causing your heartburn. When you eat, food passes from your mouth to your stomach, but only after a coordinated series of muscle movements. Muscles lining the esophagus propel the food forward in a process known as peristalsis.

The upper and lower esophageal sphincters must also open and close at proper times to move food forward or otherwise prevent food from moving in a backward direction. Any irregularities in these movements can lead to difficulty swallowing, chest pain, or heartburn.

Manometry is a test that assesses motility function. A small tube is inserted into your nose and guided through your esophagus and into the stomach. Sensors along the tube detect how well the muscles contract as you swallow. You will not be sedated during the test because you will be asked to swallow small amounts of water. Your doctor will track the coordination and strength of esophageal muscle contractions as you swallow. Altogether, the test usually lasts only 10 to 15 minutes.

While manometry can help to diagnosis GERD, it is most helpful to diagnosis other motility disorders like achalasia and esophageal spasm.

Barium Swallow

A barium swallow may not be the best test to check for GERD, but it can look for esophageal strictures, a complication of GERD. The study is also helpful in identifying a hiatal hernia or esophageal motility disorder that can contribute to heartburn symptoms.

The test is performed by taking a series of x-ray while you drink an opaque dye called barium. The barium appears darker on x-ray than your bones and tissue, making it easy for your doctor to follow muscle movement through the esophagus. Anatomic abnormalities in the esophagus can also be seen in this way.

Differential Diagnosis

Heartburn is most commonly but not always attributable to GERD. As discussed, it can also be related to dyspepsia, H. pylori infection, and esophagitis. Other conditions to consider include esophageal motility disorders like achalasia and esophageal spasm.

In the worst case and least likely scenario, esophageal cancer could be to blame. For this reason, it is recommended you see your doctor if you have heartburn symptoms that are severe or that occur more than two times per week.

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