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Functional esophageal disorders / Functional heartburn
Functional heartburn
Endoscopy revealing no evidence of esophagitis is insufficient when clinical evaluation is being performed, particularly in those patients who are evaluated while remaining on or shortly after discontinuing antireflux therapy. Ambulatory pH monitoring can better classify the patients who have normal findings on endoscopic evaluation, including those whose symptoms persist despite therapy (Figure 1). A favourable response to a brief therapeutic trial using high dosages of a proton pump inhibitor (PPI) is not specific(8), but lack of response is likely to entail a high negative predictive value for GERD.
Figure 1. Further classification of patients with heartburn and no evidence of esophagitis at endoscopy, using ambulatory pH monitoring and response to a therapeutic trial of PPIs. The subset with functional heartburn has no findings that would support a presumptive diagnosis of endoscopy-negative reflux disease (ENRD). The precise thresholds to separate subjects at each step remain uncertain. The figure shows classification categories by findings and is not meant to suggest an algorithm for use in a clinical setting(1).
Functional heartburn is defined as the presence of burning retrosternal discomfort or pain in the absence of GERD(1), histopathology-based motility disorders or structural explanations. Up to 20-40% of Western population report heartburn, depending on thresholds for a positive response(1). Functional heartburn is diagnosed in a minority of subjects (<10%) seeking care from a gastroenterologist for complaining of heartburn(1).
Rome III diagnostic criteria* for functional heartburn(1):
| Must include all of the following: | |
| 1. | Burning retrosternal discomfort or pain. |
| 2. | Absence of evidence that gastroesophageal acid reflux is the cause of the symptom. |
| 3. | Absence of histopathology-based esophageal motility disorders. |
*Criteria fulfilled for the last 3 months, with symptom onset at least 6 months before diagnosis.
The threshold for the second criterion has been modified to exclude subjects with normal esophageal acid exposure despite acid-related symptom events on ambulatory pH monitoring or symptomatic response to antireflux therapy. This group resembles other patients with GERD in terms of clinical symptoms, manometric findings, impact on quality of life, and natural history. Outcome is less satisfactory with antireflux therapy, however, and some subjects within this group will be shown to have functional symptoms that persist once their relationship to reflux events is eliminated with therapy(6). Two or more days a week of mild heartburn is enough to have an influence in GERD patients' quality of life, but thresholds for symptom frequency or severity for functional heartburn have not been determined yet(7).
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