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Functional esophageal disorders / Functional heartburn
Functional heartburn
Enhanced perception of esophageal acid is influenced by patient's psychological status. ]
Persisting symptoms unrelated to GERD may respond to low-dose tricyclic antidepressants, other antidepressants, or to psychological therapies used in many functional syndromes, although controlled trials confirming efficacy are lacking(1).
Emerging therapies include selective serotonin reuptake inhibitors and relaxation therapy(11). Reduction in transient lower esophageal sphincter relaxation with agents such as baclofen is being investigated(12). Treatment with a proton pump inhibitor provides better symptom control than placebo, but the response is attenuated relative to that in conventional reflux disease(2).
Antireflux surgery in patients with functional heartburn and non-acid reflux events has not been fully evaluated, but surgical management would not be expected to be as beneficial as is in GERD(1).
The underlying pathophysiology seems to be heterogeneous in nature. However, the disturbed visceral perception is considered as a major factor involved in pathogenesis(9). On one hand, patients with functional heartburn may have enhanced esophageal sensitivity to refluxate. Little direct evidence for alteration in central signal processing is available in these patients with heartburn, although it is suspected(1). On the other, psychological factors may also be involved.
Hypersensitivity to physiologic esophageal acid exposure, esophageal mechanosensitivity and/or psychological factors may be at times responsible for functional heartburn. ]
Psychological features in patients with functional heartburn have been poorly characterized. Heartburn not correlated with acid reflux events on pH monitoring predicts heightened anxiety, emotional lability, and poor social support compared with correlated symptoms(10).
However, psychological profiling fails to differentiate patients with normal esophageal acid exposure and no esophagitis from those with elevated acid exposure times. Experimental stress enhances perception of reflux events in susceptible (anxious) individuals, but the relevance of stress experiments in understanding potential effects of psychological factors remains unknown(2).
1. Galmiche J.P., Clouse R.E., Bálint A. Functional esophageal disorders. Gastroenterology 2006; 130 (5): 1459-1465.
6. Watson R.G.P., Tham T.C.K., Johnston B.T. Double blind cross-over placebo controlled study of omeprazole in the treatment of patients with reflux symptoms and physiological levels of acid reflux-the "sensitive esophagus. Gut 1997; 40: 587-590.
7. Dent J., Armstrong D., Delanye B. Symptom evaluation in reflux disease: workshop, background, process, terminology, recommendations, and discussion outputs. Gut 2004; 53 (Suppl IV):iv1-iv24.
8. Numans M.E., Lau J., de Wit N.J. Short-term treatment with proton-pump inhibitors as a test for gastroesophageal reflux disease: a meta-analysis of diagnostic test characteristics. Ann Intern Med 2004; 140: 518-527.
9. Fass R., Tougas G. Functional heartburn: the stimulus, the pain, and the brain. Gut 2002; 51: 885-892.
10. Johnston B.T., Lewis S.A., Collins J.S. Acid perception in gastro-oesophageal reflux disease is dependent on psychosocial factors. Scand J Gastroenterol 1995; 30: 1-5.
11. Tack J., Janssens J. Functional heartburn. Curr Treat Options Gastroenterol 2002; 5 (4): 251-258.
12. Koek G.H., Sifrim D., Lerut T. Effect of the GABA(B) agonist baclofen in patients with symptoms and duodeno-gastro-oesophageal reflux refractory to proton pump inhibitors. Gut 2003; 52: 1397-1402.
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