Not all heartburns due to acid-reflux
Proton pump inhibitor drugs (PPIs) may not be effective for treating heartburn symptoms that are not due to gastro-esophageal reflux disease (GERD), according to an expert.
GERD refers to the leakage of stomach acid upwards through the esophagus, usually due to a weakness of the lower esophangeal sphincter muscles. Symptoms include feelings of heartburn, unpleasant tastes at the back of the mouth, nausea, bad breath and difficulty swallowing.
“The main cause for referral of reflux patients to a GI clinic nowadays is a failure of response—or inadequate response—to PPI therapy,” said Professor Kenneth McColl, professor of gastroenterology at the Institute of Cardiovascular and Medical Sciences, University of Glasgow, United Kingdom. “The main reason for PPI failure—when prescribed and taken appropriately for GERD symptoms—is either incorrect administration, and/or that the persistent symptoms are not due to acid reflux itself.”
Symptoms arising from gastric acid reflux have long proven highly responsive to properly administered PPIs; a comprehensive review of 43 studies encompassing 7,635 GERD patients found that PPIs delivered total relief of symptoms in 80 to 90% of patients by the end of 2 months’ treatment or less. [Gastroenterology 1997;112(6):1798–1810] This makes PPIs a useful diagnostic tool for distinguishing reflux-induced heartburn from other causes, said McColl.
If the patient has been conforming to the treatment regimen and GERD symptoms persist, then one must consider other conditions with symptoms similar to those caused by acid reflux. According to McColl, a majority of PPI failures are due to functional heartburn—ie, heartburn symptoms that occur despite normal endoscopy, normal esophageal acid exposure results, and negative symptom correlation. [Gut 2006;55:1398–1402, Clin Gastroenterol Hepatol 2008;6:521–524]
As with other FGIDs (functional gastrointestinal disorders), recent stressful life events, chronic fatigue syndrome, anxiety/depression, fibromyalgia, or other functional diseases of the gastrointestinal tract or other parts of the body (eg, urinary tract, gynaecological system) may play a role in inducing functional heartburn, said McColl. He emphasized the importance of reassuring patients of the lack of underlying serious disease, the commonness of the diagnosis, and focusing on treating potential psychosocial issues.
Other conditions that may induce similar symptoms as GERD include cardiac chest pain; musculoskeletal back/chest pain; side effects from medication (eg NSAIDs); Candida esophagitis infection, especially if recently been on antibiotics, steroids, or immunosuppressive drugs; esophageal motility disorders; or an atopic history of eosinophilic esophagitis.
When dealing with patients unresponsive to PPI therapy, said McColl, first take the time to speak to the patient and check that they have been taking medication appropriately; in adequate doses (eg, omeprazole 40 mg daily or 20 mg twice daily) and at appropriate times (i.e. 30 minutes before a meal). Patients should also be aware that PPI therapy only works as long as medication is taken; in addition, due to their slow onset of action, PPIs must be taken regularly and not on an on-demand basis in order to be effective, so long as symptoms persist.
It must also be remembered that PPIs cannot control high-volume acid reflux, said McColl; patients who wake up choking on gastric juices in the night may require lifestyle measures to assist (eg, weight loss), and laproscopic fundoplication if other measures fail.