Update on Functional Heartburn

Abstract

The definition of functional heartburn has been refined over the years. It is currently described, based upon Rome IV criteria, as typical heartburn symptoms in the presence of normal upper endoscopy findings (including normal biopsies), normal esophageal pH testing, and a negative association between symptoms and reflux events. Functional heartburn is very common, affecting women more than men, and with reflux hypersensitivity makes up the majority of heartburn patients who fail twice-daily proton pump inhibitor therapy. These disorders overlap with other functional gastrointestinal disorders and are often accompanied by psychological comorbidities. Diagnosis is made by using endoscopy with esophageal biopsies, wireless pH capsule, pH-impedance monitoring, and high-resolution esophageal manometry. Additional diagnostic tools that may be of value include magnification endoscopy, chromoendoscopy, narrow-band imaging, autofluorescence imaging, mucosal impedance, impedance baseline values, and histopathology scores. Functional heartburn is primarily treated with neuromodulators. Psychological intervention and complementary and alternative medicine may also play important roles in the treatment of these patients.

Keywords: Heartburn; esophagus; pH testing; proton pump inhibitor; upper endoscopy.

Figure 1.

Classification of patients with normal endoscopy findings and no history of documented gastroesophageal reflux disease (GERD) using Rome IV criteria.

Figure 2.

Percentage of functional heartburn patients among patients with normal endoscopy findings. Reproduced with permission from Yamasaki T, Fass R.

Figure 3.

Diagnostic algorithm of functional heartburn in refractory heartburn patients who failed twice-daily proton pump inhibitor therapy. GERD, gastroesophageal reflux disease; MII, multichannel intraluminal impedance; NERD, nonerosive reflux disease. Adapted from Yamasaki T, Fass R.