Читать книгу The Esophagus - Группа авторов - Страница 25

Heartburn and regurgitation are two of the most common gastrointestinal complaints worldwide. Also known as pyrosis, heartburn is considered the classic symptom of gastroesophageal reflux disease (GERD). While defined as a burning sensation in the retrosternal area [26], the term heartburn is frequently misunderstood and is often described as indigestion, sour stomach, and bitter belching [6]. Heartburn typically occurs within 30–60 minutes after eating the largest meal of the day and is often exacerbated by foods such as sugars, chocolate, and fats, which are known to decrease lower esophageal sphincter pressure. Spicy, tomato‐based foods and citrus‐containing foods also worsen heartburn symptoms due to their acidity, irritating esophageal mucosa. Beverages such as alcohol and coffee can also exacerbate heartburn.

Heartburn can be accompanied by the sensation and presence of either a bitter, acidic fluid or salty fluid in the mouth. Regurgitation is the reflux of bitter or salty gastric contents or, at times, the return of food or bilious material from the stomach. Many patients experience heartburn or regurgitation shortly after a late meal, or if they lie down within two hours of eating, both of which can lead to nocturnal symptoms and nocturnal awakenings. Activities such as bending over, straining, lifting heavy objects, and running may all exacerbate heartburn and regurgitation due to an increase in intra‐abdominal pressure. Most heartburn patients report that over‐the‐counter antacids help to reduce symptoms in the short term. However, in patients on antisecretory therapy, regurgitation can occur without coexisting heartburn.

The sensitivity and specificity for the symptom‐based diagnosis of GERD is 67% and 70%, respectively, by gastroenterologists [27]. However, while many heartburn patients do have GERD, other conditions, both esophageal and non‐esophageal, need to be considered. Patients with achalasia, pill‐induced esophagitis, and eosinophilic esophagitis can all present with heartburn and dysphagia. If heartburn worsens with exercise or is associated with other symptoms such as shortness of breath or diaphoresis, then coronary artery disease should be considered. Another newer entity is functional heartburn, defined as (i) burning retrosternal discomfort or pain, (ii) no symptom relief despite antisecretory therapy, (iii) absence of GERD with a negative symptom association, and (iv) absence of a major esophageal motor disorder [28].

Regurgitation needs to be distinguished from rumination syndrome, which is the effortless, repetitive regurgitation of recently ingested food into the mouth, followed by re‐chewing and then re‐swallowing or spitting out [29]. Rumination is often misdiagnosed as GERD or vomiting, which invariably leads to a delay in diagnosis. The pathophysiology of rumination syndrome is not clear, but it usually results from the involuntary contraction of the abdominal musculature, which raises intra‐abdominal pressure, along with simultaneous relaxation of the LES. The evaluation and management of rumination syndrome are discussed in Chapter 4.