Chapter 20: Heartburn & Indigestion Evaluation

A critical component of the diagnostic reasoning process is differentiating gastrointestinal etiologies from cardiac conditions, such as angina pectoris and myocardial infarction, because pain from both systems transmits to the T1 through T5 spinal segments, often presenting with overlapping symptoms like chest pressure, nausea, and diaphoresis. The text outlines the pathophysiology and symptomatology of Gastroesophageal Reflux Disease (GERD), noting that while cardinal symptoms include pyrosis and regurgitation, patients may also present with extraesophageal manifestations like chronic cough, hoarseness, or asthma. Clinicians are guided to identify alarm symptoms—specifically dysphagia, odynophagia, unintentional weight loss, gastrointestinal bleeding, and unexplained anemia—which mandate immediate evaluation via upper endoscopy to rule out malignancy or severe complications like Barrett esophagus and esophageal strictures. The differential diagnosis is extensive, covering Peptic Ulcer Disease (PUD) often linked to Helicobacter pylori or NSAID use, gastritis, hiatal hernia, and functional disorders categorized by Rome criteria such as functional dyspepsia. Special populations are addressed, including infants with physiologic reflux versus pathologic GERD, and children or adolescents presenting with Allergic Eosinophilic Esophagitis (AEE), characterized by food refusal and atopic history. The chapter also details non-reflux causes of esophagitis, such as infectious etiologies in immunocompromised hosts and pill-induced injury from medications like tetracyclines or bisphosphonates. Diagnostic strategies are evaluated, including the utility and limitations of proton pump inhibitor (PPI) trials, the necessity of electrocardiograms (ECGs) and cardiac enzymes to exclude coronary ischemia, and the role of esophageal pH monitoring and manometry in refractory cases. Finally, the text reviews physical examination findings, which are often normal but may reveal clues such as supraclavicular lymphadenopathy (Virchow node) in metastatic gastric cancer or dental erosion associated with chronic acid exposure.