Current Treatment Options in Gastroenterology

, Volume 8, Issue 4, pp 285–291 | Cite as

Functional heartburn

  • Ram Dickman
  • Ronnie Fass

Opinion statement

Functional heartburn (FH) is a common disorder that accounts for 30% to 50% of the patients with nonerosive reflux disease. FH is composed from a heterogeneous group of patients. They primarily include the hypersensitive and the nonacid sensitive esophagus. The mechanisms responsible for pain, clinical characteristics, and the optimal therapeutic approach of FH remain to be fully elucidated. Symptom response rate to potent antireflux treatment is significantly lower in FH patients as compared with any other gastroesophageal reflux disease (GERD) group, suggesting that in proton pump inhibitor (PPI) non-responders mechanisms other than acid reflux are likely the cause of symptoms. Patients with FH should be approached therapeutically as patients with GERD and should initially receive antireflux medications. Due to the need for profound acid suppression in this group of patients, PPIs should be considered relatively early in their care. Failure to respond to standard dosage of PPI is common and will require doubling the dose. If patients continue to report heartburn symptoms while receiving PPI twice daily, adding or switching to pain modulators/visceral analgesics is an appropriate therapeutic approach. Data about the usage of other therapeutic modalities in FH such as antireflux surgery, endoscopic treatment for GERD, and psychotherapy are still unavailable. Emerging treatment will likely include novel pain modulators and more effective antireflux medications.


Omeprazole Proton Pump Inhibitor Proton Pump Inhibitor Therapy Tegaserod Esophageal Acid Exposure 
These keywords were added by machine and not by the authors. This process is experimental and the keywords may be updated as the learning algorithm improves.


Unable to display preview. Download preview PDF.

Unable to display preview. Download preview PDF.

References and Recommended Reading

  1. 1.
    Fass R, Tougas G: Functional heartburn: the stimulus, the pain, and the brain. Gut 2002, 51: 885–892. A very important paper that summarizes in detail the pathophysiology, clinical presentation and treatment of functional heartburn.PubMedCrossRefGoogle Scholar
  2. 2.
    Klinkenberg-Knol EC, Castell DO: Clinical spectrum and diagnosis of gastroesophageal reflux disease. In The Esophagus. 3rd ed. Castell DO, Richter JE, editors. Philadelphia: Lippincott Williams and Wilkins 1999, 75–380.Google Scholar
  3. 3.
    Lind T, Havelund T, Carlsson R: Heartburn without oesophagitis: efficacy of omeprazole therapy and features determining therapeutic response. Scand J Gastroenterol 1997, 32: 974–979. An important paper that describes the symptom response rate of functional heartburn patients to PPI therapy as compared to NERD patients with abnormal pH values.PubMedCrossRefGoogle Scholar
  4. 4.
    Jones RH, Hungin ADS, Phillips J: Gastroesophageal reflux disease in primary care in Europe: clinical presentation and endoscopic findings. Eur J Gen Pract 1995, 1: 14–154.CrossRefGoogle Scholar
  5. 5.
    Schenk BE, Kuipers EJ, Klinkenberg-Knol EC: Omeprazole as a diagnostic tool in gastroesophageal reflux disease. Am J Gastroenterol 1997, 92: 1997–2000.PubMedGoogle Scholar
  6. 6.
    Johnsson F, Weywadt L, Solhaug JH, et al.: One-week omeprazole treatment in the diagnosis of gastro-oesophageal reflux disease. Scand J Gastroenterol 1998, 33: 15–20.PubMedCrossRefGoogle Scholar
  7. 7.
    Fass R, Ofman JJ, Gralnek IM, Johnson C, et al.: Clinical and economic assessment of the omeprazole test in patients with symptoms suggestive of gastroesophageal reflux disease. Arch Intern Med 1999, 159: 2161–2168.PubMedCrossRefGoogle Scholar
  8. 8.
    Mayer E, Naliboff B, Lee O, Munakata J, Chang L: Review article: gender-related differences in functional gastrointestinal disorders. Aliment Pharmacol Ther 1999, 13: 65–69.PubMedCrossRefGoogle Scholar
  9. 9.
    Martinez SD, Malagon IB, Garewal HS, et al.: Non-erosive reflux disease (NERD) - acid reflux and symptom patterns. Aliment Pharmacol Ther 2003, 17: 537–545. A paper that describes the acid reflux characteristics of the different sub-groups of NERD.PubMedCrossRefGoogle Scholar
  10. 10.
    Weiner GJ, Morgan TM, Copper JB, et al.: The symptom index: A clinically important parameter of ambulatory 24-hour esophageal pH monitoring. Am J Gastroenterol 1988, 83: 358–361.Google Scholar
  11. 11.
    Meyer JH, Lembo A, Elashoff JD, et al.: Duodenal fat intensifies the perception of heartburn. Gut 2001, 49: 624–628.PubMedCrossRefGoogle Scholar
  12. 12.
    Waring JP: Nonerosive reflux disease. Semin Gastrointest Dis 2001, 12: 33–37.PubMedGoogle Scholar
  13. 13.
    Fass R, Naliboff B, Higa L, et al.: Differential effect of long-term esophageal acid exposure on mechanosensitivity and chemosensitivity in humans. Gastroenterology 1998, 115: 1363–1373.PubMedCrossRefGoogle Scholar
  14. 14.
    Hobson AR, Matthews P, Furlong P, Aziz Q: The role of esophageal afferent pathway sensitivity in non-erosive reflux disease (abstract). Gastroenterology 2004, 126: A-18, 128.Google Scholar
  15. 15.
    Rodriguez-Stanley S, Robinson M, Earnest DL, et al.: Esophageal hypersensitivity may be a major cause of heartburn. Am J Gastroenterol 1999, 94: 628–631.PubMedCrossRefGoogle Scholar
  16. 16.
    Siddiqui A, Rodriguez-Stanley S, Zubaidi S, Miner PB, Jr: Esophageal visceral sensitivity to bile salts in patients with functional heartburn and in healthy control subjects. Dig Dis Sci 2005, 50: 81–85.PubMedCrossRefGoogle Scholar
  17. 17.
    Trimble KC, Pryde A, Heading RC: Lowered oesophageal sensory thresholds in patients with symptomatic but not excess gastro-oesophageal reflux: evidence for a spectrum of visceral sensitivity in GORD. Gut 1995, 37: 7–12.PubMedGoogle Scholar
  18. 18.
    Schindlbeck NE, Wiebecke B, Klauser AG, et al.: Diagnostic value of histology in non-erosive gastrooesophageal reflux disease. Gut 1996, 39: 151–154.PubMedGoogle Scholar
  19. 19.
    Frazzoni M, De Micheli E, Zentilin P, Savarino V: Pathophysiological characteristics of patients with non-erosive reflux disease differ from those of patients with functional heartburn. Aliment Pharmacol Ther 2004, 20: 81–88.PubMedCrossRefGoogle Scholar
  20. 20.
    Watson RG, Tham TC, Johnston BT, McDougall NI: 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.PubMedGoogle Scholar
  21. 21.
    Richter JE, Campbell DR, Kahrilas PJ, et al.: Lansoprazole compared with ranitidine for the treatment of nonerosive gastroesophageal reflux disease. Arch Intern Med 2000, 160: 1803–1809.PubMedCrossRefGoogle Scholar
  22. 22.
    Fass R, Murthy U, Hayden CW, et al.: Omeprazole 40 mg once a day is equally effective as lansoprazole 30 mg twice a day in symptom control of patients with gastro-esophageal reflux disease (GERD) who are resistant to conventional-dose lansoprazole therapy - a prospective, randomized, multi-centre study. Aliment Pharmacol Ther 2000, 14: 1595–1603.PubMedCrossRefGoogle Scholar
  23. 23.
    Fass R, Quan SF, O’Connor GT, et al.: Predictors of heartburn during sleep in a large prospective cohort study. Chest 2005, 127: 1658–1666.PubMedCrossRefGoogle Scholar
  24. 24.
    Marrero JM, de Caestecker JS, Maxwell JD: Effect of famotidine on oesophageal sensitivity in gastro-oesophageal reflux disease. Gut 1994, 35: 447–450.PubMedGoogle Scholar
  25. 25.
    Rodriguez-Stanley S, Ciociola AA, Zubaidi S, et al.: A single dose of ranitidine 150 mg modulates oesophageal acid sensitivity in patients with functional heartburn. Aliment Pharmacol Ther 2004, 20: 975–982.PubMedCrossRefGoogle Scholar
  26. 26.
    Clouse RE, Lustman PJ, Eckert TC, et al.: Low-dose trazodone for symptomatic patients with esophageal contraction abnormalities. A double-blind, placebo-controlled trial. Gastroenterology 1987, 92: 1027–1036.PubMedGoogle Scholar
  27. 27.
    Cannon RO, 3rd, Quyyumi AA, Mincemoyer R, et al.: Imipramine in patients with chest pain despite normal coronary angiograms. N Engl J Med 1994, 330: 1411–1417.PubMedCrossRefGoogle Scholar
  28. 28.
    Fenton P, Terry ML, Galloway KD, et al.: Is there a role for laparoscopic fundoplication in patients with non-erosive reflux disease (NERD)? (abstract). Gastroenterology 2000, 18: A481, 2600.Google Scholar
  29. 29.
    Sarkar S, Aziz Q, Woolf CJ, et al.: Contribution of central sensitisation to the development of non-cardiac chest pain. Lancet 2000, 356: 1154–1159.PubMedCrossRefGoogle Scholar
  30. 30.
    Kahrilas PJ, Quigley EM, Castell DO, Spechler SJ: The effects of tegaserod (HTF 919) on oesophageal acid exposure in gastro-oesophageal reflux disease. Aliment Pharmacol Ther 2000, 14: 1503–1509.PubMedCrossRefGoogle Scholar

Copyright information

© Current Science Inc 2005

Authors and Affiliations

  • Ram Dickman
  • Ronnie Fass
    • 1
  1. 1.GI Section (1-111G-1)Southern Arizona VA Health Care SystemArizonaUSA

Personalised recommendations