Functional heartburn or refractory reflux disease?

Functional heartburn is important to recognize because without investigation, this condition might be considered equivalent with gastroesophageal reflux disease (GERD), and treating physicians could continue acid suppressive therapy unnecessarily or escalate antireflux treatments, which might even lead to harm.

In the AGA Clinical Practice Update on Functional Heartburn: Expert Review, published in Gastroenterology’s June issue, the authors provide the following best practice advice statements to address key issues in the clinical management of these patients:

CLINICAL PRACTICE ADVICE

1. A diagnosis of functional heartburn should be considered when retrosternal burning pain or discomfort persists despite maximal (double-dose) proton pump inhibitor (PPI) therapy taken appropriately before meals during a three-month period.
2. A diagnosis of functional heartburn requires upper endoscopy with esophageal biopsies to rule out anatomic and mucosal abnormalities, esophageal high-resolution manometry to rule out major motor disorders, and pH monitoring off PPI therapy (or pH-impedance monitoring on therapy in patients with proven GERD), to document physiologic levels of esophageal acid exposure in the distal esophagus with absence of reflux–symptom association (ie, negative symptom index and symptom association probability).
3. Overlap of functional heartburn with proven GERD is diagnosed according to Rome IV criteria when heartburn persists despite maximal PPI therapy in patients with a history of proven GERD (ie, positive pH study, erosive esophagitis, Barrett’s esophagus or esophageal ulcer), and pH impedance testing on PPI therapy demonstrates physiologic acid exposure without reflux–symptom association (ie, negative symptom index and symptom association probability).
4. PPIs have no therapeutic value in functional heartburn, the exception being proven GERD that overlaps with functional heartburn.
5. Neuromodulators, including tricyclic antidepressants, selective serotonin reuptake inhibitors, tegaserod and histamine-2 receptor antagonists have benefit as either primary therapy in functional heartburn or as add-on therapy in functional heartburn that overlaps with proven GERD.
6. Based on available evidence, acupuncture and hypnotherapy may have benefit as monotherapy in functional heartburn, or as adjunctive therapy combined with other therapeutic modalities.
7. Based on available evidence, anti-reflux surgery and endoscopic GERD treatment modalities have no therapeutic benefit in functional heartburn and should not be recommended.

For more information, view the full AGA Clinical Practice Update on Functional Heartburn: Expert Review.