Characteristics of Functional Heartburn
Functional heartburn is characterized by episodes of burning discomfort in the chest, behind the breastbone. There is no evidence of inflammation in the lining of the esophagus or other disease. The discomfort generally comes in waves, occurs after meals and can be accompanied by belching, regurgitation, or dyspeptic symptoms, such as upper abdominal discomfort, bloating, or early feeling of being full. It occurs primarily during the day.
Functional heartburn is thought to be very common, occurring in about 20% of individuals according to several studies, and tends to affect more women than men.
If the symptoms of functional heartburn are occasional, short lasting, and well-controlled with antacids, diagnostic tests are not needed.
With more severe symptoms, a physician will test with upper GI endoscopy (a diagnostic test which allows a physician to inspect the lining of the upper gastrointestinal tract through a thin flexible tube which is swallowed). This test looks for inflammation in the lining of the esophagus – a condition called esophagitis.
If esophagitis is not detected, gastric acid activity in the esophagus will be investigated, looking for the presence of gastroesophageal reflux disease (GERD). This can be done with 24-hour esophageal pH monitoring to measure acid reflux – the backflow of stomach acid into the esophagus.
If the number of acid reflux episodes or the amount of time gastric acid spends in the esophagus exceeds normal values a diagnosis of GERD will be made.
On the other hand, reflux values falling within the normal range, especially for people who are active and eating regular meals, suggest the presence of functional reflux. Traditional anti-reflux treatment will likely help if the heartburn is noted to be in relationship with acid reflux.
Studies suggest that people with functional heartburn may be divided into two groups.
The first and smallest group is those that have a solid correlation between heartburn and acid reflux by 24 hour pH monitoring. These people may be hypersensitive to a normal amount of acid or, more likely, pH monitoring may be missing abnormal quantities of acid reflux.
The second group is made up of those whose symptoms are generally unrelated to specific reflux episodes. The underlying cause is unknown but may be related to other factors, including heightened esophageal awareness.
Many reflux patients believe that environmental stressors increase the likelihood of reflux symptoms. A Gallup survey reported that 64% of respondents believe that stress worsened their reflux symptoms. Laboratory studies tend to confirm these observations.
From a practical standpoint, an approach to treating functional heartburn should begin with the use of acid-reducing agents and lifestyle changes. Examples include:
- Eliminating foods that provoke reflux, like certain spicy or fatty foods
- Changing eating habits
- Elevating the head of the bed while sleeping
- Decreasing or stopping smoking
- Reducing activities that cause stress
If this approach fails, your doctor may prescribe a short course of medication that inhibits or prevents reflux, such as H2 blockers, or proton pump inhibitors (PPIs). However, generally the response to these medications in those with functional heartburn is not as good as in those with esophagitis or GERD.
Relaxation techniques may affect the lower esophageal sphincter (LES), the muscle group that closes the passage between the stomach and the esophagus. When the LES relaxes at an inappropriate time, it allows acid to reflux into the esophagus.
Relaxation therapy with deep breathing may reduce functional heartburn symptoms. In a study, this technique was associated with both decreased report of symptoms and decreased reflux episodes. It is possible that the diaphragmatic breathing associated with relaxation training increases the pressure of the surrounding diaphragm. This then increases overall LES pressure which in turn reduces the number of reflux episodes and associated heartburn.
Adapted from IFFGD Publication: Functional Heartburn by Joel Richter, MD, Chair, Dept. of Gastroenterology, The Cleveland Clinic Foundation and Professor of Internal Medicine, Ohio State University, OH.