功能性烧心

功能性烧心 (ｆｕｎｃｔｉｏｎａｌｈｅａｒｔｂｕｒｎ)是指在无病理性胃食管反流或病理基础的食管动力或结构异常的情况下 ,反复发作的胸骨后烧灼感[1] 。功能性烧心病人在症状发作时可伴有酸反流 ,但 2 4ｈ食管ｐＨ监测食管酸暴露时间正常。功能性烧心病人往往白天症状明显 ,亦可伴嗳气、反胃、腹胀、上腹不适、早饱等症状。一、流行病学在西方国家烧心症状相当常见。美国人群调查显示 ,33%～ 4 4 %的人至少每月有烧心症状 ,7%～ 13%的人每天均有烧心症状。但尚不知其中功能性烧心和病理性烧心 (主要由胃食管反流病所致 )所占比例。据报道…     

Functional heartburn and non-erosive reflux disease

Gastroesophageal reflux disease (GERD) is a common disorder in Western countries. For many years our attention has been focused on patients with erosive esophagitis, but in recent times we have realized that endoscopy-negative reflux disease is the most common presentation of this illness, affecting up to 70% of these individuals. Patients with the non-erosive form (NERD) are a heterogeneous group including various subpopulations with different mechanisms for their main symptom of heartburn: reflux of acidic and non-acidic gastric contents, mucosal hypersensitivity, intraesophageal distension by gas, intraduodenal infusion of fat, muscle contractions and psychological abnormalities. As to esophageal acid exposure, patients with NERD can be subdivided into those with abnormal and normal pH testing. The latter group includes patients with a positive correlation between symptoms and reflux events, in whom heartburn can be controlled by proton pump inhibitor (PPI) therapy. According to the recent Rome III criteria, they are still in the realm of GERD. An additional group is called functional heartburn, because this typical symptom is associated neither with an abnormal pH test nor with a positive symptom index. Their response to PPIs is very disappointing. Therefore, there is an increasing consensus on the fact that they do not have GERD and should be treated with drugs other than PPIs.     

Functional heartburn: the stimulus,the pain,and the brain

Functional heartburn is a common disorder and appears to be composed of several distinct subgroups. Identifying the different subgroups based on clinical history only is not achievable at present. The mechanisms responsible for pain, clinical characteristics, and the optimal therapeutic approach remain poorly understood. Response to potent antireflux treatment is relatively limited. Current and future treatment strategies for functional heartburn patients who have failed standard dose proton pump inhibitors (PPIs) include increased PPI dose in some, as well as addition of pain modulators in others.     

Mechanisms of heartburn

Heartburn is a typical symptom of GERD. The spectrum of diseases associated with GERD includes reflux esophagitis, Barrett's esophagus and nonerosive reflux disease (NERD). Although acid reflux is the classic cause of heartburn in patients with erosive esophagitis, the relationship between acid and heartburn is far from clear, especially in patients with NERD. Strong evidence exists that weakly acidic reflux and/or non-acid-related events have a significant role in the generation of heartburn. In addition to the role of nonacidic refluxate components, activation of mechanoreceptors and chemoreceptors, and a possible role for central and peripheral sensitization, has been described. Although patients with erosive esophagitis respond well to acid-suppressive therapy, the same does not hold true for those with NERD. NERD represents a major clinical problem, and its management remains a challenge. Discussion of NERD focuses on the mechanisms that cause chest pain in this subgroup of patients. Improved understanding of the pathogenesis underlying heartburn in patients with GERD, in particular those with NERD, will shape our understanding of this condition. Such understanding will serve as a platform for further research and allow additional therapies to be developed for this increasingly encountered clinical condition.     

Hiatus hernia and heartburn

The symptoms in a group of 80 patients with a pure sliding hiatus hernia were investigated using the pyloric regulation test (Capper, Airth, and Kilby, 1966). It was found that there was a high correlation between the symptoms of heartburn and the reflux of duodenal barium into the stomach.     

On the genesis of heartburn

The primary function of the lower esophageal sphincter is to prevent reflux of acid gastric contents, and heartburn is the cardinal symptom of its failure. Standard meals of protein, carbohydrate, and fat have been shown to have significant effects on lower esophageal sphincter pressure. Most patients with heartburn relate their symptoms to certain foods, few of which contain pure protein, carbohydrate, or fat. We have studied the effects of some of these foods on the lower esophageal sphincter. Whole and nonfat milk were also studied because of their frequent use in heartburn therapy. Pressure in the lower esophageal sphincter was recorded continously in normal subjects using an infused open-tipped system. Test meals consisted of 240-cc quantities of water (control), whole milk, nonfat milk, orange juice, a mixture of tomato paste and water, and dilutions of chocolate syrup. Slight, but significant (P<0.05) decreases in lower esophageal sphincter pressure occurred after whole milk ingestion. By contrast, nonfat milk produced significant (P<0.05) increases in pressure. Orange juice and tomato both caused only transient decreases in pressure with gradual return to the baseline and considerable pressure variation and secondary contractions. Chocolate syrup (1.2% fat) produced immediate and sustained decreases in sphincter pressure (P<0.005) associated with symptomatic reflux in some subjects.     

非糜烂性反流病与功能性烧心

罗马Ⅲ标准提出了非糜烂性反流病(NERD)和功能性烧心(FH)的诊断标准,实际上,临床上有时很难区分NERD和FH。NERD和FH是两种发病机制及临床特点不同的异质性疾病,本综述结合目前研究进展,从食管内脏敏感性、食管动力、精神心理因素、与功能性疾病关系、症状特点及治疗效果方面阐述两者特点,并探讨其相互关系。     

The association of heartburn with gastritis

Esophageal, fundal, antral, and duodenal mucosal biopsies from 10 patients with heartburn were compared with biopsies from 18 patients with dyspepsia but without heartburn or radiographic or endoscopic evidence of peptic, ulcer disease, gastric retention, or esophageal stricture. There was a highly significant correlation between heartburn and antral gastritis and duodenitis (P<0.01). It is suggested that histologic reflux changes are determined by the severity of reflux and reparative potential of the esophageal mucosa. Heartburn, on the other hand, is more related to the nature of the refluxed fluid. The fluid most likely to induce heartburn is one containing duodenal fluid, which is also believed to be an important cause of antral gastritis.Supported in part by NIAMDD Training Grant AM 05095.Presented in part at the 76th Annual Meeting of the American Gastroenterological Association, May 1975, San Antonio, Texas.     

Is amiodarone good for heartburn?

Three cases are reported in which resolution of severe esophagitic dyspepsia followed amiodarone therapy for cardiac arrhythmias. This effect has proved long lasting. The mechanism of amiodarone action may be related to its calcium antagonist or nitratelike properties that reduce lower esophageal sphincter tone. An alternate hypothesis calls attention to structural similarities between amiodarone and the histamine antagonist ranitidine, and suggests a previously unrecognized action of amiodarone on histamine receptors.     

Functional heartburn patients demonstrate traits of functional bowel disorder but lack a uniform increase of chemoreceptor sensitivity to acid

BACKGROUND: Functional heartburn (FH) patients have a profound impact on the response to anti-reflux therapy of the nonerosive reflux disease (NERD) group as compared to the response of the erosive esophagitis group. Thus far, there is paucity of information about their physiological and clinical characteristics that may separate them from the other NERD patients. AIM: To compare physiological and clinical characteristics of patients with FH to their counterparts within the NERD group (NERD-positive [NERD+]). METHODS: Subjects with typical heartburn symptoms, at least twice a week, were evaluated by an upper endoscopy. Only those with normal esophageal mucosa were recruited into the study and underwent pH testing to assess esophageal acid exposure. The patients were divided into those with normal pH test (FH) and those with abnormal pH test (NERD+). The groups were compared for demographics, gastroesophageal reflux disease symptom characteristics, psychological profile, and reported quality of life. Additionally, the two patient groups were compared for stimulus response functions to acid, autonomic function response, and rate of Helicobacter pylori infection. RESULTS: Fifty-two patients included 30 with FH and the rest with NERD+. There was no statistical difference in demographics, frequency of hiatal hernia and H. pylori infection between the two groups. Patients with FH had a significantly longer history of heartburn and reported more episodes of chest pain than NERD+ patients (M--7.5 yr and M--once a week vs M--3.5 yr and M--once a month, respectively, p < 0.05). Patients with FH scored significantly higher in the somatization domain than patients with NERD+ (M--60 vs 52.5, p < 0.05), but had similar reported quality of life. Patients with NERD+ demonstrated a significantly shorter time to symptom perception and higher intensity rating (p < 0.05). Only patients with FH demonstrated a statistically significant increase in heart rate and skin conductance after acid perfusion, as compared to those with NERD+ (p < 0.05). CONCLUSION: Patients with FH demonstrate increased reports of chest pain and somatization, an alteration in autonomic function but lack a uniform increase in chemoreceptor sensitivity to acid as compared to those with NERD+. This suggests that while FH patients harbor clinical traits of a functional bowel disorder, hypersensitivity to acid is not a general phenomenon.     

Determinants of perception of heartburn and regurgitation

BACKGROUND AND AIMS: It is not known why some reflux episodes evoke symptoms and others do not. We investigated the determinants of perception of gastro-oesophageal reflux. METHODS: In 32 patients with symptoms suggestive of gastro-oesophageal reflux, 24 hour ambulatory pH and impedance monitoring was performed after cessation of acid suppressive therapy. In the 20 patients who had at least one symptomatic reflux episode, characteristics of symptomatic and asymptomatic reflux episodes were compared. RESULTS: A total of 1807 reflux episodes were detected, 203 of which were symptomatic. Compared with asymptomatic episodes, symptomatic episodes were associated with a larger pH drop (p<0.001), lower nadir pH (p<0.05), and higher proximal extent (p<0.005). Symptomatic reflux episodes had a longer volume and acid clearance time (p<0.05 and p<0.002). Symptomatic episodes were preceded by a higher oesophageal cumulative acid exposure time (p<0.05). The proximal extent of episodes preceding regurgitation was larger than those preceding heartburn; 14.8% of the symptomatic reflux episodes were weakly acidic. In total, 426 pure gas reflux episodes occurred, of which 12 were symptomatic. Symptomatic pure gas reflux was more frequently accompanied by a pH drop than asymptomatic gas reflux (p<0.05). CONCLUSIONS: Heartburn and regurgitation are more likely to be evoked when the pH drop is large, proximal extent of the refluxate is high, and volume and acid clearance is delayed. Sensitisation of the oesophagus occurs by preceding acid exposure. Weakly acidic reflux is responsible for only a minority of symptoms in patients off therapy. Pure gas reflux associated with a pH drop ("acid vapour") can be perceived as heartburn and regurgitation.