Determining the Cause

Chief Complaint: Heartburn

https://claude.ai/public/artifacts/e86962be-b7c5-4b21-a720-e554086cdcf2

graph TD
A[Patient with Heartburn/Reflux Symptoms] --> B[Step 1: Clinical Assessment]
B --> C{Alarm Symptoms Present?}

C -->|YES| D[🚨 Immediate EGD<br/>Alarm symptoms:<br/>• Dysphagia<br/>• Odynophagia<br/>• GI bleeding/anemia<br/>• Weight loss<br/>• Persistent vomiting<br/>• Age > 50 with new onset]

C -->|NO| E[Step 2: Empiric PPI Trial<br/>4-8 weeks]

E --> F{Symptoms Improve?}

F -->|YES| G[✓ Presumptive GERD Diagnosis<br/>Continue PPI therapy<br/>Consider step-down]

F -->|NO| H[Step 3: Upper Endoscopy EGD]

D --> I{Endoscopy Findings}
H --> I

I -->|Abnormal| J[Treat Based on Findings:<br/>• Esophagitis → Continue PPI<br/>• Barrett's → Surveillance<br/>• Stricture → Dilation + PPI<br/>• Malignancy → Oncology referral]

I -->|Normal| K[Step 4: Physiologic Testing]

K --> L[24-hr pH Monitoring<br/>± Impedance Testing]
L --> M{Pathological<br/>Reflux Confirmed?}

M -->|YES| N[GERD Confirmed<br/>Optimize PPI therapy<br/>Consider surgical referral]

M -->|NO| O[Esophageal Manometry<br/>if dysphagia present]

O --> P{Motility<br/>Disorder?}

P -->|YES| Q[Treat motility disorder:<br/>• Achalasia<br/>• Esophageal spasm<br/>• Other dysmotility]

P -->|NO| R[Step 5: Consider Alternative Dx:<br/>• Functional heartburn<br/>• H. pylori/PUD<br/>• Gallbladder disease<br/>• Cardiac causes<br/>• Eosinophilic esophagitis]

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style D fill:#ffebee
style G fill:#e8f5e9
style N fill:#e8f5e9
style C fill:#fff9c4
style F fill:#fff9c4
style M fill:#fff9c4
style P fill:#fff9c4

 

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1: Initial Clinical Assessment

• History

  • Classic symptoms: burning retrosternal pain, regurgitation, worse after meals/lying down, better with antacids.

  • Alarm symptoms: dysphagia, odynophagia, GI bleeding, anemia, weight loss, persistent vomiting.

• Physical Exam

  • Often normal, but helps exclude abdominal tenderness, signs of anemia, or other pathology.

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Step 2: Empiric Therapy (First-line)

• In patients without alarm symptoms, start a proton pump inhibitor (PPI) trial for 4–8 weeks.

  • Improvement → Diagnosis of GERD is likely.

  • No improvement → Further work-up needed.

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Step 3: Endoscopy (EGD)

• Indications:

  • Alarm symptoms.

  • Age > 50 with new symptoms.

  • Refractory symptoms after PPI trial.

• Findings:

  • Esophagitis, peptic stricture, Barrett’s esophagus, malignancy.

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Step 4: Physiologic Testing

If endoscopy is normal but symptoms persist:

1. Ambulatory 24-hour pH monitoring (± impedance testing):

   • Gold standard for diagnosing pathological acid reflux.

   • Can distinguish acid vs non-acid reflux.

2. Esophageal manometry:

   • Evaluates for motility disorders (achalasia, spasm) if dysphagia or non-reflux etiology suspected.

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Step 5: Rule Out Other Causes

• Peptic ulcer disease (H. pylori testing, endoscopy).

• Gallbladder disease (ultrasound, LFTs).

• Cardiac causes if atypical chest pain, especially in high-risk patients (ECG, stress test).

• Functional heartburn – diagnosis of exclusion if tests are negative.

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✅ Summary Flowchart:

1. Heartburn symptoms → Check for alarm features.

   • If present → Endoscopy immediately.

   • If absent → PPI trial.

2. Improves → GERD likely.

3. No improvement → Endoscopy.

   • If abnormal → Treat based on findings.

   • If normal → pH monitoring ± manometry.

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Would you like me to make this into a visual flowchart diagram (easy to follow for teaching or clinical use)?

 

Differential Diagnosis

Gastroesophageal Reflux Disease, Esophagitis, pill esophagitis, eosinophilic esophagitis,  reflux hypersensitivity or functional heartburn, peptic ulcer disease

Pivotal Assessment	Findings
History	Gnawing, burning discomfort (dyspepsia) relieved by intake of certain foods or liquids (eg, ice cream, milk) or antacids	Regurgitation