Heartburn and Regurgitation

Heartburn and regurgitation are two of the most common symptoms experienced by patients. Heartburn is usually characterized as a burning substernal or epigastric discomfort which radiates towards the mouth. Regurgitation refers to reflux of food or bitter-tasting gastric contents from the stomach into the mouth. In this review, gastroesophageal reflux disease (GERD) refers to any clinically-significant symptomatic condition or histopathologic alteration presumed to be secondary to reflux of gastric contents into more proximal structures. The more restricted term reflux esophagitis refers to the situation where histopathologic changes in the esophageal mucosa thought secondary to reflux are present. Since the correlation between gastroesophageal reflux symptoms and histologic changes or complications is imperfect, many patients will have gastroesophageal reflux disease without evidence of reflux esophagitis.

MESH search strings used in this review include GASTROESOPHAGEAL-REFLUX, HEARTBURN, and REGURGITATION. These search strings were used in a search of Medline for years 1990-2000. Certain articles prior to 1990, and other recent published guidelines concerning this topic have also been reviewed (1, 2, 3, 4, 5, 6, 7, 8). This chapter will review the current literature available relating to the evaluation and management of adult patients with heartburn and regurgitation and formulate a management strategy based on these available data. 2.0. Epidemiology Heartburn and regurgitation clearly are exceedingly common symptoms. Approximately 7-10% of Americans experience heartburn every day and 40% every month (9, 10). Heartburn was listed as the primary or secondary reason for 2.5 million office visits in 1985 in the U.S, and the cost of treating patients with esophagitis (a subset of patients with GERD) was estimated to be 1 billion dollars in 1985 (11). Omeprazole and ranitidine, two of the medications used to treat GERD, are among the most prescribed drugs in the world. Although gastroesophageal reflux is a spectrum of disease and may occur in healthy adults without adverse clinical consequences, patients who complain of heartburn or regurgitation to their primary care provider or who take medication regularly for these symptoms generally are diagnosed with gastroesophageal reflux disease (GERD). Limited data are available concerning the percentage of patients seeking medical attention for their symptoms of heartburn or regurgitation. In a 1988 Gallup survey of Americans, more than 40% of adults took antacids for their heartburn, and 25% sought medical attention from their physicians (12). The percentage of patients with GERD referred to subspecialists is not known. In terms of mucosal damage to the esophagus, a 3-4% prevalence of esophagitis exists in the general population (13), with 65 to 97% of these patients having mild or moderate esophagitis (14). As heartburn and regurgitation rarely cause hospital admission or death, most epidemiologic data concerning these symptoms are obtained by questionnaire studies with their inherent inaccuracies.