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Pyrosis

Heartburn or pyrosis is a painful or burning sensation in the esophagus, just below the breastbone caused by regurgitation of gastric acid. The pain often rises in the chest and may radiate to the neck or throat. more...

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Medicines

Heartburn is also identified as one of the causes of asthma and chronic cough.

Pathophysiology

The sensation of heartburn is caused by exposure of the lower esophagus to the acidic contents of the stomach. Normally, the lower esophageal sphincter (LES) separating the stomach from the esophagus is supposed to contract to prevent this situation. If the sphincter relaxes for any reason (as normally occurs during swallowing), stomach contents, mixed with gastric acid, can return into the esophagus. This return is also known as reflux, and may progress to gastroesophageal reflux disease (GERD) if it occurs frequently. Peristalsis, the rhythmic wave of muscular contraction in the esophagus, normally moves food down and past the LES and is responsible for ultimately clearing refluxed stomach contents. In addition, gastric acid can be neutralized by buffers present in saliva.

Causes

Foods that may cause Heartburn:

  • Alcohol
  • Coffee, tea, cola, and other caffeinated and carbonated beverages
  • Chocolate
  • Citrus fruits and juices
  • Tomatoes and tomato sauces (such as pizza and pasta sauce)
  • Spicy foods and fatty foods (including full-fat dairy products)
  • Peppermint and spearmint
  • Dry fruits such as peanuts

Diagnosis

Physicians typically diagnose gastroesophageal reflux disease (GERD) based on symptoms alone. When the clinical presentation is unclear, other tests can be performed to confirm the diagnosis or exclude other disorders. Confirmatory tests include:

Ambulatory pH Monitoring

A probe can be placed via the nose into the esophagus to record the level of acidity in the lower esophagus. Because some degree of variation in acidity is normal, and small reflux events are relatively common, such monitors must be left in place for at least a 24-hour period to confirm the diagnosis of GERD. The test is particularly useful when the patient's symptoms can be correlated to episodes of increased esophageal acidity.

Upper Gastrointestinal (GI) Series

A series of x-rays of the upper digestive system are taken after drinking a barium solution. These can demonstrate reflux of barium into the esophagus, which suggests the possibility of gastroesophageal reflux disease. More accurately, fluoroscopy can be used to document reflux in real-time.

Manometry

In this test, a pressure sensor (manometer) is passed through the mouth into the esophagus and measures the pressure of the lower esophageal sphincter directly.

Endoscopy

The esophageal mucosa can be visualized directly by passing a thin, lighted tube with a tiny camera attached (an endoscope) through the mouth to examine the esophagus and stomach. In this way, evidence of esophageal inflammation can be detected, and biopsies taken if necessary.

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Eosinophilic esophagitis
From Ear, Nose & Throat Journal, 10/1/05 by S. Punjab Gupta

Most cases of eosinophilic esophagitis involve young children who present with epigastric pain, regurgitation, and/or vomiting. When it affects adolescents and adults, presenting features are more often dysphagia or food impaction. Male sex, a positive skin-prick or radioallergosorbent test (RAST), and the presence of other atopic diseases are correlated with eosinophilic esophagitis. In most patients, findings on 24-hour pH monitoring are normal. Endoscopic abnormalities--including furrows, vertical lines in the mucosa, rings, adherent whitish plaques, microabscesses, and/or "crepe-paper" mucosa--are very common. Histology is diagnostic when the eosinophil infiltration is greater than 20 eosinophils per high-power field (HPF) in the squamous epithelium. In reflux esophagitis, eosinophilic infiltration is less than 10 eosinophils/HPF.

The etiology of eosinophilic esophagitis is unclear, but it appears that it is the result of an eosinophil-associated inflammation of epithelia, similar to that seen in bronchial asthma and atopic dermatitis. Food antigens and aeroallergens likely play a role in its pathogenesis.

Eosinophilic esophagitis can be treated with inhaled aerosolized steroids, systemic steroids, and leukotriene receptor antagonists, as well as by following an elimination/elemental diet.

We describe 2 cases of eosinophilic esophagitis that were atypical in that they occurred in an adult male and a teenage boy.

Case reports

Patient 1. A 34-year-old man presented with a 4-month history of progressive dysphagia, which was worse with solids than liquids, and a 9-lb weight loss. His medical history included intermittent pyrosis and seasonal allergies. A fiberoptic endoscopic evaluation of his swallowing revealed that the oral and oropharyngeal phases of deglutition were normal. An unsedated transnasal esophagoscopy revealed a corrugated, ringed ("trachealized") esophagus and diminished motility (figure 1). A biopsy of the friable mucosa revealed more than 20 intraepithelial eosinophils/HPF. The patient was treated with a proton-pump inhibitor and oral fluticasone for 6 weeks, and his dysphagia resolved completely.

[FIGURE 1 OMITTED]

Patient 2. A 14-year-old boy with a l-year history of progressive dysphagia with solids complained of an inability to swallow his secretions alter he had eaten a chicken dinner. The patient had a lifelong history of asthma and allergic rhinitis. His father had also experienced several episodes of food impaction of unknown cause, for which he had been treated with esophageal dilation. The patient denied any weight loss or symptoms of gastroesophageal reflux disease or laryngopharyngeal reflux.

Endoscopy demonstrated a diffuse inflammation with linear furrows as well as friable mucosa and linear tears. After the food bolus was removed, biopsies were taken. Histology demonstrated abundant eosinophils (>20/HPF) with bright-red-staining cytoplasm surrounded by norreal-appearing squamous epithelium (figure 2). No other evidence of inflammation was noted. This patient was lost to follow-up.

[FIGURE 2 OMITTED]

Suggested reading

Arora AS, Yamazaki K. Eosinophilic esophagitis: Asthma of the esophagus? Clin Gastroenterol Hepatol 2004:2:523-30.

Liacouras C, Ruchelli E. Eosinophilic esophagitis. Curr Opin Pediatr 2004:16:560-6.

S. Punjab Gupta, MD; Daniel J. Kirse, MD; Gregory N. Postma, MD; Peter C. Belafsky, MD

From the Center for Voice and Swallowing Disorders of Wake Forest University. Winston-Salem, N.C.: www.wfubmc.edu/voice (Dr. Postma. Dr. Gupta, and Dr. Kirse): and the Department of Otolaryngology, University of California, Davis, School of Medicine (Dr. Belafsky).

COPYRIGHT 2005 Medquest Communications, LLC
COPYRIGHT 2005 Gale Group

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