Heartburn & Dyspesia

Be able to take a detailed history using QuEST & SCHOLAR-MAC

Use QuEST (Quickly assess, Establish self-care appropriateness, Suggest care, Talk) and SCHOLAR-MAC (Symptoms, Characteristics, History, Onset, Location, Aggravating factors, Remitting factors, Medications, Allergies, Conditions) to determine severity, frequency, alarm symptoms, triggers, and whether the patient can self-treat.

Etiology of heartburn

Heartburn is caused by reflux of acidic gastric contents due to transient LES relaxation; triggered by foods (spicy, fatty, caffeine), lifestyle (lying down after meals, obesity), medications (NSAIDs, CCBs), pregnancy, and diseases like motility disorders.

Clinical presentation of heartburn

Burning sensation behind breastbone rising toward throat, occurring within 1 hour after eating; episodic (<2 days/wk), frequent (≥2 days/wk), or persistent (≥3 months). Alarm symptoms: dysphagia, odynophagia, bleeding, weight loss, choking.

Etiology of dyspepsia

Dyspepsia is caused by food, caffeine, alcohol, stress, smoking, NSAIDs, bisphosphonates, iron/potassium supplements, and underlying conditions such as GERD, PUD, gastric cancer, or GI dysmotility.

Clinical presentation of dyspepsia

Epigastric burning or pain with postprandial fullness, early satiety, bloating, nausea, vomiting, or belching.

Risk factors for heartburn and dyspepsia

Dietary triggers (fatty foods, chocolate, caffeine, citrus, alcohol), lifestyle (smoking, obesity, stress, lying down after eating), medications (NSAIDs, bisphosphonates, doxycycline, iron, potassium), and conditions like pregnancy or motility disorders.

Exclusions for self-treatment

Frequent heartburn ≥3 months, severe or nocturnal symptoms, alarm symptoms (GI bleeding, dysphagia, odynophagia), black tarry stools, persistent/worsening symptoms despite therapy, chronic cough/hoarseness, children <2 for antacids, <12 for H2RAs, <18 for PPIs.

Non-pharmacologic treatment recommendations

Weight loss, avoid trigger foods, smaller meals, avoid lying down for 3 hours after eating, elevate head of bed, avoid tight clothing, limit alcohol/caffeine, quit smoking, and review medications that worsen symptoms.

Role of antacids

Antacids provide rapid onset (<5 min) and short relief (20–30 min). Used for mild, infrequent heartburn. Include calcium carbonate (Tums), magnesium hydroxide (Milk of Magnesia), aluminum hydroxide (Maalox), alginates (Gaviscon).

Drugs classified as antacids (examples)

Tums (calcium carbonate), Rolaids (calcium carbonate + magnesium hydroxide), Maalox (aluminum hydroxide + magnesium hydroxide), Mylanta (aluminum + magnesium), Gaviscon (alginate + antacid), Alka-Seltzer (sodium bicarbonate).

Role of H2-receptor antagonists

H2RAs reduce gastric acid secretion; good for mild-to-moderate, infrequent heartburn; onset 30–45 minutes, duration 4–10 hours. Helpful when antacids do not provide enough relief. Can be combined with antacids.

Drugs classified as H2RAs (examples)

Famotidine (Pepcid), Cimetidine (Tagamet), Nizatidine (Axid). Ranitidine (Zantac) was removed from the market due to NDMA contamination.

Role of proton pump inhibitors (PPIs)

PPIs inhibit H+/K+ ATPase and are the most potent acid-suppressing drugs. Best for frequent heartburn (≥2 days/week) or GERD. Take 30 minutes before breakfast; full effect 1–4 days. Should not be used >14 days without provider oversight.

Drugs classified as PPIs (examples)

Omeprazole (Prilosec OTC), Esomeprazole (Nexium 24HR), Lansoprazole (Prevacid 24HR), Omeprazole/sodium bicarbonate (Zegerid OTC), Dexlansoprazole (Rx).

Onset and duration of antacids, H2RAs, PPIs

Antacids: fastest onset (<5 min), short duration (20–30 min). H2RAs: onset 30–45 min, duration 4–10 hours. PPIs: slow onset (2–3 hrs), full relief may take 1–4 days, duration 12–24 hours.

Side effects of antacids

Calcium or aluminum cause constipation; magnesium causes diarrhea; sodium bicarbonate can cause fluid retention and is avoided in CHF/HTN. All antacids can interact with medications like tetracyclines, iron, and quinolones.

Counseling for PPIs

Take 30 minutes before breakfast; do not crush or chew; may take several days for full effect; limit to 14-day course; avoid repeat courses more frequently than every 4 months unless instructed by a provider.

Common lifestyle triggers for heartburn

Fatty foods, chocolate, peppermint, caffeine, alcohol, spicy foods, citrus, tomatoes, carbonated beverages, large meals, lying down after eating.

Medications that worsen heartburn

NSAIDs, aspirin, bisphosphonates, tetracyclines, doxycycline, iron supplements, potassium, CCBs, estrogen, TCAs, zidovudine.

Goals of treatment

Reduce symptoms, decrease recurrence, heal esophageal mucosa, and prevent complications such as strictures, Barrett’s esophagus, and esophageal cancer.

Treatment approach

Mild intermittent symptoms → antacids or H2RA. Frequent symptoms → PPI daily. Persistent GERD → PPI maintenance therapy. Non-responders or patients with alarm symptoms → refer.

Follow-up recommendations

Refer if symptoms worsen during treatment, persist after 2 weeks of OTC PPI, or if alarm symptoms develop. Patients using antacids >2× weekly should switch to H2RA or PPI.