Esophageal symptom assessment

Typical symptoms

Heartburn (pyrosis) and acid regurgitation

Definition

Heartburn is a substernal burning sensation, usually occurring from 30 minutes to 2 hours post-prandial, that can radiate up to the neck and throat. Heartburn is usually worsened by lying down and bending over, and can awaken patients from sleep. Large meals before sleeping are associated with heartburn. Certain foods (alcohol, caffeine, coffee, chocolate, peppermint, tomatoes), as well as cigarettes and medications are also associated with an increased risk of heartburn. Symptoms are usually improved with antacids. Heartburn is extremely prevalent, and occurs in up to 33% of Americans on a monthly basis.

Acid regurgitation occurs when a small amount of acidic or bitter fluid that appears spontaneously and effortlessly in the back of the throat or mouth. It is most common after meals, but it can also awaken patients from sleep and can be associated with coughing or choking. It is separated from ‘vomiting’ by an absence of retching and associated nausea.

Diagnosis

These are the classic symptoms of GERD and, in the absence of warning signs (GI bleeding, weight loss, iron deficiency anemia, dysphagia), empiric therapy with acidsuppressive agents can be instituted. If symptoms do not improve after a sufficient trial (up to 12 weeks), or warning signs are present, further investigation is warranted. Upper endoscopy is often the first diagnostic test in the presence of warning signs, and pH monitoring is useful in associating symptoms with increased intraesophageal acid exposure.

Non-acid regurgitation

Definition

Non-acid regurgitation is described as food or fluid being present in the mouth without a recognized associated ‘vomiting’ episode. The food seems to effortlessly appear in the mouth.

Etiology

The contents that appear in the mouth can be undigested food, which is almost always associated with esophageal obstruction of some degree. This can be seen in association with strictures, rings, achalasia, or a pharyngeal pouch.

Water brash

Definition

Water brash is defined as a sudden filling of the mouth with a large amount of fluid, that is often clear and salty in taste.

Etiology

This is caused by a reflex secretion (cholinergic) from salivary glands in the mouth, in response to stimulation from distal esophageal acid irritation. Water brash is often associated with GERD, especially if acid regurgitation and heartburn are present.

Atypical symptoms

Globus

Definition

The globus sensation is defined as the feeling of fullness, or a lump in the throat. Patients may also describe a ‘tickling’ sensation in their throat. Globus is often a constant symptom, and may improve with swallowing.

Etiology

If pharyngeal, laryngeal, and neck physical and mechanical etiologies are excluded, globus can be associated with multiple esophageal etiologies. Possibilities include – hypertensive UES, altered visceral sensation, GERD, webs, diverticula, and dysmotility disorders (achalasia, ineffective esophageal motility).

Chest pain

Chest pain, often qualitatively similar to ischemic chest pain, can be secondary to an esophageal abnormality. This is due to a shared embryologic sensory innervation. As this symptom mimics the pain of myocardial ischemia, all evaluations must first definitively rule out a cardiac etiology. Like ischemic chest pain, it may be relieved by nitroglycerin. Esophageal chest pain is classically non-exertional, and can be spontaneous, post-prandial, or occur at night. Symptoms may last for minutes to hours. It is often associated with other esophageal symptoms, such as heartburn, regurgitation, and dysphagia. If thought to be non-cardiac, this chest pain is often secondary to an abnormal visceral nociception, an esophageal motor disorder, or GERD.

Respiratory

Multiple respiratory symptoms, such as asthma, bronchitis, and cough, have been associated with GERD. These symptoms may be due to GERD as well as oropharyngeal swallowing disorders. Continued acidic aspiration can lead to coughing, throat clearing, and hoarseness. Patients may also present with pneumonia from aspiration of gastric contents.

Hiccup

Definition

An acute, involuntary lowering of diaphragm with glottis closure – produces a characteristic sound.

Etiology

Uremia, reflux, obstruction (achalasia or stricture).

Odynophagia

Definition

The symptom of odynophagia is best defined as the sensation of pain with swallowing. This symptom is strongly associated with an esophageal or pharyngeal abnormality, and is produced from local inflammation or neoplasm in the mouth and pharynx. The symptom is described as burning or pain after swallowing, and can be associated with acidic, spicy, or hot or cold food.

Etiology

Odynophagia is most often associated with erosive esophagitis of any etiology – pill-induced, infectious (CMV, HSV, Candida sp.), acid related, radiation, or caustic injury, and is commonly seen in patients with AIDS and patients undergoing chemotherapy. When severe, cessation of swallowing may occur.

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