Heartburn Diagnosis

Medical Author: Jay W. Marks, M.D.

It happens about once a week. A patient arrives in the office, referred by his or her doctor for esophageal acid testing. The patient has had what he or she calls "heartburn" (the main symptom of acid reflux, or GERD, gastroesophageal reflux) for years and has been taking prescription medication for acid reflux once and sometimes twice a day. How much is the medication helping? Not a lot, maybe 25%. Nevertheless, the patient's been faithful about taking the medicine for the last two years......at no small expense. I proceed with the testing. I put the tiny catheter down into the patient's esophagus, attach it to the recorder, and begin measuring the acid that is refluxing (or backwashing) into the esophagus. The patient leaves the office and comes back the next day when I remove the catheter and calculate the amount of acid that is refluxing. There is none.

Why, then, is the patient having heartburn? In fact, he or she is not. There is some cause for the discomfort other than acid reflux. All along the patient mistakenly thought that the discomfort was due to acid reflux. So has the doctor. Why wasn't more attention paid to the fact that the "heartburn" did not improve much with what should have been appropriate and effective medication? Why did it take two years to realize that acid reflux was not the problem? I never know for sure. All I can say is that there has been a lot of unnecessary expense buying the prescribed medication and a delay in diagnosing and treating the true cause of the symptoms. Fortunately for the patient, the medicines that are taken for heartburn are very safe, so there was only a small chance of a serious side effect from the unnecessary drug.

When medication is not helping, there are two possible explanations. Either the medication is not doing what it should, or the diagnosis is incorrect. Often enough, as in patient's like this one, there are means of determining which is the correct explanation. If the medication is not doing what it should, it needs to be changed. If the diagnosis is incorrect, a correct diagnosis needs to be sought. This is a simple principle, but it often is forgotten.

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