The Diagnosis and Management of Patients With Functional Heartburn

In this podcast, Craig Zalvan, MD, talks about the diagnosis and management of patients with functional heartburn, including what treatment options are available and what lifestyle modifications can be made to help improve symptoms of functional heartburn.

Craig Zalvan, MD, is the medical director of the Institute for Voice and Swallowing Disorders, the chief of the Otolaryngology Department at Phelps Hospital, and a member of the Voice and Swallowing Team at ENT and Allergy Associates. Dr Zalvan is based in Sleepy Hollow, New York.

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Jessica Bard: Hello everyone and welcome to another installment of "Podcasts360," your go‑to resource for medical news and clinical updates. I'm your moderator Jessica Bard, with Consultant360 Specialty Network.

According to the American Gastroenterological Association, functional heartburn is recognized as a separate entity in the GERD spectrum of disorders. There are several lifestyle modifications that can help improve the symptoms of functional heartburn. Dr Craig Zalvan is here to speak with us about that today.

Dr Zalvan is the medical director of the Institute for Voice and Swallowing Disorders, the chief of the Otolaryngology Department at Phelps Hospital and a member of the Voice and Swallowing team at ENT and Allergy Associates. He's based in Sleepy Hollow, New York.

Thank you for joining us today, Dr Zalvan. When should a diagnosis of functional heartburn be considered?

Dr Craig Zalvan: First of all, let's just define what heartburn is. It's a typical symptom that patients often complain about, and it is occurring almost always in the setting of people with gastroesophageal disease or GERD.

GERD results with acid refluxing up into the esophagus, which can lead to chronic inflammation, irritation and a host of symptoms, which include heartburn, indigestion, early satiety, bloating and abdominal discomfort. Heartburn itself is that feeling of burning or discomfort that is typically mid‑chest, retrosternal, adjacent to the area of the heart, thus the name.

We also know some people continue to have reflux and symptoms of burning that go up into the throat or laryngopharynx. These can be associated with a sour taste, lump in the throat feeling, trouble swallowing, voice changes and a chronic recurring cough, especially coughing at night. This is termed laryngopharyngeal reflux.

Functional heartburn refers to the sensation of burning and discomfort, typically in the upper chest or upper abdominal area, which occurs in the absence of true acid reflux events from the stomach. If pH testing or intraluminal impedance pH testing is performed, there are no acid events that correlate with these symptoms. Thus, a very low correlation in acid exposure.

This is a true functional heartburn that occurs in the absence of true acid presence. Whereas reflexive hypersensitivity is similar in that the symptoms of this burning sensation are present, and there is acid but acid at the normal level. There's no exaggerated amounts or pathological acid present.

Typically, both reflexive hypersensitivity as well as functional heartburn do not respond to the typical GERD treatment. We know that people with functional heartburn are typically treated for months, or even years, with the standard treatments of acid suppression using H2 blockers and, more commonly now, proton‑pump inhibitors.

Some people do have some slight improvements, but often those symptoms typically remain, despite any attempt of treatment. Many of these people do undergo further testing such as upper endoscopy. Often the findings are normal or near‑normal and certainly don't correlate with the severity of patient symptoms.

In addition, there can be similar sensory changes that occur in the laryngopharynx. Often, people complain of that same burning sensation they have in the chest, up in the laryngopharyngeal area, and again in the absence of true reflux events.

All of these symptoms of reflexive hypersensitivity and functional heartburn are really part of a spectrum of hypersensitivity, because of vagal neuropathy or changes of the vagus nerve, which lead to the sensation that is exaggerated beyond the exposure of any acid events that occur.

Not only are there sensory issues that occur with vagal neuropathy, there can also be motor events that occur as well. We often see vocal fold paresis, asymmetric vocal fold vibration, and esophageal dysmotility.

JB: That's a great segue for the next question. How should a patient with functional heartburn be managed?

Dr Zalvan: I think management of the symptoms really does begin with a full work‑up. We need to ensure that there are no other abnormalities of the esophagus, both luminal and extra‑luminal.

This includes an upper endoscopy and, in many cases, acid testing, especially when patients have failed to improve at their symptoms despite what we think is an adequate treatment of acid suppression. Similarly, patients with ongoing throat clearing, burning in the throat and swallowing issues, as well as recurrent sore throats, should be seen by a laryngologist.

We need to ensure that there are also no other abnormalities of the anatomy of the laryngopharynx, and also to rule out other disease processes often confused for laryngopharyngeal reflux disease such as allergy, sinus disease, and even asthma.

We can also do acid testing of the oropharynx itself, again, to demonstrate correlation of symptoms with the presence or absence of acid or pathological acid. Once the anatomy and function of the throat and the esophagus have been evaluated, and found to not have significant acid exposure, management really is based on a constellation of various approaches.

I will argue that I believe the dietary approach is by far the most important. We'd need to remove certain triggers that can set off or exacerbate these symptoms, and in some cases, move forward with neuromodulating medications that help to dampen down the sensitivity of the nervous system, primarily the vagus nerve, to decrease the symptoms the patients are feeling.

JB: What treatment options are available for patients with functional heartburn?

Dr Zalvan: Again, going back to the basics, I believe removing triggers is very important. There are clearly certain foods, there are certain activities, certain environmental exposures that often exacerbate patient symptoms. Not only they are functional heartburn or reflexive heartburn symptoms, but also their laryngopharyngeal symptoms.

For instance, nasal drainage can be a trigger, not often the cause of throat clearing or globus sensation. By decreasing some of that drainage, we can remove that trigger. Dietary changes, which are often either briefly discussed or ignored altogether, are the single most important factor in, not only symptom suppression, but also cure of the disease or reflux itself.

We can also use a variety of different mucosal protectants. I personally use a lot of alginate therapy, which is very safe to use, low side effects, and by coating the throat and the esophagus, you create a barrier that acid can bind, and decrease inflammation of the mucosa and irritation of the mucosa.

I also use a lot of alkaline water. This is high pH water which, for laryngopharyngeal reflux disease, helps to minimize acid exposure, neutralize some of the acid, and also can irreversibly denature pepsin, which is one of the major factors causing laryngopharyngeal disease.

Medications can be utilized for functional heartburn that help suppress that hypersensitive state of the vagus nerve. These neuromodulating medications certainly have to be discussed in the context of their side effects, which include many issues such as fatigue, dryness, urinary and visual problems, sleep, sexual and cognitive dysfunctions.

It's this risk‑benefit calculation that we need to make for patients that are having these symptoms, versus the side effects that some of these medications can provide.

JB: Let's talk about improving symptoms of functional heartburn. What lifestyle modifications can be made to help improve symptoms of functional heartburn?

Dr Zalvan: I'm glad you asked that question because, frankly, I believe this is the most important place that we, as physicians, can intervene to help improve patients with reflux, whether it's a true reflux event, laryngopharyngeal reflux, GERD, or any other functional reflux events.

Diet, by far, is the most important factor, and as I said earlier, this is often what we gloss over in a five‑second conversation, or even ignore altogether. We know that there are many common triggers that have really been studied extensively in the GERD literature. This includes coffee, tea, chocolate, soda, greasy food, fried food, fatty food, spicy food, alcohol.

I don't think these are actual causes of reflux disease. They are really triggers. They do increase the amount of acid exposure, they do increase the amount of reflux events. The cause itself is ultimately in our diet.

In addition to avoiding those triggers, like I said earlier, the use of alkaline water and mucosal protection agents are very important, but the primary way that we can prevent and reverse reflux disease, both GERD and laryngopharyngeal reflux, is by changing our American diet.

By switching to a mostly plant‑based, Mediterranean‑style diet, 90 to 95 percent fruits, vegetables, grains, and nuts, and really trying to limit the animal protein content, including dairy, to three to four times a week, three to four ounces, which equates to about 5 to 10 percent of your diet.

This approach, we've shown, and others have shown as well, decreases the acid production in the reflux events. By decreasing acid exposure, you're going to decrease the symptoms. In addition, there's clear evidence that switching to the more Mediterranean style diet is protective against heart disease, diabetes, stroke, and even cancer.

JB: Anti‑reflux surgery or endoscopic treatment for GERD should be avoided in patients with functional heartburn. Can you explain why?

Dr Zalvan: It's a great question. Many people who have these chronic symptoms are often desperate, and try many different approaches which often do include both endoscopic interventions, for tightening of the lower esophageal sphincter, and also anti‑reflux surgery, laparoscopic fundoplications.

In the patients that have persistent symptoms and truly have acid exposure, these types of interventions can be very helpful to decrease the acid exposure time and thus symptom correlation. Those with functional heartburn are having symptoms, not because of true acid events.

These are because of sensory changes that have occurred, with hypersensitivity as the primary etiology due to vagal neuropathy. Therefore, doing some type of endoscopic procedure or laparoscopic procedure to create more of a barrier isn't going to decrease the symptoms because we're not decreasing acid exposure.

It can be somewhat helpful for those that have more of a reflexive hypersensitivity, because they are having symptoms due to normal acid exposure, and therefore decreasing even normal amounts of acid maybe helpful. The problem is picking and choosing which patient will respond. Unless the patient has documented significant acid exposure time, then I advise against these types of procedures.

JB: I want to thank you so much for joining us today. Is there anything else that you'd like to add that you think we should touch on today?

Dr Zalvan: The most important thing in dealing with patients with chronic reflux disease, who are not responding either to the treatments you're giving, or at least responding to the way that you would like or the patients would like, we have to keep in mind that there are other possibilities.

There are whole host of symptoms that are sensory related. These include throat‑related symptoms such as the burning, throat clearing, and globus sensation, as well as functional heartburn and indigestion, bloating and satiety, which can all be because of nerve‑based disease.

It's come to light that we now are very aware that viruses can cause nerve dysfunction, COVID with loss of smell and taste. Patients are now quite aware of this role viruses can have. We've known for many years that viruses can affect that vagal nerve function.

For patients that have ongoing persistent disease, I think it's time to start opening up our horizons and realize that we can intervene by decreasing triggers, and intervene with neuromodulating medications to help minimize the symptoms these patients are having.

JB: Thank you again for joining us on the podcast today. We really do appreciate your time and thanks for being here.

Dr Zalvan: Jessica, thank you very much for having me and hosting me today.