About the Diagnosis and Management of Functional Heartburn: Heartburn and Oesophageal Motility Disorders.

Abstract

To the Editor: We read with interest the clinical and systematic review on diagnosis and management of functional heartburn by Christine Hachem and Nicholas J. Shaheen (1). Authors have done a remarkable job that help readers to enter patients in correct categories of disease, despite the confusing nature of the topic. In a pathophysiological point of view they highlighted how patients with functional heartburn do not have acid-mediated symptoms, differentiating them from those with oesophageal hypersensitivity because of the absence of correlation between reflux events and symptoms. They evoked different mechanism as heightened sensitivity of mechano-receptors and chemoreceptors or alteration of central visceral afferent sensitization. Authors also reported that there is no consensus on the diagnostic criteria for pH-impedance testing in functional heartburn patients and that the value of oesophageal motility testing is similarly unclear, suggesting that the interpretation of these studies is limited. We believe that this is a very interesting point of discussion and, about that, we would add some comments suggested by the lesson learned with bariatric surgery. Some restrictive bariatric procedures such as adjustable gastric banding represent unintentionally an experimental model because of the modification induced in oesophageal motility makes these patients at higher risk for developing oesophageal motility disorders. These abnormalities are frequently related to heartburn and are often reversible after desufflation of the banding but they may be also permanent (2). Sometimes they are similar to those reported for acalasia but can also be minimal and non-specific. Consequently, the oesophago-gastric junction plays as a very sensitive anatomical region and, in a similar manner, we are encouraged to think that FH could be mostly related to a disfunction of the oesophago-gastric junction rather than a psychological disorder. Nevertheless, with actual functional tests, we are not capable of interpreting minimal motility disorders, because of their low sensitivity. Moreover, considering that obese patients are at higher risk for gastroesophageal reflux disease (refs 3, 4) and given the lack of evidence on the impact of lifestyle, body mass index, eating behaviour, and weight loss on FH, it seems a priority to investigate these aspects as possible factors acting in the manifestation of symptoms. On this point of view a large population-based study seems appropriate, with the aims to detect the real incidence of such variables and its correlation with FH, which we believe underestimated. If these factors may be able to cause dysfunction of oesophago-gastric junction is an interesting question to answer.