How to diagnose and manage adults with functional heartburn: C Hachem, NJ Shaheen Am J Gastroenterol 2016; 111-53-61 (thanks to Ben Gold for reference).

Functional heartburn is defined as chronic symptoms of heartburn without objective evidence of reflux.  The authors algorithm (Figure 2) recommends endoscopy for patients who have had heartburn that is unresponsive to a 2 month trial of PPI.  If endoscopy is normal, pH-impedance study is recommended.  If abnormal, impedance indicates nonerosive reflux disease.  If normal and there is symptom correlation, this suggests esophageal hypersensitivity.  If normal and there is no symptom correlation, this suggests functional heartburn (though authors note a role for motility testing in this circumstance in their algorithm).

Their conclusions:

• Functional heartburn (FH) responds poorly to PPI therapy
• The pathophysiology of FH is unknown but it is often associated with visceral hypersensitivity
• Modulation of pain perception and alternative therapies (melatonin, TCA, SSRI, biofeedback, acupuncture, or hypnotherapy) may be helpful

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• Why didn’t patient with documented reflux get better with PPI …
• Failure of PPI test | gutsandgrowth
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