Functional heartburn is a type of gastroesophageal reflux disease (GERD) where individuals experience heartburn symptoms. It does not include observable damage to the esophagus during endoscopy and abnormal acid exposure in the esophagus.

Heartburn is due to the reflux of stomach acid into the esophagus, a condition known as gastroesophageal reflux disease (GERD).

When the lower esophageal sphincter — the valve between the esophagus and stomach — either does not close properly or relaxes inappropriately, stomach contents can back up into the esophagus, causing irritation and the characteristic burning sensation.

Functional heartburn, on the other hand, displays similar symptoms but without the stomach acid in the esophagus.

This article looks at what to know about functional heartburn, including symptoms, causes, and treatment.

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Key features of functional heartburn include:

  • Burning sensation in the chest: The most common symptom is a burning feeling in the chest, often behind the breastbone. This sensation can vary in intensity and might be mistaken for typical heartburn.
  • Chest discomfort that may radiate: The discomfort is usually located in the central part of the chest, and it might radiate to the neck, throat, or jaw in some cases.
  • No correlation with acid reflux: Unlike typical GERD, functional heartburn does not show a clear relationship with acid reflux events. Symptoms can occur even in the absence of acid reflux.
  • Symptoms that persist despite acid-suppression therapy: People with functional heartburn often do not respond to medications that reduce stomach acid, such as proton pump inhibitors (PPIs).
  • No esophageal damage: Endoscopic examinations typically do not reveal damage to the esophagus, which is often seen in traditional GERD cases.
  • Absence of dysphagia: Unlike some cases of GERD, functional heartburn usually does not include difficulty swallowing (dysphagia).

Functional heartburn may co-occur with other functional gastrointestinal (GI) disorders, such as irritable bowel syndrome (IBS).

Functional heartburn is a condition that arises from the esophagus’s hypersensitivity or a nonacid-related mechanism.

While the exact causes are not entirely understood, experts believe that several factors may contribute to its development:

  • Esophageal hypersensitivity: Esophageal hypersensitivity may be the primary factor. In functional heartburn, the esophagus may be overly sensitive to stimuli, leading to the sensation of heartburn even in the absence of significant acid reflux or esophageal damage.
  • Psychological factors: Stress, anxiety, and depression often have an association with functional GI disorders, including functional heartburn. These psychological factors can exacerbate the perception of pain and discomfort.
  • Abnormal esophageal motility: Although not always present, abnormalities in the movement of the esophagus might contribute to symptoms.
  • Microscopic inflammation: In some cases, microscopic changes in the esophageal lining, not visible in standard endoscopic examinations, might play a role.
  • Nonacid reflux: Reflux of nonacidic stomach contents into the esophagus might cause symptoms similar to acid reflux, leading to functional heartburn.
  • Central sensitization: Changes in the way the central nervous system processes pain can lead to an increased sensitivity to pain or discomfort in the esophagus.
  • Genetics: There might be a genetic predisposition to functional GI disorders, including functional heartburn, although this area requires more research.
  • Diet and lifestyle: While not direct causes, certain dietary habits and lifestyle factors can exacerbate symptoms. These include the consumption of spicy foods, caffeine, and alcohol, along with smoking and taking certain medications.

The diagnostic process for functional heartburn often involves a detailed medical history, physical examination, and possibly a series of diagnostic tests to rule out other causes of the symptoms.

The goal is to ensure that the symptoms are not due to acid reflux or other GI disorders and to identify functional heartburn as a distinct clinical entity. The process includes:

  • Medical history and physical examination: To rule out other causes and help understand symptom patterns.
  • Endoscopy: To inspect the esophagus for damage. In functional heartburn, the esophagus usually appears normal.
  • Esophageal pH monitoring: To measure acid levels in the esophagus. Normal acid levels can indicate functional heartburn.
  • Esophageal manometry: To evaluate the esophageal muscle function.

What are the criteria for functional heartburn?

The Rome IV criteria, which are widely used for diagnosing functional GI disorders, outline the following for functional heartburn:

  • Normal endoscopy results: An upper GI endoscopy (esophagogastroduodenoscopy or EGD) is usually normal, showing no evidence of esophageal damage that could be attributed to acid reflux, such as erosions or Barrett’s esophagus.
  • Normal esophageal acid exposure: Esophageal pH monitoring, which measures acid in the esophagus, should show normal acid exposure. This test helps rule out GERD, where abnormal acid reflux would be detected.
  • Exclusion of other causes: A doctor must rule out other potential causes of the symptoms, such as eosinophilic esophagitis, esophageal motility disorders, and psychological comorbidities.
  • Absence of major esophageal motor disorder: Esophageal manometry, if performed, should not show any major disorders of esophageal motility.
  • Duration of symptoms: The symptoms should be present for at least 6 months, with the onset of symptoms at least 3 months before diagnosis.

Treatment and management of functional heartburn includes the following:

  • Making dietary changes: Avoid foods and drinks that may trigger symptoms, such as spicy foods, caffeine, alcohol, and fatty foods.
  • Modifying eating habits: Eating smaller, more frequent meals and avoiding eating close to bedtime.
  • Managing weight: Maintain a moderate weight, as excess weight can increase abdominal pressure and exacerbate symptoms.
  • Avoiding tobacco: Quit or avoid smoking, as smoking can impair the function of the lower esophageal sphincter.
  • Taking pain modulators: Low-dose antidepressants, such as tricyclic antidepressants (TCAs) or selective serotonin reuptake inhibitors (SSRIs), can be used to modulate pain perception.
  • Taking prokinetics: In some cases, medications that enhance GI motility may be helpful.
  • Trying gut-directed hypnotherapy: This specialized form of hypnotherapy is designed to reduce the sensitivity of the gut nerves and can be effective in some functional GI disorders.

The outlook for people with functional heartburn can vary. Some individuals may find their symptoms easier to manage, while others may find it difficult to get effective relief.

Functional heartburn is typically a chronic condition. While it does not cause physical damage to the esophagus like traditional GERD, it can persist over time and may require ongoing management.

With appropriate treatment, including lifestyle modifications, medications, and psychological therapies, many individuals can achieve effective management of their symptoms. The effectiveness of treatment varies among individuals, and finding the right combination of therapies can take time.

While functional heartburn can be challenging and may affect quality of life, effective management can significantly reduce symptoms and improve overall well-being.

Unlike GERD, which can sometimes lead to complications such as Barrett’s esophagus and an increased risk of esophageal cancer, functional heartburn does not carry these risks, as it does not involve chronic acid damage to the esophagus.

Functional heartburn is characterized by symptoms similar to those of gastroesophageal reflux disease (GERD). However, it is distinct in that it does not show evidence of acid reflux or damage to the esophagus.

The primary symptom is a burning sensation in the chest, often resembling typical heartburn, yet without a clear association with acid reflux.

Management of functional heartburn includes lifestyle changes, medications, and treatment of any underlying psychological conditions.