Modern concepts of heartburn pathogenesis

Heartburn is one of the most widely spread symptoms particularly in population of economically developed Western countries. Traditionally it is considered to be related to activation of chemo- and mechanoreceptors of esophageal primary sensory neurons. Repeated stimulation may provoke visceral sensitization. Its development is facilitated by the stress hormone corticotropin-releasing factor. An attentive analysis of heartburn with an assessment of the provoking factors and effectiveness of drug therapy is required for differentiation of gastro-intestinal reflux disease and functional esophageal disease. The lack of response to proton pump inhibitors is an important criterion for suspicion on functional esophageal pathology although sensitization also plays an important role in genesis of heartburn in non-erosive reflux disease. In cases of refractory and «endoscopically negative heartburn», additional studies are justified: endoscopy with esophageal biopsies, 24h-pH-metry/pH-impedansometry, high-resolution manometry. Proton pump inhibitors, highly effective in reflux disease, may relieve heartburn only in some cases of functional heartburn and reflux hypersensitivity. In functional diseases medical therapy affecting visceral hypersensitivity may be used empirically.