EpistemisNocturnal heartburn
Specialty: Gastrointestinal.
Why it occurs
- Gastroesophageal reflux disease (GERD) with lower esophageal sphincter dysfunction that worsens in the supine position due to loss of gravity
- Large sliding hiatus hernia
- Delayed gastric emptying after heavy or fatty dinners
- Decrease in saliva production and esophageal peristaltic clearance during sleep.
Initial workup
Upper gastrointestinal endoscopy (EDA) to assess the presence of reflux esophagitis or Barrett's esophagus | 24-hour pH-metry with impedanciometry | High resolution esophageal manometry.
red flags
Persistent chronic cough or new-onset wheezing (suggestive of bronchial microaspiration), morning hoarseness (reflux laryngitis), progressive dysphagia, suffocation or waking up with a feeling of suffocation.
Standard management
- Proton pump inhibitors — esomeprazole 40 mg or pantoprazole 40 mg administered in the afternoon, 30-60 minutes before dinner
- Histamine H2 receptor antagonists — famotidine 20-40 mg at bedtime, added to PPI treatment to control histamine-mediated nocturnal acid escape, monitoring for the development of tachyphylaxis
- Sodium alginate plus potassium bicarbonate (10 ml at bedtime to form a protective physical barrier at the gastroesophageal junction).
Educational guidance for study. It is NOT a prescription recommendation. The actual choice depends on the cause, the patient, and current guidelines.
- Area
- Gastrointestinal
- Listed causes
- 4
- Treatment options
- 3