AGA Develops 7 Best Practices for Functional Heartburn

The American Gastroenterological Association (AGA) has released a clinical practice update on the presentation, diagnosis, and management of functional heartburn.

Although functional heartburn is an important condition to recognize, its prevalence in the community is difficult to determine. Functional heartburn can be mistaken for gastroesophageal reflux disease (GERD) and can lead physicians to treat patients with acid-suppressive therapy or escalate anti-reflux treatment, both of which may cause harm.

To guide clinicians in the diagnosis and management of functional heartburn, the authors of an expert review developed the following 7 best practice advice statements:

  1. When retrosternal burning pain or discomfort persists despite maximal proton-pump inhibitor (PPI) therapy taken appropriately before meals over a 3-month period, consider a diagnosis of functional heartburn.
  2. A diagnosis of functional heartburn requires upper endoscopy with esophageal biopsies to rule out anatomic and mucosal abnormalities, esophageal high-resolution manometry to rule out major motor disorders, and pH monitoring off PPI therapy (or pH-impedance monitoring on therapy in patients with proven GERD) to document physiologic levels of esophageal acid exposure in the distal esophagus with absence of reflux-symptom association.
  3. Overlap of functional heartburn with proven GERD is diagnosed according to Rome IV criteria when heartburn persists despite maximal PPI therapy in patients with history of proven GERD, and pH impedance testing on PPI therapy demonstrates physiologic acid exposure without reflux-symptom association.
  4. Except for proven GERD that overlaps with functional heartburn, PPIs have no therapeutic value in functional heartburn.
  5. Neuromodulators have benefit as either primary therapy in functional heartburn or as add-on therapy in functional heartburn that overlaps with proven GERD.
  6. Acupuncture and hypnotherapy may have benefit as monotherapy in functional heartburn; they also may be an effective adjunctive therapy when combined with other therapeutic modalities.
  7. Because anti-reflux surgery and endoscopic GERD treatment modalities have no therapeutic benefit in functional heartburn, they should not be recommended.

“While functional heartburn does not have long-term pathological consequences, the impact on patient quality of life can be substantial and very limiting,” according to the review authors.

—Colleen Murphy


Fass R, Zerbib F, Gyawali CP. AGA clinical practice update on functional heartburn: expert review [published online February 1, 2020]. Gastroenterology. doi:10.1053/j.gastro.20200.01.034.