Diagnosing the cause of heartburn


From a physical exam as well as your description of symptoms – when and how often they occur, the sensations you feel, and to what extent they affect your quality of life – your GP or gastroenterologist may be able to tell what’s causing heartburn and whether it’s something to worry about.

The symptoms of gastro-oesophageal reflux (GORD) may be so obvious that tests may not be necessary to make a diagnosis. And, if you respond well to medicines that reduce or block stomach acid, more tests may not be required.

However, because heartburn can have a variety of causes, some of which may be life-threatening, additional tests may be needed.

These may include:


This diagnostic tool (also known as “upper endoscopy” or “oesophagogastroduodenoscopy”) involves, in laymen’s terms, swallowing a camera. A gastroscopy is an examination of the inside of your oesophagus, stomach and duodenum (the first part of the small intestine immediately beyond your stomach) and is used to rule out any serious gastrointestinal conditions.

During this examination, your doctor will pass a thin, flexible instrument called a “scope”, which contains a small light and camera, into your mouth and down your throat to see whether there’s any damage to the lining of the oesophagus, stomach or duodenum.

The doctor will also look for bleeding, inflammation, growths and ulcers, and whether any other abnormalities are present. The exam also makes it easy to diagnose hiatus hernia and pick up signs of Barrett’s oesophagus (see "Possible complications").

The procedure is relatively painless, is performed under a light sedative, lasts only a few minutes, and is usually done in a hospital or day clinic.

Unfortunately, however, the gastroscopy has its limits: for instance, it’s not an effective way of picking up cancer or motility problems. For this reason, more tests may be required.


During a gastroscopy, your doctor may choose to do a biopsy. This involves taking a tissue sample of the lining of your oesophagus, so that the sample can be examined under a microscope for signs of Barrett’s oesophagus or abnormal cell growth, which could indicate cancer (see "Possible complications"). A scope can also be used to identify what’s causing an infection.

Oesophageal pH monitoring 

This test measures how often acid enters your oesophagus, and how long it stays there. Specifically, it’s used to diagnose gastro-oesophageal reflux disease (GORD) and to see if the medicines you’re using are effective, or not. If you experience atypical symptoms (e.g. coughing or wheezing), pH monitoring can also help identify if your symptoms are caused by acid regurgitation, or something else.

There are two types of oesophageal pH monitoring tests: 1. combined pH/impedance monitoring and; 2. wireless, capsule oesophageal pH monitoring. Each type of test uses pH sensors to register acid reflux from your stomach into the oesophagus; however, the two types work in slightly different ways.

Combined pH/impedance monitoring detects both acidic and non-acidic reflux episodes. A thin, plastic catheter with a pH sensor is used to measure flow in your oesophagus, while a recorder is worn on the outside of your body to monitor what’s happening throughout the day. Your doctor will expect you to visit again 24 hours after the catheter has been inserted.

With wireless capsule oesophageal pH monitoring, a small capsule is attached to the wall of your oesophagus during a gastroscopy. This temporary capsule then measures pH levels and transmits readings wirelessly to a receiver worn on the outside of your body.

Note that you might have to stop taking your acid-suppressing medication before pH monitoring is done.

Barium tests

Barium tests are used to make the gastrointestinal (GI) tract clearly visible on X-rays. In other words, X-rays are taken after you’ve swallowed a liquid that contains barium sulphate (a white, chalky powder), which coats the inner walls of the GI tract, making them appear white. Depending on what your doctor would like to investigate, a barium swallow or barium meal may be required.

A barium swallow uses barium liquid to help identify motility disorders, strictures, inflammation, tumours and hernias in the upper gastrointestinal tract. It can also indicate the volume of acid reflux into your oesophagus, and how serious the problem is. An X-ray is taken as you swallow the liquid.

A barium meal is quite similar, but focuses on the stomach and the duodenum. Instead of standing in front of an X-ray machine to be scanned (as is the case with a barium swallow), you lie down, while X-rays are taken of your stomach.

Barium tests are inexpensive, readily available and non-invasive. 

Oesophageal manometry

GORD can be the result of a functional defect in your oesophagus. To find out whether this is the case, your doctor might do oesophageal manometry. This tests the function of your lower-oesophageal sphincter (LOS), the valve that controls the flow of food into the stomach from the oesophagus, as well as the muscles of the oesophagus.

During this test, a catheter will be passed through your nose, into your oesophagus and stomach. At some point, you will have to swallow bits of water, while your doctor starts to pull the catheter back to test the muscle contractions in your oesophagus. Thanks to medication that numbs your nose and throat, the test should be relatively painless, although some irritation of the nose and throat may occur.

Special investigations

Since a variety of conditions may cause heartburn, other tests may be required. Two examples include:

  • An ultrasound scan to diagnose gallstones.
  • An electrocardiogram (EKG), stress test or chest X-ray to diagnose angina. The chest pain associated with angina, in turn, may point to underlying heart disease. If the angina is unstable, you may need emergency treatment.

Reviewed by Dr Estelle Wilken, senior specialist in Internal Medicine and Gastroenterology at Tygerberg Hospital. March 2017.

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