Do you need diagnostic tests for heartburn?

You just enjoyed a delicious meal, but now there's a burning feeling creeping up your chest—classic heartburn. Heartburn is a common symptom of gastroesophageal reflux disease (GERD), or "acid reflux," which occurs when stomach acid flows back into the esophagus.  But sometimes, this pain can be so intense it mimics a heart attack, making you wonder if it's something more serious.

While doctors often skip extensive tests for straightforward cases, certain red flags—like trouble swallowing, internal bleeding, or severe, unresponsive symptoms—can call for deeper investigation. Here's a look at some of the diagnostic tests your doctor might recommend to get to the root of persistent heartburn.

• Upper GI endoscopy. This is the most commonly ordered initial test when people have worrisome symptoms. For this test, a person receives intravenous medicine to induce relaxation. It's called conscious sedation. The doctor sprays a local anesthetic in the back of the throat to prevent gagging. Next the doctor inserts a flexible tube called an endoscope down the throat. The tube has a light and camera attached, which let the doctor inspect the lining of the esophagus, stomach and first part of the small intestine to look for areas of irritation, ulcers, or strictures. Special tools can be inserted through the endoscope to take a biopsy (tissue sample), if necessary.
• Barium study. After drinking a liquid barium mixture, a person has an x-ray of the chest and upper abdomen. Barium helps define the esophagus on the x-ray image and can help the physician identify problems such as a hiatal hernia, esophageal ulcers, or a stricture (narrowing) of the esophagus. This test is called an upper GI series when the stomach and first part of the small intestine are also examined.
• pH monitoring. This test is used less frequently than those described above. It monitors a person's reflux episodes over 24 hours via a thin, acid sensing probe inserted through the nose and positioned at the bottom of the esophagus just above the lower esophageal sphincter (LES). This is an excellent method for documenting acid reflux in people who have unexplained chest pain, coughing, wheezing, or hoarseness. It's also used to assess the effectiveness of acid-suppressing drugs when symptoms persist. A wireless form of the pH monitor is contained in a capsule and looks like a pill. It is placed in the esophagus and can be used to monitor pH levels for 48 hours, during periods while the person is both on and off acid-suppressing therapy. The wireless pH system is particularly useful in people who do not respond to PPIs.
• Impedance testing. This test can be done at the same time as pH monitoring. It measures how well food and gas pass through the esophagus and is a good way to evaluate both acid- and non-acid reflux.

To learn more about GERD and heartburn, read Cooling Heartburn , a Special Health Report from Harvard Medical School.

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