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Heartburn, Esophagogastroduodenoscopy, Gastroesophageal reflux disease, What&,rsquo s Known Retrosternal burning is frequently associated with gastroesophageal reflux disease. However, its diagnostic value for other upper gastrointestinal disorders remains a subject of debate. What&,rsquo s New This large-scale study identified a strong association between retrosternal burning and mucosal or anatomical abnormalities, including esophagitis and hiatal hernia. The finding suggested that the symptom had significant clinical relevance for diagnosing these conditions. IntroductionRetrosternal burning, commonly referred to as heartburn, is a prevalent symptom in clinical practice. 1, It is primarily associated with gastroesophageal reflux disease (GERD), although it may also indicate other conditions, such as esophagitis, peptic ulcers, gastritis, and even non-gastrointestinal (GI) diseases. 2, , 3, Due to its high prevalence, heartburn often prompts diagnostic investigations, such as upper gastrointestinal (UGI) endoscopy to determine its underlying cause. 4, UGI endoscopy, also known as esophagogastroduodenoscopy (EGD), is a cornerstone diagnostic tool as it allows direct inspection of the esophageal, gastric, and duodenal mucosa. It is crucial for identifying mucosal and structural lesions, such as erosions, ulcers, strictures, and malignancies. 5, , 6, Given the high prevalence and wide variety of GI disorders associated with retrosternal burning, understanding its relationship with specific endoscopic findings is clinically essential. This study aimed to investigate and compare the upper endoscopic findings in patients with and without retrosternal burning to evaluate the clinical significance of this symptom.Patients and Methods Study Design and Population This analytical cross-sectional study examined the association between retrosternal burning and endoscopic findings in patients visiting gastroenterology clinics in Khorramabad, Iran, between 2018 and 2023. The study population included all patients who underwent UGI endoscopy during this period for any indication. This research was approved by the Research Ethics Committee of Lorestan University of Medical Sciences (code, IR.LUMS.REC.1403.121). Written informed consent was obtained from all participants. All patient data were anonymized and securely archived. Ethical guidelines were strictly followed throughout the study. Inclusion and Exclusion Criteria The inclusion criteria were patients aged 16 years and older who were referred to gastroenterology clinics, underwent UGI endoscopy, and had no prior history of UGI surgery. The exclusion criteria included patients whose retrosternal burning was attributed to cardiovascular causes, those with previously diagnosed GI malignancies, and patients taking medications that relax the lower esophageal sphincter (LES), such as beta-blockers and calcium channel blockers. Data Collection Procedure Data were acquired retrospectively from medical records of patients who visited GI clinics, with approval from the Ethics Committee of Lorestan University of Medical Sciences. Nearly all UGI endoscopies were performed using Fujifilm EG-530WR flexible video endoscopes connected to Fujifilm VP-3500HD high-definition video processors and XL-4450 xenon light sources (Fujifilm Corporation, Tokyo, Japan). Required data, including age, sex, sliding hiatal hernia size, severity of esophagitis according to the Los Angeles classification (A-D), 7, presence of an inlet patch, and retrosternal burning, were collected using a researcher-provided checklist. Statistical Analysis Data analysis was performed using STATA software (version 18, StataCorp LLC, USA). Descriptive statistics, including means and standard deviations, percentages, and frequencies, were calculated. The normality of continuous variables was assessed via the Kolmogorov-Smirnov test. For inferential analysis, independent t tests were used to compare continuous variables, and Chi square or Fisher&,rsquo s exact tests were employed for categorical variables. P&,lt 0.05 was considered statistically significant.Results Demographic Characteristics A total of 5,561 patients underwent UGI endoscopy in this study. The mean age of the patients was 46.84&,plusmn 15.51 years. Patients with no retrosternal burning had a significantly higher mean age (50.43&,plusmn 16.36 years) than those with retrosternal burning (45.14&,plusmn 14.55 years), which was statistically significant (P&,lt 0.0001). Of the participants, 3,174 (57.08%) were women, and 2,387 (42.92%) were men. The mean age of the female patients was 46.69&,plusmn 15.49 years, and the mean age of the male patients was 47.99&,plusmn 15.52 years. The indications for UGI endoscopy were evaluated, noting that a single patient could have more than one indication. The most common indications were dyspepsia in 4,044 (72.72%) patients, retrosternal burning in 3,343 (60.12%) patients, abdominal pain in 1,362 (24.49%) patients, dysphagia in 131 (2.36%) patients, sensation of a mass in 61 (1.10%) patients, anemia in 41 (0.74%) patients, positive anti-tissue transglutaminase antibody test in 40 (0.72%) patients, nausea in 19 (0.34%) patients, melena in 8 (0.14%) patients, pre-kidney transplant evaluation in 7 (0.13%) patients, and hematemesis in 1 (0.02%) patient. Endoscopic Examination Results Among the patients who underwent endoscopy, antral gastropathy was observed in 4,256 patients (76.53%), sliding hiatal hernia in 2,766 (49.73%), and esophagitis in 3,339 (60.04%). Additionally, duodenal ulcers were identified in 557 patients (10.02%), gastric ulcers in 198 (3.56%), inlet patches in 63 (1.13%), gastric masses in 32 (0.58%), and esophageal masses in 27 (0.49%). Other findings included gastroduodenopathy in 678 patients (12.19%), pangastritis in 248 (4.46%), bulbar deformities in 154 (2.77%), D2 atrophy in 154 (2.77%), candidiasis in 116 (2.08%), gastric polyps in 63 (1.13%), gastric outlet obstruction in 30 (0.54%), and submucosal lesions in 23 (0.41%). Patients with sliding hiatal hernias were further evaluated on the basis of size and grade. Among these, 654 individuals (23.64%) had Grade 1 hernias, 2,069 (74.80%) had Grade 2 hernias, and 43 (1.55%) had Grade 3 hernias. Esophagitis cases were similarly graded. Among patients with esophagitis, 2,917 individuals (87.36%) had Grade A esophagitis, 309 (9.25%) had Grade B esophagitis, 99 (2.96%) were diagnosed with Grade C esophagitis, and 14 (0.41%) exhibited Grade D esophagitis. Associations between Retrosternal Burning and Endoscopic Findings A comparison of endoscopic findings between patients with and without retrosternal burning revealed several significant associations. The prevalence of sliding hiatal hernia and esophagitis was markedly higher in patients with retrosternal burning (78.0% and 99.6%, respectively, P&,lt 0.001) than in those without (7.0% and 0.3% P&,lt 0.001). Similarly, gastric antral gastropathy and inlet patches were significantly more prevalent in the group with retrosternal burning. Conversely, the absence of retrosternal burning was associated with a higher frequency of gastric ulcers, gastric and esophageal masses, duodenal ulcers, and bulbar deformities. Other findings, such as submucosal lesions, gastric polyps, and candidiasis, were also more common in patients without retrosternal burning. No significant differences were observed for pangastritis, gastric outlet obstruction, D2 atrophy, or gastroduodenopathy. Full comparisons are presented in table 1,.Endoscopic findingsPatients without retrosternal burning (n=2,218)Patients with retrosternal burning (n=3,343)P valueSliding hiatal hernia155 (6.99%)2,611 (78.10%)&,lt 0.001Esophagitis6 (0.27%)3,333 (99.70%)&,lt 0.001Inlet patch6 (0.27%)57 (1.71%)&,lt 0.001Gastric antral gastropathy1,536 (69.25%)2,720 (81.36%)&,lt 0.001Gastric ulcer132 (5.95%)66 (1.97%)&,lt 0.001Duodenal ulcer245 (11.05%)312 (9.33%)0.037Gastric mass31 (1.40%)1 (0.03%)&,lt 0.001Esophageal mass27 (1.22%)0 (0.00%)&,lt 0.001D2 atrophy64 (2.89%)90 (2.69%)0.667Gastroduodenopathy275 (12.40%)403 (12.06%)0.701Submucosal lesion16 (0.72%)7 (0.21%)0.004Gastric outlet obstruction17 (0.77%)13 (0.39%)0.060Gastric polyp36 (1.62%)27 (0.81%)0.005Pangastritis107 (4.82%)141 (4.22%)0.283Candidiasis59 (2.66%)57 (1.70%)0.020Bulbar deformities76 (3.43%)78 (2.33%)0.015Chi square test or Fisher&,rsquo s exact test was used, as appropriate. P&,lt 0.05 was considered statistically significant. |