Persistent heartburn in a multiethnic population: treatment gaps, ethnic disparities, and diagnostic yield from a large cohort

BACKGROUND: Persistent heartburn is a common indication for gastroscopy. However, the diagnostic yield and contribution of patient-level factors, including ethnicity, to clinically significant findings (CSFs) remain incompletely defined. METHODS: This retrospective cohort included 6813 adults who underwent gastroscopy between 2012 and 2023 for persistent heartburn despite prior acid-suppressive therapy. Arab (n = 1831) and Jewish (n = 4982) patients were compared in terms of demographics, treatment history, procedural characteristics, and endoscopic outcomes. Multivariable logistic regression identified independent predictors of CSFs. RESULTS: Arab patients were significantly older than Jewish patients (56.2 ± 18.7 vs. 50.2 ± 14.6 years; P < 0.001), with no difference in sex distribution. Pre-endoscopy treatment differed markedly by ethnicity: Arab patients more frequently received antacids only (17.6 vs. 3.2%) or H2-blockers (18.0 vs. 11.5%), whereas Jewish patients were more likely to receive proton pump inhibitors (PPIs), including high-dose and twice-daily regimens. CSFs were more prevalent among Arabs (18.9 vs. 12.3%; P < 0.001), primarily because of higher rates of Barrett's esophagus and severe reflux esophagitis. Multivariable analysis showed that Arab ethnicity, male sex, older age, and presence of hiatus hernia were independently associated with CSFs, while adequate PPI therapy (particularly prolonged or high-dose regimens) was protective. CONCLUSION: Gastroscopy in patients with persistent heartburn frequently reveals clinically significant esophageal pathology, particularly among Arab patients. Ethnic disparities in pre-endoscopy management and outcomes suggest that tailored therapy may mitigate disease burden and improve endoscopy utilization.