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GERD: Diagnosing and treating the burn

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ABSTRACTGastroesophageal reflux disease (GERD) is chronic, very common, and frequently encountered in internal medicine and subspecialty clinics. It is often diagnosed on clinical grounds, but specialized testing such as endoscopy and pH monitoring may be necessary in certain patients. Although proton pump inhibitors (PPIs) are the mainstay of treatment, clinicians should be aware of their short-term and long-term side effects.

KEY POINTS

  • GERD symptoms may be typical (eg, heartburn, regurgitation) or atypical (eg, cough, chest pain, hoarseness).
  • In patients with typical symptoms, a 6- to 8-week trial of a PPI is a reasonable and cost-effective approach to diagnosing GERD.
  • Endoscopy is indicated for patients who have alarm symptoms such as dysphagia, weight loss, and bleeding; it is unnecessary in patients who have typical GERD symptoms.
  • Ambulatory pH monitoring should be used in patients whose symptoms do not respond to a PPI and those in whom antireflux surgery is being considered.
  • Weight loss and head-of-bed elevation are the only lifestyle interventions that have been proven effective for GERD.
  • While risks of PPI use are rare, they should be discussed with patients on long-term therapy.
  • Symptoms that do not respond to a PPI are less likely to improve with antireflux surgery.


 

References

Gastroesophageal reflux disease (GERD) is a chronic and common medical problem, with up to 40% of the population experiencing its symptoms at least once per month.1 The condition develops when the reflux of stomach contents causes troublesome symptoms or complications.2

GERD symptoms can range from heartburn and regurgitation to cough and hoarseness. While many patients’ symptoms respond to medical treatment, the diagnosis and treatment in those whose symptoms do not respond to a proton pump inhibitor (PPI) may be challenging.

This article reviews the diagnosis and treatment options for GERD.

SYMPTOMS: TYPICAL, ATYPICAL, AND ALARM

Symptoms of GERD (Table 1) can be classified as typical (heartburn and regurgitation) or atypical (cough, asthma, hoarseness, chronic laryngitis, throat-clearing, chest pain, dyspepsia, and nausea). Atypical symptoms are more likely to be due to GERD if patients also have typical symptoms and if the symptoms respond to a trial of a PPI.3

Alarm symptoms. Keep in mind that extraesophageal presentations may be multifactorial, and it may be difficult to establish that reflux, even if present, is actually the cause. While chest pain may be due to GERD, it is important to rule out cardiac chest pain before considering GERD as a cause. Similarly, dysphagia along with typical or atypical symptoms warrants investigation for potential complications such as underlying motility disorder, esophageal stricture, esophageal ring, or malignancy.4 Other alarm symptoms include odynophagia, bleeding, weight loss, and anemia.

DIAGNOSING GERD: RESPONSE TO A PPI IS DIAGNOSTIC

Figure 1.

Patients with typical symptoms that respond to PPI therapy need no further evaluation for a diagnosis of GERD to be made.5 On the other hand, further testing should be undertaken in patients with typical symptoms that do not respond to PPI therapy, in patients presenting with atypical symptoms, and in patients in whom antireflux surgery is being considered. Figure 1 shows our proposed algorithm.

Try a PPI for 6–8 weeks

Relief of heartburn and regurgitation after a 6- to 8-week course of a PPI strongly suggests GERD.6 However, a negative trial of a PPI does not rule out GERD, as this approach has been found to have a sensitivity of 78% and specificity of 54%.6

Despite this limitation, a trial of PPI therapy should be offered to patients presenting with typical symptoms and no alarm features. This approach has been found to be more cost-effective than proceeding directly to diagnostic testing.7

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