History

Fact Explanation
Heartburn There is relaxation of the lower esophageal sphincter, leading to acid reflux in to the esophagus that causes heart burn. [1]
Reflux Reflux of acidic substance in to the esophagus occurs due to the lax lower esophageal sphincter. [1][2]
Acid brash Reflux of acid sometimes reaches the mouth, this causes an unpleasant bitter taste, known as acid brash. [5]
Odynophagia Difficulty of swallowing is due to esophagitis, which occurs due to the acid reflux. [1][2]
Chronic cough Micro aspiration of gastric fluid in to the upper respiratory tract leading to laryngeal irritation and cough.[3]
Hoarseness Micro aspiration of gastric fluid in to the upper respiratory tract causes laryngitis. [3]
Chest pain This is non cardiac in origin, and is usually described as being of a non radiating, burning type. [3]
Globus Patient complains of a feeling of having something stuck in his/her throat. This may be a presenting feature in reflux disease. [3]
References
  1. MARK SCOTT, AIMEE R. GELHOT, Gastroesophageal Reflux Disease: Diagnosis and Management, Am Fam Physician[online]. 1999 Mar 1;59(5):1161-1169.[viewed 22 May 2014] Available from: http://www.aafp.org/afp/1999/0301/p1161.html
  2. MARK H. EBELL, Diagnosis of Gastroesophageal Reflux Disease,Am Fam Physician[online]. 2010 May 15;81(10):1278-1280.[viewed 22 May 2014] Available from:http://www.aafp.org/afp/2010/0515/p1278.html
  3. JOEL J. HEIDELBAUGH, ARVIN S. GILL, et al, Atypical Presentations of Gastroesophageal Reflux Disease , Am Fam Physician[online]. 2008 Aug 15;78(4):483-488.[viewed 22 May 2014] Available from: http://www.aafp.org/afp/2008/0815/p483.html
  4. BAGHURST PA, NICHOL LW. The binding of organic phosphates to human methaemoglobin A. Perturbation of the polymerization of proteins by effectors. Biochim Biophys Acta [online] 1975 Nov 18, 412(1):168-80 [viewed 23 May 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/80
  5. CHAIT MM. Gastroesophageal reflux disease: Important considerations for the older patients World J Gastrointest Endosc [online] 2010 Dec 16, 2(12):388-396 [viewed 23 May 2014] Available from: doi:10.4253/wjge.v2.i12.388

Examination

Fact Explanation
Overweight Obesity causes increased intra abdominal pressure. Which when greater than the intra thoracic pressure leads to incompetence of the lower esophageal sphincter, causing reflux. [2][3]
Loss of weight Loss of weight in GERD is due to anorexia caused by long standing disease. [3]
Rhonchi Asthma is a risk factor for the development of GERD. As it creates negative intra thoracic pressure causing incompetence of the lower esophageal sphincter that leads to reflux. [1]
Lung crepitations Long term illness can cause aspiration pneumonia, chemical pneumonitis and lung fibrosis.
ENT examination: Laryngeal erythema, ulcers or granulomas and associated edema of the vocal cords Due to acute inflammation of the larynx by micro aspiration of gastric fluid. [1]
Abnormal cardiovascular reflexes It has been shown that an abnormality in vagal function maybe present in patients with GERD. Maintenance of the lower esophageal sphincter tone is a vago-vagal reflex, therefore such patients are predisposed towards the development of GERD. [4]
References
  1. JOEL J. HEIDELBAUGH, ARVIN S. GILL, et al, Atypical Presentations of Gastroesophageal Reflux Disease , Am Fam Physician[online]. 2008 Aug 15;78(4):483-488.[viewed 22 May 2014] Available from: http://www.aafp.org/afp/2008/0815/p483.html
  2. KAPLAN LM. Treatment of Gastroesophageal Reflux Disease in Obese Patients Gastroenterol Hepatol (N Y) [online] 2008 Dec, 4(12):841-843 [viewed 26 May 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3093685
  3. SCHOLTEN T. Long-term management of gastroesophageal reflux disease with pantoprazole Ther Clin Risk Manag [online] 2007 Jun, 3(2):231-243 [viewed 26 May 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1936305
  4. CHAKRABORTY TK, OGILVIE AL, HEADING RC, EWING DJ. Abnormal cardiovascular reflexes in patients with gastro-oesophageal reflux. Gut [online] 1989 Jan, 30(1):46-49 [viewed 26 May 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1378229
  5. ISOLAURI J, LAIPPALA P. Prevalence of symptoms suggestive of gastro-oesophageal reflux disease in an adult population. Ann Med [online] 1995 Feb, 27(1):67-70 [viewed 26 May 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/7742002

Differential Diagnoses

Fact Explanation
Achalasia There is a failure of the smooth muscles of LOS to relax, dysphagia for liquids is the predominant feature. While nocturnal regurgitation of undigested food is also common. Features of heartburn, acid brash and reflux suggestive of GERD are absent. Esophageal manometry is needed for diagnosis. [1],[2],[9]
Esophagitis GERD is the commonest cause for esophagitis. However esophagitis may also be caused by other causes such as NSAIDS, certain antibiotics or a hiatus hernia. Symptoms are heartburn odynophagia and a burning type chest pain. Endoscopy and biopsy is needed for diagnosis and to screen for a esophageal adenocarcinoma.[3],[10]
Angina pectoris Angina is a differential that needs to ruled out on presentation, GERD typically causes a burning type, non radiating chest pain that relieves with antacids. If suspicion persists, an immediate electrocardiogram must be performed. [5]
Acute/chronic gastritis Dyspeptic symptoms may present in both gastritis and GERD. However acid brash and reflux are more in favor of GERD. [6] Look for risk factors of gastritis such as chronic NSAID use, smoking, alcoholism, stressful lifestyle etc.
Peptic ulcer disease Nausea, vomiting and heart burn are common for both peptic ulcer disease (PUD) and GERD[6][7], in addition a history of chronic NSAID use should also raise the possibility of PUD. However acid brash and reflux is more towards GERD. Upper GI endoscopy will confirm ulcers of the stomach or duodenum in peptic ulcer disease.
Lower lobe pneumonia Lower lobe pneumonia may sometimes present as upper abdominal pain and dry cough can be confused with GERD in some cases. Heart burn , regurgitation and acid brash more towards GERD. Chest Xray findings and endoscopy findings will help to differentiate further. [8]
Pancreatitis Pancreatitis also present with dyspeptic symptoms such as nausea vomiting abdominal pain, which is also commonly seen in GERD [6] pancreatic pain radiates directly through the body to the back. In GERD there is epigastric pain, heart burn and acid brash. If any doubt persists, an elevated serum amylase will be more suggestive of pancreatitis.
References
  1. BORIA PA, WEBSTER CR, BERG J. Esophageal achalasia and secondary megaesophagus in a dog Can Vet J [online] 2003 Mar, 44(3):232-234 [viewed 23 May 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC340085
  2. HORVáTH ÖP, KALMáR K, VARGA G. Reflux After Heller's Myotomy for Achalasia Ann Surg [online] 2007 Mar, 245(3):502-503 [viewed 23 May 2014] Available from: doi:10.1097/01.sla.0000256108.41616.32
  3. HASOSAH MY, SUKKAR GA, ALSAHAFI AF, THABIT AO, FAKEEH ME, AL-ZAHRANI DM, SATTI MB. Eosinophilic Esophagitis in Saudi Children: Symptoms, Histology and Endoscopy Results Saudi J Gastroenterol [online] 2011, 17(2):119-123 [viewed 23 May 2014] Available from: doi:10.4103/1319-3767.77242
  4. MCSHERRY CK, FERSTENBERG H, CALHOUN WF, LAHMAN E, VIRSHUP M. The natural history of diagnosed gallstone disease in symptomatic and asymptomatic patients. Ann Surg [online] 1985 Jul, 202(1):59-63 [viewed 23 May 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1250837
  5. RAO SS. Diagnosis and Management of Esophageal Chest Pain Gastroenterol Hepatol (N Y) [online] 2011 Jan, 7(1):50-52 [viewed 23 May 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3038318
  6. HARMON RC, PEURA DA. Evaluation and management of dyspepsia Therap Adv Gastroenterol [online] 2010 Mar, 3(2):87-98 [viewed 23 May 2014] Available from: doi:10.1177/1756283X09356590
  7. SCHWARTZ MD. Dyspepsia, peptic ulcer disease, and esophageal reflux disease West J Med [online] 2002 Mar, 176(2):98-103 [viewed 23 May 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1071675
  8. PATRIA F, LONGHI B, TAGLIABUE C, TENCONI R, BALLISTA P, RICCIARDI G, GALEONE C, PRINCIPI N, ESPOSITO S. Clinical profile of recurrent community-acquired pneumonia in children BMC Pulm Med [online] :60 [viewed 26 May 2014] Available from: doi:10.1186/1471-2466-13-60
  9. ELAKKARY E, DUFFY A, ROBERTS K, BELL R. Recent advances in the surgical treatment of achalasia and gastroesophageal reflux disease. J Clin Gastroenterol [online] 2008 May-Jun, 42(5):603-9 [viewed 27 May 2014] Available from: doi:10.1097/MCG.0b013e3181653a3b
  10. DANIEL J. MULDER, DAVID J. HURLBUT,Clinical Features Distinguish Eosinophilic and Reflux-induced Esophagitis[online][viewed 27 May 2014] Available from: http://www.naspghan.org/user-assets/Documents/pdf/CME/JPGN%20CME/March/Clinical_Features_Distinguish_Eosinophilic_and.8.pdf

Investigations - for Diagnosis

Fact Explanation
Upper GI Endoscopy and Biopsy Only 50% of patients will have manifestations of GERD or esophagitis. Endoscopy is more useful in diagnosis of complications like Barret esophagus and hiatus hernia. [1] Endoscopy will demonstrate esophageal erythema and traachealization that indicate inflammation. [9] Hiatus hernia which is also a contributory factor for GERD, can be visualized. [10]
Radiological Investigation Barium studies will show features suggestive of esophagitis such as erosions and ulcerations, strictures,hiatal hernia, thickening of mucosal folds and poor distensibility. [1]
Ambulatory pH monitoring This is the gold standard in the diagnosis of GERD. Probe of pH monitor is placed within the lower oesophagus , above the lower esophageal sphincter and pH is recorded over 24 hours. [1,2,3]
Biopsy Used to diagnose esophagitis associated with GERD. [1,4,5] It can also be used screen patients with long standing reflux, for lower esophageal adenocarcinoma. [11]
Esophageal manometry Important in detecting the function of the lower esophageal sphincter, it is recommended that manometry is performed prior to the pH monitoring test. It will exclude achalasia cardia as a possible differential.
References
  1. MARK SCOTT, AIMEE R. GELHOT, Gastroesophageal Reflux Disease: Diagnosis and Management,Am Fam Physician[online]. 1999 Mar 1;59(5):1161-1169.[viewed 23 May 2014] Available from: http://www.aafp.org/afp/1999/0301/p1161.html
  2. SIFRIM D, CASTELL D, DENT J, KAHRILAS PJ. Gastro-oesophageal reflux monitoring: review and consensus report on detection and definitions of acid, non-acid, and gas reflux Gut [online] 2004 Jul, 53(7):1024-1031 [viewed 23 May 2014] Available from: doi:10.1136/gut.2003.033290
  3. MAINIE I, TUTUIAN R, SHAY S, VELA M, ZHANG X, SIFRIM D, CASTELL DO. Acid and non-acid reflux in patients with persistent symptoms despite acid suppressive therapy: a multicentre study using combined ambulatory impedance-pH monitoring Gut [online] 2006 Oct, 55(10):1398-1402 [viewed 23 May 2014] Available from: doi:10.1136/gut.2005.087668
  4. GREMSE DA. GERD in the Pediatric Patient: Management Considerations MedGenMed [online] , 6(2):13 [viewed 23 May 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1395762
  5. SCHOLTEN T. Long-term management of gastroesophageal reflux disease with pantoprazole Ther Clin Risk Manag [online] 2007 Jun, 3(2):231-243 [viewed 23 May 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1936305
  6. SCHENK BE, KUIPERS EJ, KLINKENBERG-KNOL EC, FESTEN HP, JANSEN EH, TUYNMAN HA, SCHRIJVER M, DIELEMAN LA, MEUWISSEN SG. Omeprazole as a diagnostic tool in gastroesophageal reflux disease. Am J Gastroenterol [online] 1997 Nov, 92(11):1997-2000 [viewed 23 May 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/9362179
  7. HYUN JJ, BAK YT. Clinical Significance of Hiatal Hernia Gut Liver [online] 2011 Sep, 5(3):267-277 [viewed 23 May 2014] Available from: doi:10.5009/gnl.2011.5.3.267
  8. YAGNIK VD. Is oesophageal manometry a must before laparoscopic fundoplication? J Minim Access Surg [online] 2011, 7(2):161 [viewed 23 May 2014] Available from: doi:10.4103/0972-9941.78357
  9. HASOSAH MY, SUKKAR GA, ALSAHAFI AF, THABIT AO, FAKEEH ME, AL-ZAHRANI DM, SATTI MB. Eosinophilic Esophagitis in Saudi Children: Symptoms, Histology and Endoscopy Results Saudi J Gastroenterol [online] 2011, 17(2):119-123 [viewed 23 May 2014] Available from: doi:10.4103/1319-3767.77242
  10. HYUN JJ, BAK YT. Clinical Significance of Hiatal Hernia Gut Liver [online] 2011 Sep, 5(3):267-277 [viewed 23 May 2014] Available from: doi:10.5009/gnl.2011.5.3.267
  11. BRAMS JA. Chemoprevention of Esophageal Adenocarcinoma Therap Adv Gastroenterol [online] 2008 Jul, 1(1):7-18 [viewed 23 May 2014] Available from: doi:10.1177/1756283X08093568

Management - General Measures

Fact Explanation
Dietary modification: Avoid large meals [1] Avoidance of large meals reduces reflux, as it reduces the volume of stomach contents, that can distend the lower esophageal sphincter. [1]
Dietary modification: Avoid acidic foods [1] Certain food items increase gastric acid secretion, and cause relaxation of the lower esophageal sphincter. Patients are advised to avoid foods such as citrus- and tomato-based products, alcohol, caffeinated beverages, chocolate, onions, garlic and peppermint.
Dietary modification: Reduce fat intake [1] Foods rich in fat increases reflux, in addition, obesity is a risk factor for GERD. [1],[2]
Change of sleeping position[1] Patient should be advised to avoid lying down within three to four hours of a meal. The head end of the bed can be elevated 10 to 20 cm.[1]
Avoidance of tight cloths [1] Wearing tight clothes around the waist is thought to cause increased reflux activity, by increasing intra abdominal pressure.[1],[3]
Avoid or substitute medicine that worsens GERD [1] Some medications increase gastric acid secretion, including calcium channel blockers, beta agonists, alpha-adrenergic agonists, theophylline, nitrates, and some sedatives. [1],[4],[5]
Weight loss Exercises and dietary modification is recommended for weight loss in GERD patients because obesity is a proven risk factor. Obestiy increases intra abdominal pressure which worsens reflux. [2],[6],[7][8]
References
  1. JOEL J. HEIDELBAUGH, TIMOTHY T. NOSTRANT, CLARA KIM, R. VAN HARRISON, Management of Gastroesophageal Reflux Disease,Am Fam Physician[online]. 2003 Oct 1;68(7):1311-1319.[viewed 23 May 2014] Available from: http://www.aafp.org/afp/2003/1001/p1311.html
  2. HURT RT, KULISEK C, BUCHANAN LA, MCCLAVE SA. The Obesity Epidemic: Challenges, Health Initiatives, and Implications for Gastroenterologists Gastroenterol Hepatol (N Y) [online] 2010 Dec, 6(12):780-792 [viewed 23 May 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3033553
  3. LEE BE, KIM GH. Globus pharyngeus: A review of its etiology, diagnosis and treatment World J Gastroenterol [online] 2012 May 28, 18(20):2462-2471 [viewed 23 May 2014] Available from: doi:10.3748/wjg.v18.i20.2462
  4. HUGHES J, LOCKHART J, JOYCE A. Do calcium antagonists contribute to gastro-oesophageal reflux disease and concomitant noncardiac chest pain? Br J Clin Pharmacol [online] 2007 Jul, 64(1):83-89 [viewed 23 May 2014] Available from: doi:10.1111/j.1365-2125.2007.02851.x
  5. FASS R, MCCALLUM RW, PARKMAN HP. Treatment Challenges in the Management of Gastroparesis-Related GERD Gastroenterol Hepatol (N Y) [online] 2009 Oct, 5(10 Suppl 18):4-16 [viewed 23 May 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2886367
  6. STORR MA. What is nonacid reflux disease? Can J Gastroenterol [online] 2011 Jan, 25(1):35-38 [viewed 23 May 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3027332
  7. FASS R, MCCALLUM RW, PARKMAN HP. Treatment Challenges in the Management of Gastroparesis-Related GERD Gastroenterol Hepatol (N Y) [online] 2009 Oct, 5(10 Suppl 18):4-16 [viewed 23 May 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2886367
  8. Advances in GERD: Current Developments in the Management of Acid-Related GI Disorders Gastroenterol Hepatol (N Y) [online] 2009 Sep, 5(9):613-615 [viewed 23 May 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2886414

Management - Specific Treatments

Fact Explanation
Antacids [1] Antacids are to neutralize the gastric acid and to quick relieve symptoms.[1] alginate combined with antacids were proven more effective[2][3]
H2 receptor antagonist[1] H2 receptive antagonists are proven to be beneficial in oesophagitis especially with higher and frequent dosing.[4][5][6] H2-receptor blockers act by inhibiting histamine stimulation of the gastric parietal cell, thereby suppressing gastric acid secretion.
Proton Pump Inhibitors[1] PPI irreversibly inhibit the H+-K+ adenosine triphosphatase pump of the parietal cell. By blocking the final common pathway of gastric acid secretion, the proton pump inhibitors provide a greater degree and duration of gastric acid suppression compared with H2-receptor blockers.[1][5][6][7][8]
Pro kinetic medication Pharmacological agents that improve gastric motility such as domperidone and metoclorpramide can be used. Rapid transit of food through the stomach, reduces reflux.
Anti reflux surgery: Fundoplication [1] Recommended for who patients that fail to respond to medical therapy, or for GERD with a large hiatus hernia or severe erosive gastritis. Open or laparoscopic Niessen Fundoplication has a higher success rate but laparoscopic fundoplication has fewer complications and faster recovery compared to open surgery. [1] Common postoperative symptoms are dysphagia, belching, flatulence and diarrhea. [9,][10],[11]
Endoscopic treatment [1] Radio frequency heating of the gastro esophageal junction (Stretta procedure) and endoscopic gastroplasty (Endocinch procedure) are proven to improve quality of life and decrease reflux symptoms in patients.
References
  1. JOEL J. HEIDELBAUGH, TIMOTHY T. NOSTRANT, CLARA KIM, R. VAN HARRISON, Management of Gastroesophageal Reflux Disease,Am Fam Physician[online]. 2003 Oct 1;68(7):1311-1319.[viewed 23 May 2014] Available from: http://www.aafp.org/afp/2003/1001/p1311.html
  2. AW R, MALTEPE C, BOZZO P, EINARSON A. Treatment of heartburn and acid reflux associated with nausea and vomiting during pregnancy Can Fam Physician [online] 2010 Feb, 56(2):143-144 [viewed 23 May 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2821234
  3. SAVARINO E, DE BORTOLI N, ZENTILIN P, MARTINUCCI I, BRUZZONE L, FURNARI M, MARCHI S, SAVARINO V. Alginate controls heartburn in patients with erosive and nonerosive reflux disease World J Gastroenterol [online] 2012 Aug 28, 18(32):4371-4378 [viewed 23 May 2014] Available from: doi:10.3748/wjg.v18.i32.4371
  4. V.I. Gavrilov. Acta Virol [online] 1975 Nov, 19(6):510 [viewed 23 May 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/2003
  5. KINOSHITA Y, ISHIHARA S. Causes of, and Therapeutic Approaches for, Proton Pump Inhibitor-Resistant Gastroesophageal Reflux Disease in Asia Therap Adv Gastroenterol [online] 2008 Nov, 1(3):191-199 [viewed 23 May 2014] Available from: doi:10.1177/1756283X08098181
  6. KINOSHITA Y, ISHIHARA S. Causes of, and Therapeutic Approaches for, Proton Pump Inhibitor-Resistant Gastroesophageal Reflux Disease in Asia Therap Adv Gastroenterol [online] 2008 Nov, 1(3):191-199 [viewed 23 May 2014] Available from: doi:10.1177/1756283X08098181
  7. KINOSHITA Y, ISHIHARA S. Causes of, and Therapeutic Approaches for, Proton Pump Inhibitor-Resistant Gastroesophageal Reflux Disease in Asia Therap Adv Gastroenterol [online] 2008 Nov, 1(3):191-199 [viewed 23 May 2014] Available from: doi:10.1177/1756283X08098181
  8. THOMSON A. Impact of PPIs on patient focused symptomatology in GERD Ther Clin Risk Manag [online] 2008 Dec, 4(6):1185-1200 [viewed 23 May 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2643100
  9. STORR MA. What is nonacid reflux disease? Can J Gastroenterol [online] 2011 Jan, 25(1):35-38 [viewed 23 May 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3027332
  10. SCHOLTEN T. Long-term management of gastroesophageal reflux disease with pantoprazole Ther Clin Risk Manag [online] 2007 Jun, 3(2):231-243 [viewed 23 May 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1936305
  11. BOWREY DJ, PETERS JH, DEMEESTER TR. Gastroesophageal Reflux Disease in Asthma: Effects of Medical and Surgical Antireflux Therapy on Asthma Control Ann Surg [online] 2000 Feb, 231(2):161-172 [viewed 23 May 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1420982
  12. BIANCO M, ROTONDANO G, GAROFANO M, CIPOLLETTA L. Endoscopic treatment of gastro-oesophageal reflux disease Acta Otorhinolaryngol Ital [online] 2006 Oct, 26(5):281-286 [viewed 23 May 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2639974
  13. LIU JJ. Endoscopic treatment for gastroesophageal reflux disease: Should you learn the techniques? Can J Gastroenterol [online] 2007 Apr, 21(4):213-215 [viewed 23 May 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2657692