Updated: 12/21/2019

Gastroesophageal Reflux Disease (GERD)

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Snapshot
  • A 45-year-old man with hypertension and obesity presents with complaints of heartburn and regurgitation with a sour taste that is aggravated by drinking coffee and eating spicy foods. He also endorses intermittent night time coughing when he eats a late dinner with occasional sore throat and hoarseness. He has tried an antacid with slight improvement but his symptoms are still bothersome.
Introduction
  • Clinical definition
    • reflux of gastric contents into the esophagus
  • Epidemiology
    • demographics
      • common
      • increases with age
    • risk factors
      • alcohol
      • smoking
      • coffee
      • pregnancy
      • obesity
  • Pathogenesis
    • ↓ lower esophageal sphincter (LES) tone allowing gastric contents to reflux into the esophagus
    • ↓ esophageal motility leading to ↓ clearance of retrograde gastric contents
    • ↓ gastric emptying
  • Associated conditions
    • hiatal hernia
    • gastric outlet obstruction
    • scleroderma
Presentation
  • Symptoms
    • classic
      • postprandial retrosternal pain, may radiate to neck or chest
      • regurgitation or sour taste
    • other
      • hypersalivation
      • dysphagia or globus sensation
      • odynophagia
      • cough
      • hoarseness
      • early satiety
      • weight loss
  • Physical exam
    • dental enamel erosion
    • wheezing
    • benign abdominal exam
Studies
  • Diagnostic testing
    • diagnostic approach 
      • classic presentation does not require work up below
      • may require ruling out cardiac etiology
    • imaging
      • esophagogastroduodenoscopy (EGD) with biopsy 
        • visualize erosive disease, complications, and other anatomical abnormalities 
        • first test of choice for atypical presentations
    • studies
      • manometry
        • evaluate LES and motility
        • indicated if empirical therapy fails or atypical work up
      • 24-hour intraesophageal pH monitoring
        • gold standard diagnostic test but not always indicated
        • indicated for atypical history or inconclusive EGD
Differential
  • Angina pectoralis
    • distinguishing factor
      • not associated with eating
  • Chemical esophagitis
    • distinguishing factor
      • no reflux
  • Peptic ulcer disease
    • distinguishing factor
      • localized epigastric or central abdominal pain that does not radiate
Treatment 
  • Management approach
    • empiric treatment with lifestyle modification and acid suppression therapy for classic presentation
    • step-up therapy for mild or intermittent symptoms
      • histamine H2 receptor antagonist → proton pump inhibitor
    • step-down therapy for severe or erosive symptoms for faster relief
      • proton pump inhibitor → histamine H2 receptor antagonist
  • All patients
    • lifestyle modification
      • avoid triggering foods (fatty, caffeine, acidic, and alcohol)
      • stop smoking
      • sleep in an elevated position
    • antacids
  • Mild to intermittent symptoms
    • histamine H2 receptor antagonist 
      • cimetidine, famotidine, or ranitidine
  • Moderate to severe symptoms
    • proton pump inhibitor 
      • omeprazole or lansoprazole
      • side effects include pneumonia, Clostridium difficile, hypergastrinemia, fractures, and hypomagnesemia
  • Surgical
    • fundoplication
      • for failed medical management or complications
Complications
  • Barrett esophagus
  • Esophageal cancer
  • Esophageal ulcer with bleeding or perforation
  • Peptic stricture
  • Pulmonary aspiration
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(M2.GI.16.60) A 38-year-old obese male smoker presents to the emergency department complaining of severe chest pain. The pain is stabbing, burning and retrosternal. The pain has occurred intermittently for the last few months. The pain is not brought on by exercise, but he does experience it often at night upon lying down after dinner. He denies any dysphagia, weight loss, vomiting, or bloody stools, but does endorse a foul taste in his mouth. Vitals signs are T 98.8 F, HR 79 bpm, BP 123/89, RR 16 Sat 100%. Exam reveals an obese male with dental erosions; cardiopulmonary exam is unremarkable. An EKG is shown in Figure A. What is the next best step in management? Tested Concept

QID: 104066
FIGURES:
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Aspirin, morphine, sublingual nitroglycerin, and cardiac enzyme labs

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Esophageal manometry

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Upper endoscopy

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Upper GI series

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Treatment with a Proton Pump Inhibitor (PPI)

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(M3.GI.12.31) A 40-year-old overweight man presents to the office complaining of heartburn for 6 months. He describes burning in his chest brought on by meals. He has a 20 pack-year smoking history and drinks 2 glasses of red wine with dinner nightly. He denies dysphagia, odynophagia, weight loss, melena, and hematemesis. Over the past month, he has reduced his intake of fatty and spicy foods with some moderate relief of his symptoms; however, his symptoms are still present. He also has stopped smoking. Which of the following is the most appropriate next step in the care of this patient? Tested Concept

QID: 102660
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Esophagogastroduodenoscopy

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Nissen fundoplication

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Omeprazole

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Pantoprazole, sucralfate, and amoxicillin

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Ranitidine

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Topic COMMENTS (27)
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