Gastroesophageal Reflux Disease (GERD)




© Springer International Publishing Switzerland 2017
Bobby Desai and Alpa Desai (eds.)Primary Care for Emergency Physicians10.1007/978-3-319-44360-7_11


11. Gastroesophageal Reflux Disease (GERD)



Tara Dyson1  


(1)
Division of Gastroenterology, Department of Internal Medicine, 100277, Gainesville, FL 32610-0277, USA

 



 

Tara Dyson

Email:


Keywords
RefluxHiatal herniaHistamine antagonistsProton pump inhibitorsBloating



11.1 Introduction


Gastroesophageal reflux disease (GERD) is the reflux of gastric content into the esophagus causing discomfort. It is the most commonly diagnosed GI disorder. The exact prevalence of the disease is unclear as the most common symptom, heartburn, is not ubiquitous which will underestimate the prevalence. Additionally, a large subset of patients will have no subjective symptoms at all but will have objective evidence of reflux disease on endoscopy or pH monitoring and thus are underrepresented on survey-based population studies. An Olmsted County survey found 42 % of people queried had an episode of heartburn in the preceding year while 45 % noted regurgitation. Of this cohort, approximately 5 % visited a physician for the symptoms during this same time period [5].


11.2 History


The diagnosis of GERD can be made by history alone in a patient with the typical symptoms of heartburn and regurgitation, and empiric therapy can be initiated. Given the myriad of over-the-counter (OTC) preparations available, patients have often tried various therapies unsuccessfully prior to seeking medical care. The ineffectiveness of OTC preparations, including proton pump inhibitors (PPIs), does not exclude the diagnosis of GERD, and further investigation is warranted [3].

When chest pain is a presenting symptom, a cardiac etiology should be excluded prior to empiric GERD treatment and/or gastrointestinal work-up. Thought of a cardiac work-up should also be considered for women, who often present with atypical ischemia symptoms, if GERD symptoms are atypical and/or the diagnosis is unclear.


11.3 Risk Factors for GERD






  • Obesity, particularly central


  • Hiatal hernia


  • Pregnancy


  • Smoking


  • Acid hypersecretion, such as Zollinger-Ellison syndrome


  • Lower esophageal dysfunction, such as post myotomy


  • Dysfunctional esophageal clearance, as with scleroderma


  • Delayed gastric emptying as seen in gastroparesis


11.4 Symptoms (Red Flags*)






  • Heartburn


  • Regurgitation


  • Dysphagia*


  • Burping


  • Dyspepsia


  • Nausea


  • Epigastric pain


  • Bloating


  • Chest pain


  • Bronchospasm


  • Odynophagia*


  • Sore throat


  • Hoarseness


  • Water brash


  • Chronic cough


  • Chronic otitis media/sinusitis


  • Sleep disturbance


  • Weight loss*


11.5 Physical Exam


As the esophagus is not directly accessible, the physical evaluation for GERD focuses on evaluating for other possible etiologies particularly for extraesophageal symptoms, when present:



  • Vital signs



    • Pulse oximetry

      GERD is not likely the primary cause of hypoxia but can exacerbate hypoxia in an individual with underlying pulmonary disease.


  • Head, neck, and throat



    • Laryngeal and pharyngeal inflammation


    • Dental enamel erosion


    • Sinus inflammation


    • Otitis media

      The above symptoms are related to chronic recurrent irritation of regurgitated acid resulting in inflammation and hyperplasia.


  • Pulmonary



    • Wheezing and crackles

      Severe GERD can result in primary pulmonary disease but more often triggers an exacerbation of an underlying chronic pulmonary disease.


  • Abdomen



    • Substernal chest pain or epigastric pain

      Possible if GERD is associated with mucosal-based disease like erosive esophagitis or ulceration


    • Abdominal pain with palpation

      Not a common finding. It may indicate alternative diagnosis.


    • Bowel sounds

      If high-pitched or tympanic sounds are present, it may be suggestive of a bowel obstruction, particularly if nausea or vomiting is present.


11.6 Differential Diagnosis


Diagnostic testing is reserved for alarm symptoms, recurrent symptoms, complications, or when the diagnosis remains unclear [7].

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Nov 20, 2017 | Posted by in Uncategorized | Comments Off on Gastroesophageal Reflux Disease (GERD)

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