Chapter 9-7: Gastroesophageal Reflux Disease (GERD)

TEXTBOOK PRESENTATION

Heartburn (a burning, substernal, chest discomfort) is usually the presenting symptom in a patient with GERD. Other classic symptoms are regurgitation or dysphagia; chest pain is a common alternative presentation. Patients often report that their symptoms are worst at night and after large meals.

Although dysphagia is a common presentation of GERD, its presence raises the possibility of an obstructing lesion and thus mandates prompt evaluation, usually with upper endoscopy.

DISEASE HIGHLIGHTS

1. The symptoms of GERD are so well-known that some patients diagnose themselves before visiting a physician.

2. GERD is a common cause of chest pain.

3. GERD can be further classified as either erosive or nonerosive based on endoscopic examination findings.

4. There are GI and non-GI complications of GERD.

   1. GI

      1. Esophagitis

      2. Stricture formation

      3. Barrett esophagus

      4. Esophageal adenocarcinoma

   2. Non-GI

      1. Chronic cough

      2. Hoarseness

      3. Worsening of asthma

5. Esophageal disorders, other than GERD, might also present as chest pain.

   1. Esophagitis or esophageal ulcer

      1. Often causes odynophagia

      2. Multiple causes include infection and pill esophagitis.

      3. Common causes of pill esophagitis include bisphosphonates, tetracyclines, nonsteroidal anti-inflammatory drugs (NSAIDs), and potassium.

   2. Esophageal cancer

      1. Often associated with dysphagia

      2. Smoking, alcohol use, and chronic reflux are risk factors.

   3. Esophageal rupture (Boerhaave syndrome). Often presents with acute pain after retching.

   4. Esophageal spasm and motility disorders. Often present with intermittent chest pain and dysphagia.

EVIDENCE-BASED DIAGNOSIS

1. Cardiac causes should be excluded in patients with chest pain before beginning a GI evaluation.

2. GERD should be high in the differential diagnosis of chest pain when heartburn, regurgitation, or dysphagia is present or when other commonly associated symptoms or complications (eg, chronic cough and asthma) are present.

3. Identifying factors that exacerbate the symptoms of GERD is helpful both in diagnosis and management. Such factors include:

   1. Ingesting large (especially fatty) meals

   2. Lying down after a meal

   3. Using tobacco

   4. Eating foods that relax the lower esophageal sphincter

      1. Chocolate

      2. Alcohol

      3. Coffee

      4. Peppermint

4. Historical features help differentiate esophageal from cardiac chest pain.

   1. A small study analyzed the prevalence of several historical features in 100 patients in an emergency department with either esophageal or cardiac chest pain.

   2. The differences that reached statistical significance are listed in Table 9-4. Although the study was small, the data are instructive.

   3. From these data, it is clear that history cannot differentiate esophageal chest pain from pain due to cardiac ischemia. That said, pain that occurs with swallowing, is persistent, wakes the patient from sleep, is positional, and is associated with heartburn or regurgitation is more likely to be of esophageal origin.

   4. Note that only 83% of patients with an esophageal cause of pain in this study had GI symptoms (ie, heartburn, regurgitation, dysphagia, or vomiting).

   5. Certain characteristics generally thought to suggest a cardiac origin of pain were nearly equally common in patients with cardiac and esophageal causes of chest pain.

      1. Radiation to the left arm: 38% of patients of cardiac cause; 33% of patients ...