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For further information, see CMDT Part 15-15: Gastroesophageal Reflux Disease

Key Features

Essentials of Diagnosis

  • Heartburn exacerbated by meals, bending, or recumbency

  • Typical uncomplicated cases do not require diagnostic studies

  • Endoscopy demonstrates abnormalities in one-third of patients

General Considerations

  • In a 2020 survey or US adults, 31% reported GERD symptoms within the prior week

  • Most patients have mild disease

  • However, esophageal mucosal damage (reflux esophagitis) develops in up to one-third patients

  • Serious complications develop in a few patients

  • Pathogenesis includes

    • Relaxation or incompetence of lower esophageal sphincter

    • Hiatal hernia

    • Abnormal acid clearance (esophageal peristalsis), eg, systemic sclerosis (scleroderma)

    • Impaired salivation (exacerbates GERD), eg, Sjögren syndrome, anticholinergics, oral radiation therapy

    • Delayed gastric emptying (exacerbates GERD), eg, gastroparesis

Clinical Findings

Symptoms and Signs

  • Heartburn, most often 30–60 minutes after meals and upon reclining, with relief from antacids

  • Regurgitation—spontaneous reflux of sour or bitter gastric contents into the mouth

  • Dysphagia common due to erosive esophagitis, abnormal esophageal peristalsis, or stricture

  • Other symptoms include dyspepsia, dysphagia, belching, and hoarseness

  • Atypical manifestations

    • Asthma

    • Chronic cough

    • Chronic laryngitis

    • Sore throat

    • Noncardiac chest pain

    • Sleep disturbances

  • Gradual development of solid food dysphagia progressive over months to years suggests stricture formation

  • Physical examination normal

Differential Diagnosis

  • Angina pectoris

  • Eosinophilic esophagitis

  • Peptic ulcer disease, gastritis, functional disorders

  • Infectious esophagitis: Candida, herpes simplex virus, cytomegalovirus

  • Pill-induced esophagitis

  • Esophageal motility disorders, eg, achalasia, esophageal spasm, systemic sclerosis

  • Zollinger-Ellison syndrome (gastrinoma) may cause severe esophagitis due to acid hypersecretion


Laboratory Tests

  • Laboratory test results are normal

Imaging Studies

  • Upper endoscopy reveals visible mucosal abnormalities (known as reflux esophagitis) in up to one-third

  • Endoscopy is indicated

    • In patients who have not responded to empiric medical management

    • In patients with symptoms suggesting complicated disease (dysphagia, odynophagia, weight loss, or iron deficiency anemia)

    • In patients who have long-standing (> 5 years) symptoms to look for Barrett esophagus

    • To differentiate peptic stricture from other benign or malignant causes of dysphagia

  • Barium esophagography

    • Should not be used to diagnose GERD

    • May be performed before endoscopy is used to detect stricture in patients with severe dysphagia

Diagnostic Procedures

  • Clinical diagnosis has sensitivity and specificity of about 65%

  • In patients with typical GERD symptoms without complications, empiric medical management is recommended without diagnostic procedures

  • Esophageal pH monitoring measures the amount of esophageal acid reflux, whereas combined pH-impedance testing measures both acidic and nonacidic reflux

    • Unnecessary in most patients who have typical symptoms and satisfactory response to empirical anti-secretory therapy

    • Most accurate studies for documenting gastroesophageal reflux

    • Indications include

      • Unsatisfactory response to empiric therapy

      • Atypical or extraesophageal symptoms

      • Consideration of antireflux surgery

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