Gastroesophageal reflux disease: Clinical sciences

Gastroesophageal reflux disease, or GERD for short, is a condition where the lower esophageal sphincter is abnormally relaxed, allowing acid contents from the stomach to enter the esophagus and damage its mucosa. Now, based on clinical manifestations, a person with GERD can present with alarm, typical, and atypical signs and symptoms.

First, you should suspect GERD when a patient complains of epigastric burning that radiates under the sternum, also called pyrosis or heartburn, and a sour or bitter taste in the mouth caused by acid regurgitation.

If that’s the case, the next step should be to assess alarm signs and symptoms, which are typically associated with complications of GERD. Start by obtaining a focused history and physical examination. History typically reveals chest pain, persistent severe heartburn, dysphagia, odynophagia, unintentional weight loss, melena, frequent vomiting, and even hematemesis. At the same time, a physical exam might reveal general discomfort, pallor, or evidence of GI bleeding. For example, the patient might vomit blood right in front of you!

Now, in order to confirm the suspected complications of GERD, you should order an esophagogastroduodenoscopy, or EGD for short, with biopsies, and get some blood work, including a CBC and iron studies. If the EGD, biopsies, and blood work are normal, you should consider an alternative diagnosis. On the flip side, the EGD may often reveal pathologic findings. For example, the biopsy might show tongues of pink mucosa with columnar metaplasia, which suggests Barrett esophagus. On the other hand, it might reveal friable, erythematous epithelium with inflammatory cells, which suggests erosive esophagitis. Additionally, important endoscopic findings might include an esophageal mass or peptic strictures.

But that’s not all; the patient’s blood work might reveal microcytic anemia with iron deficiency. These findings confirm a diagnosis of GERD complications, so you should treat the patient with antacids like proton pump inhibitors, or PPIs, and recommend lifestyle modifications, like smoking cessation. Don’t forget to treat anemia if it’s present!

Additionally, a surgical consult might suggest esophageal dilation, endoscopic ablation, or laparoscopic fundoplication. Esophageal dilation is used to stretch the walls of the esophagus and relieve symptoms of dysphagia; while endoscopic ablation treats precancerous lesions caused by chronic reflux of gastric contents. Finally, laparoscopic fundoplication involves wrapping the top part of the stomach around the lower portion of the esophagus, forming an “artificial” valve that prevents reflux. An important fact to keep in mind is that Barrett esophagus has a high risk of transitioning into esophageal adenocarcinoma, so these individuals will need regular EGD screenings.

Alright, now let’s move on to individuals that present with Typical GERD symptoms. Their history commonly reveals heartburn, and a sour or bitter taste in the mouth. The physical exam is usually normal. However, an oral exam might reveal dental erosions or halitosis. If so, you should start empiric treatment prior to diagnostic workup.

Empiric treatment includes antacid medications, such as proton pump inhibitors, like omeprazole; or histamine-2 receptor blockers, like famotidine. Proton pump inhibitors cause greater acid suppression than H2 receptor blockers, so they are usually preferred. Additionally, all individuals with suspected or diagnosed GERD should receive counseling on lifestyle modifications, like tobacco cessation and weight loss.

Now, if the individual responds well to this medical therapy, this confirms the clinical diagnosis of typical GERD. The patient should continue the current medical therapy, and get an EGD after 1 year to evaluate for conditions like Barret Esophagus and establish the best long-term management plan. On the other hand, if there’s no improvement after empiric therapy, then stop the current medication for 7 to 14 days, and perform an EGD with biopsies to rule out complications of GERD. If the patient presents with an abnormal EGD with biopsies, this confirms the diagnosis of GERD complications, so treat accordingly.