Gastroesophageal reflux disease: Clinical sciences

Gastroesophageal reflux disease, or GERD for short, is a chronic condition in which the lower esophageal sphincter becomes weak or relaxes at the wrong time. This allows acidic content from the stomach to flow back up into the esophagus. Over time, exposure to gastric acid can irritate and damage the lining of the esophagus and cause a variety of symptoms, which are commonly grouped into typical, atypical, and alarm symptoms.

Now, if your patient presents with signs and symptoms suggestive of GERD, you should first perform an ABCDE assessment to determine if your patient is unstable or stable.

If unstable, stabilize their airway, breathing, and circulation. Next, obtain IV access and administer IV fluids, and don’t forget to put your patient on continuous vital sign monitoring. Finally, if you identify signs of active gastrointestinal bleeding, such as melena or hematemesis, perform an emergent esophagogastroduodenoscopy, or EGD.

Now, let’s go back and take a look at stable patients.

In this case, start with a focused history and physical examination. Individuals with GERD might report classic symptoms, like heartburn, also known as pyrosis, acid regurgitation, or a sour or bitter taste in the back of the mouth.

Some might also experience non-specific symptoms, such as chronic cough, hoarseness, or frequent throat clearing.

On physical exam, findings are usually normal. However, in some cases, you might notice subtle signs of acid damage, such as dental erosion. If your patient reports any of these symptoms, suspect GERD.

Next, assess the patient for alarm signs and symptoms that warrant urgent evaluation for GERD complications. These include anemia, dysphagia or odynophagia, gastrointestinal bleeding, frequent vomiting, or unintentional weight loss.

If one or more alarm signs and symptoms are present, you should suspect a GERD complication and proceed with an urgent EGD with biopsies.

If the biopsy reveals friable, erythematous epithelium with inflammatory cells consistent with erosive esophagitis, the diagnosis is GERD.

Management of course includes lifestyle modifications, such as smoking cessation, and reducing foods that trigger reflux symptoms, such as tomatoes and alcohol.

However, the cornerstone of treatment is acid suppression, which typically involves proton pump inhibitors, or PPIs, such as omeprazole, and histamine-2 receptor antagonists, or H2-blockers, such as famotidine. Although both PPIs and H2-blockers reduce acid secretion, PPIs are the primary treatment because they relieve symptoms more effectively and promote better healing of esophageal damage than H2-blockers.

Now, here’s a clinical pearl to keep in mind! For intermittent symptom relief, you can also opt for antacids, such as magnesium hydroxide, which work by neutralizing stomach acid.

On the flip side, sucralfate, a nonabsorbable mucosal protective agent, is not commonly used in GERD treatment outside of special situations.

Finally, if your patient experiences recurrent symptoms or you need to evaluate the healing of the esophageal lining, consider repeating an EGD.

Now, let’s go back to EGD and biopsy because in some individuals, erosive esophagitis can progress to more serious conditions.

During the procedure, you might detect an esophageal mass or stricture, while a biopsy might reveal columnar metaplasia or dysplasia, a finding known as Barrett esophagus.

All these findings are suggestive of chronic GERD complications.

In these individuals, again, encourage lifestyle modifications and initiate medical therapy with PPIs or H2-blockers. Additional treatment options include endoscopic interventions, like esophageal dilation to reduce stricture, and endoscopic ablation for dysplasia. Sometimes, you will have to consult your surgical team for esophageal resection of a mass.

Finally, in individuals with Barrett esophagus, repeated EGDs are essential to monitor the esophageal mucosa, because metaplasia can progress to dysplasia, which is a precancerous stage, and eventually to esophageal adenocarcinoma.

Now that we’ve covered how to approach individuals with alarm signs and symptoms, let’s take a step back and look at what to do when these features are absent.

In this case, your first step is to assess the type of GERD presentation.

Now, if your patient reports typical GERD symptoms, such as heartburn, acid regurgitation, or sour or bitter taste in the mouth, and their physical examination is normal, suspect GERD with typical features.

But sometimes, a person may report both typical and atypical GERD symptoms. Atypical symptoms can include chronic cough, hoarseness, frequent throat clearing, laryngitis, pharyngitis, or even sinusitis.

On physical exam, you might find wheezing or signs of acid regurgitation in the mouth, such as dental erosions or erythema. In this case, you should suspect GERD with both typical and atypical features.

In both groups, treatment starts with lifestyle modifications and an eight-week trial of PPIs. After eight weeks, assess the patient’s response to treatment.

If symptoms show an adequate response, diagnose GERD and continue encouraging lifestyle changes, while closely monitoring for any recurrence.

On the other hand, if there’s an inadequate response, or in other words, if symptoms persist during the trial or return after it ends, proceed with an EGD and biopsy.