Gastroesophageal reflux disease: Clinical sciences
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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!
Sources
- "ACG Clinical Guideline for the Diagnosis and Management of Gastroesophageal Reflux Disease" Am J Gastroenterol (2022)
- "AGA Clinical Practice Update on the Personalized Approach to the Evaluation and Management of GERD: Expert Review" Clin Gastroenterol Hepatol (2022)
- "How to Interpret Esophageal Impedance pH Monitoring" J Neurogastroenterol Motil (2010)
- "Diseases of the Esophagus" Goldman-Cecil Medicine, 26th ed. (2020)
- "Gastroesophageal Reflux Disease" CDIM CORE MEDICINE CLERKSHIP CURRICULUM GUIDE, 4TH EDITION (2020)
- "Extraesophageal Symptoms and Diseases Attributed to GERD: Where is the Pendulum Swinging Now?" Clin Gastroenterol Hepatol (2018)