Gastro Esophageal Reflux Disease - Clinicals, Diagnosis, and Management

Upper GI

Clinicals - History

Fact Explanation
Heartburn There is relaxation of the lower esophageal sphincter, leading to acid reflux in to the esophagus that causes heart burn. Heartburn
There is relaxation of the lower esophageal sphincter, leading to acid reflux in to the esophagus that causes heart burn.
Reflux Reflux of acidic substance in to the esophagus occurs due to the lax lower esophageal sphincter. Reflux
Reflux of acidic substance in to the esophagus occurs due to the lax lower esophageal sphincter.
Acid brash Reflux of acid sometimes reaches the mouth, this causes an unpleasant bitter taste, known as acid brash. Acid brash
Reflux of acid sometimes reaches the mouth, this causes an unpleasant bitter taste, known as acid brash.
Odynophagia Difficulty of swallowing is due to esophagitis, which occurs due to the acid reflux. Odynophagia
Difficulty of swallowing is due to esophagitis, which occurs due to the acid reflux.
Chronic cough Micro aspiration of gastric fluid in to the upper respiratory tract leading to laryngeal irritation and cough. Chronic cough
Micro aspiration of gastric fluid in to the upper respiratory tract leading to laryngeal irritation and cough.
Hoarseness Micro aspiration of gastric fluid in to the upper respiratory tract causes laryngitis. Hoarseness
Micro aspiration of gastric fluid in to the upper respiratory tract causes laryngitis.
Chest pain This is non cardiac in origin, and is usually described as being of a non radiating, burning type. Chest pain
This is non cardiac in origin, and is usually described as being of a non radiating, burning type.
Globus Patient complains of a feeling of having something stuck in his/her throat. This may be a presenting feature in reflux disease. Globus
Patient complains of a feeling of having something stuck in his/her throat. This may be a presenting feature in reflux disease.

Clinicals - Examination

Fact Explanation
Overweight Obesity causes increased intra abdominal pressure. Which when greater than the intra thoracic pressure leads to incompetence of the lower esophageal sphincter, causing reflux. Overweight
Obesity causes increased intra abdominal pressure. Which when greater than the intra thoracic pressure leads to incompetence of the lower esophageal sphincter, causing reflux.
Loss of weight Loss of weight in GERD is due to anorexia caused by long standing disease. Loss of weight
Loss of weight in GERD is due to anorexia caused by long standing disease.
Rhonchi Asthma is a risk factor for the development of GERD. As it creates negative intra thoracic pressure causing incompetence of the lower esophageal sphincter that leads to reflux. Rhonchi
Asthma is a risk factor for the development of GERD. As it creates negative intra thoracic pressure causing incompetence of the lower esophageal sphincter that leads to reflux.
Lung crepitations Long term illness can cause aspiration pneumonia, chemical pneumonitis and lung fibrosis. Lung crepitations
Long term illness can cause aspiration pneumonia, chemical pneumonitis and lung fibrosis.
ENT examination: Laryngeal erythema, ulcers or granulomas and associated edema of the vocal cords Due to acute inflammation of the larynx by micro aspiration of gastric fluid. ENT examination: Laryngeal erythema, ulcers or granulomas and associated edema of the vocal cords
Due to acute inflammation of the larynx by micro aspiration of gastric fluid.
Abnormal cardiovascular reflexes It has been shown that an abnormality in vagal function maybe present in patients with GERD. Maintenance of the lower esophageal sphincter tone is a vago-vagal reflex, therefore such patients are predisposed towards the development of GERD. Abnormal cardiovascular reflexes
It has been shown that an abnormality in vagal function maybe present in patients with GERD. Maintenance of the lower esophageal sphincter tone is a vago-vagal reflex, therefore such patients are predisposed towards the development of GERD.

Investigations - Diagnosis

Fact Explanation
Upper GI Endoscopy and Biopsy Only 50% of patients will have manifestations of GERD or esophagitis. Endoscopy is more useful in diagnosis of complications like Barret esophagus and hiatus hernia. Endoscopy will demonstrate esophageal erythema and traachealization that indicate inflammation. Hiatus hernia which is also a contributory factor for GERD, can be visualized. Upper GI Endoscopy and Biopsy
Only 50% of patients will have manifestations of GERD or esophagitis. Endoscopy is more useful in diagnosis of complications like Barret esophagus and hiatus hernia. Endoscopy will demonstrate esophageal erythema and traachealization that indicate inflammation. Hiatus hernia which is also a contributory factor for GERD, can be visualized.
Radiological Investigation Barium studies will show features suggestive of esophagitis such as erosions and ulcerations, strictures,hiatal hernia, thickening of mucosal folds and poor distensibility. Radiological Investigation
Barium studies will show features suggestive of esophagitis such as erosions and ulcerations, strictures,hiatal hernia, thickening of mucosal folds and poor distensibility.
Ambulatory pH monitoring This is the gold standard in the diagnosis of GERD. Probe of pH monitor is placed within the lower oesophagus , above the lower esophageal sphincter and pH is recorded over 24 hours. Ambulatory pH monitoring
This is the gold standard in the diagnosis of GERD. Probe of pH monitor is placed within the lower oesophagus , above the lower esophageal sphincter and pH is recorded over 24 hours.
Biopsy Used to diagnose esophagitis associated with GERD. It can also be used screen patients with long standing reflux, for lower esophageal adenocarcinoma. Biopsy
Used to diagnose esophagitis associated with GERD. It can also be used screen patients with long standing reflux, for lower esophageal adenocarcinoma.
Esophageal manometry Important in detecting the function of the lower esophageal sphincter, it is recommended that manometry is performed prior to the pH monitoring test. It will exclude achalasia cardia as a possible differential. Esophageal manometry
Important in detecting the function of the lower esophageal sphincter, it is recommended that manometry is performed prior to the pH monitoring test. It will exclude achalasia cardia as a possible differential.

Management - Supportive

Fact Explanation
Dietary modification: Avoid large meals Avoidance of large meals reduces reflux, as it reduces the volume of stomach contents, that can distend the lower esophageal sphincter. Dietary modification: Avoid large meals
Avoidance of large meals reduces reflux, as it reduces the volume of stomach contents, that can distend the lower esophageal sphincter.
Dietary modification: Avoid acidic foods Certain food items increase gastric acid secretion, and cause relaxation of the lower esophageal sphincter. Patients are advised to avoid foods such as citrus- and tomato-based products, alcohol, caffeinated beverages, chocolate, onions, garlic and peppermint. Dietary modification: Avoid acidic foods
Certain food items increase gastric acid secretion, and cause relaxation of the lower esophageal sphincter. Patients are advised to avoid foods such as citrus- and tomato-based products, alcohol, caffeinated beverages, chocolate, onions, garlic and peppermint.
Dietary modification: Reduce fat intake Foods rich in fat increases reflux, in addition, obesity is a risk factor for GERD. , Dietary modification: Reduce fat intake
Foods rich in fat increases reflux, in addition, obesity is a risk factor for GERD. ,
Change of sleeping position Patient should be advised to avoid lying down within three to four hours of a meal. The head end of the bed can be elevated 10 to 20 cm. Change of sleeping position
Patient should be advised to avoid lying down within three to four hours of a meal. The head end of the bed can be elevated 10 to 20 cm.
Avoidance of tight cloths Wearing tight clothes around the waist is thought to cause increased reflux activity, by increasing intra abdominal pressure., Avoidance of tight cloths
Wearing tight clothes around the waist is thought to cause increased reflux activity, by increasing intra abdominal pressure.,
Avoid or substitute medicine that worsens GERD Some medications increase gastric acid secretion, including calcium channel blockers, beta agonists, alpha-adrenergic agonists, theophylline, nitrates, and some sedatives. ,, Avoid or substitute medicine that worsens GERD
Some medications increase gastric acid secretion, including calcium channel blockers, beta agonists, alpha-adrenergic agonists, theophylline, nitrates, and some sedatives. ,,
Weight loss Exercises and dietary modification is recommended for weight loss in GERD patients because obesity is a proven risk factor. Obestiy increases intra abdominal pressure which worsens reflux. ,, Weight loss
Exercises and dietary modification is recommended for weight loss in GERD patients because obesity is a proven risk factor. Obestiy increases intra abdominal pressure which worsens reflux. ,,

Management - Specific

Fact Explanation
Antacids Antacids are to neutralize the gastric acid and to quick relieve symptoms. alginate combined with antacids were proven more effective Antacids
Antacids are to neutralize the gastric acid and to quick relieve symptoms. alginate combined with antacids were proven more effective
H2 receptor antagonist H2 receptive antagonists are proven to be beneficial in oesophagitis especially with higher and frequent dosing. H2-receptor blockers act by inhibiting histamine stimulation of the gastric parietal cell, thereby suppressing gastric acid secretion. H2 receptor antagonist
H2 receptive antagonists are proven to be beneficial in oesophagitis especially with higher and frequent dosing. H2-receptor blockers act by inhibiting histamine stimulation of the gastric parietal cell, thereby suppressing gastric acid secretion.
Proton Pump Inhibitors PPI irreversibly inhibit the H+-K+ adenosine triphosphatase pump of the parietal cell. By blocking the final common pathway of gastric acid secretion, the proton pump inhibitors provide a greater degree and duration of gastric acid suppression compared with H2-receptor blockers. Proton Pump Inhibitors
PPI irreversibly inhibit the H+-K+ adenosine triphosphatase pump of the parietal cell. By blocking the final common pathway of gastric acid secretion, the proton pump inhibitors provide a greater degree and duration of gastric acid suppression compared with H2-receptor blockers.
Pro kinetic medication Pharmacological agents that improve gastric motility such as domperidone and metoclorpramide can be used. Rapid transit of food through the stomach, reduces reflux. Pro kinetic medication
Pharmacological agents that improve gastric motility such as domperidone and metoclorpramide can be used. Rapid transit of food through the stomach, reduces reflux.
Anti reflux surgery: Fundoplication Recommended for who patients that fail to respond to medical therapy, or for GERD with a large hiatus hernia or severe erosive gastritis. Open or laparoscopic Niessen Fundoplication has a higher success rate but laparoscopic fundoplication has fewer complications and faster recovery compared to open surgery. Common postoperative symptoms are dysphagia, belching, flatulence and diarrhea. , Anti reflux surgery: Fundoplication
Recommended for who patients that fail to respond to medical therapy, or for GERD with a large hiatus hernia or severe erosive gastritis. Open or laparoscopic Niessen Fundoplication has a higher success rate but laparoscopic fundoplication has fewer complications and faster recovery compared to open surgery. Common postoperative symptoms are dysphagia, belching, flatulence and diarrhea. ,
Endoscopic treatment Radio frequency heating of the gastro esophageal junction (Stretta procedure) and endoscopic gastroplasty (Endocinch procedure) are proven to improve quality of life and decrease reflux symptoms in patients. Endoscopic treatment
Radio frequency heating of the gastro esophageal junction (Stretta procedure) and endoscopic gastroplasty (Endocinch procedure) are proven to improve quality of life and decrease reflux symptoms in patients.

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  1. AW R, MALTEPE C, BOZZO P, EINARSON A. Treatment of heartburn and acid reflux associated with nausea and vomiting during pregnancy Can Fam Physician [online] 2010 Feb, 56(2):143-144 [viewed 23 May 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2821234
  2. Advances in GERD: Current Developments in the Management of Acid-Related GI Disorders Gastroenterol Hepatol (N Y) [online] 2009 Sep, 5(9):613-615 [viewed 23 May 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2886414
  3. BAGHURST PA, NICHOL LW. The binding of organic phosphates to human methaemoglobin A. Perturbation of the polymerization of proteins by effectors. Biochim Biophys Acta [online] 1975 Nov 18, 412(1):168-80 [viewed 23 May 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/80
  4. BIANCO M, ROTONDANO G, GAROFANO M, CIPOLLETTA L. Endoscopic treatment of gastro-oesophageal reflux disease Acta Otorhinolaryngol Ital [online] 2006 Oct, 26(5):281-286 [viewed 23 May 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2639974
  5. BOWREY DJ, PETERS JH, DEMEESTER TR. Gastroesophageal Reflux Disease in Asthma: Effects of Medical and Surgical Antireflux Therapy on Asthma Control Ann Surg [online] 2000 Feb, 231(2):161-172 [viewed 23 May 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1420982
  6. BRAMS JA. Chemoprevention of Esophageal Adenocarcinoma Therap Adv Gastroenterol [online] 2008 Jul, 1(1):7-18 [viewed 23 May 2014] Available from: doi:10.1177/1756283X08093568
  7. CHAIT MM. Gastroesophageal reflux disease: Important considerations for the older patients World J Gastrointest Endosc [online] 2010 Dec 16, 2(12):388-396 [viewed 23 May 2014] Available from: doi:10.4253/wjge.v2.i12.388
  8. CHAKRABORTY TK, OGILVIE AL, HEADING RC, EWING DJ. Abnormal cardiovascular reflexes in patients with gastro-oesophageal reflux. Gut [online] 1989 Jan, 30(1):46-49 [viewed 26 May 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1378229
  9. FASS R, MCCALLUM RW, PARKMAN HP. Treatment Challenges in the Management of Gastroparesis-Related GERD Gastroenterol Hepatol (N Y) [online] 2009 Oct, 5(10 Suppl 18):4-16 [viewed 23 May 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2886367
  10. GREMSE DA. GERD in the Pediatric Patient: Management Considerations MedGenMed [online] , 6(2):13 [viewed 23 May 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1395762
  11. HASOSAH MY, SUKKAR GA, ALSAHAFI AF, THABIT AO, FAKEEH ME, AL-ZAHRANI DM, SATTI MB. Eosinophilic Esophagitis in Saudi Children: Symptoms, Histology and Endoscopy Results Saudi J Gastroenterol [online] 2011, 17(2):119-123 [viewed 23 May 2014] Available from: doi:10.4103/1319-3767.77242
  12. HUGHES J, LOCKHART J, JOYCE A. Do calcium antagonists contribute to gastro-oesophageal reflux disease and concomitant noncardiac chest pain? Br J Clin Pharmacol [online] 2007 Jul, 64(1):83-89 [viewed 23 May 2014] Available from: doi:10.1111/j.1365-2125.2007.02851.x
  13. HURT RT, KULISEK C, BUCHANAN LA, MCCLAVE SA. The Obesity Epidemic: Challenges, Health Initiatives, and Implications for Gastroenterologists Gastroenterol Hepatol (N Y) [online] 2010 Dec, 6(12):780-792 [viewed 23 May 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3033553
  14. HYUN JJ, BAK YT. Clinical Significance of Hiatal Hernia Gut Liver [online] 2011 Sep, 5(3):267-277 [viewed 23 May 2014] Available from: doi:10.5009/gnl.2011.5.3.267
  15. ISOLAURI J, LAIPPALA P. Prevalence of symptoms suggestive of gastro-oesophageal reflux disease in an adult population. Ann Med [online] 1995 Feb, 27(1):67-70 [viewed 26 May 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/7742002
  16. JOEL J. HEIDELBAUGH, TIMOTHY T. NOSTRANT, CLARA KIM, R. VAN HARRISON, Management of Gastroesophageal Reflux Disease,Am Fam Physician[online]. 2003 Oct 1;68(7):1311-1319.[viewed 23 May 2014] Available from: http://www.aafp.org/afp/2003/1001/p1311.html
  17. JOEL J. HEIDELBAUGH, ARVIN S. GILL, et al, Atypical Presentations of Gastroesophageal Reflux Disease , Am Fam Physician[online]. 2008 Aug 15;78(4):483-488.[viewed 22 May 2014] Available from: http://www.aafp.org/afp/2008/0815/p483.html
  18. KAPLAN LM. Treatment of Gastroesophageal Reflux Disease in Obese Patients Gastroenterol Hepatol (N Y) [online] 2008 Dec, 4(12):841-843 [viewed 26 May 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3093685
  19. KINOSHITA Y, ISHIHARA S. Causes of, and Therapeutic Approaches for, Proton Pump Inhibitor-Resistant Gastroesophageal Reflux Disease in Asia Therap Adv Gastroenterol [online] 2008 Nov, 1(3):191-199 [viewed 23 May 2014] Available from: doi:10.1177/1756283X08098181
  20. LEE BE, KIM GH. Globus pharyngeus: A review of its etiology, diagnosis and treatment World J Gastroenterol [online] 2012 May 28, 18(20):2462-2471 [viewed 23 May 2014] Available from: doi:10.3748/wjg.v18.i20.2462
  21. LIU JJ. Endoscopic treatment for gastroesophageal reflux disease: Should you learn the techniques? Can J Gastroenterol [online] 2007 Apr, 21(4):213-215 [viewed 23 May 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2657692
  22. MAINIE I, TUTUIAN R, SHAY S, VELA M, ZHANG X, SIFRIM D, CASTELL DO. Acid and non-acid reflux in patients with persistent symptoms despite acid suppressive therapy: a multicentre study using combined ambulatory impedance-pH monitoring Gut [online] 2006 Oct, 55(10):1398-1402 [viewed 23 May 2014] Available from: doi:10.1136/gut.2005.087668
  23. MARK H. EBELL, Diagnosis of Gastroesophageal Reflux Disease,Am Fam Physician[online]. 2010 May 15;81(10):1278-1280.[viewed 22 May 2014] Available from:http://www.aafp.org/afp/2010/0515/p1278.html
  24. MARK SCOTT, AIMEE R. GELHOT, Gastroesophageal Reflux Disease: Diagnosis and Management,Am Fam Physician[online]. 1999 Mar 1;59(5):1161-1169.[viewed 23 May 2014] Available from: http://www.aafp.org/afp/1999/0301/p1161.html
  25. SAVARINO E, DE BORTOLI N, ZENTILIN P, MARTINUCCI I, BRUZZONE L, FURNARI M, MARCHI S, SAVARINO V. Alginate controls heartburn in patients with erosive and nonerosive reflux disease World J Gastroenterol [online] 2012 Aug 28, 18(32):4371-4378 [viewed 23 May 2014] Available from: doi:10.3748/wjg.v18.i32.4371
  26. SCHENK BE, KUIPERS EJ, KLINKENBERG-KNOL EC, FESTEN HP, JANSEN EH, TUYNMAN HA, SCHRIJVER M, DIELEMAN LA, MEUWISSEN SG. Omeprazole as a diagnostic tool in gastroesophageal reflux disease. Am J Gastroenterol [online] 1997 Nov, 92(11):1997-2000 [viewed 23 May 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/9362179
  27. SCHOLTEN T. Long-term management of gastroesophageal reflux disease with pantoprazole Ther Clin Risk Manag [online] 2007 Jun, 3(2):231-243 [viewed 23 May 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1936305
  28. SIFRIM D, CASTELL D, DENT J, KAHRILAS PJ. Gastro-oesophageal reflux monitoring: review and consensus report on detection and definitions of acid, non-acid, and gas reflux Gut [online] 2004 Jul, 53(7):1024-1031 [viewed 23 May 2014] Available from: doi:10.1136/gut.2003.033290
  29. STORR MA. What is nonacid reflux disease? Can J Gastroenterol [online] 2011 Jan, 25(1):35-38 [viewed 23 May 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3027332
  30. THOMSON A. Impact of PPIs on patient focused symptomatology in GERD Ther Clin Risk Manag [online] 2008 Dec, 4(6):1185-1200 [viewed 23 May 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2643100
  31. V.I. Gavrilov. Acta Virol [online] 1975 Nov, 19(6):510 [viewed 23 May 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/2003
  32. YAGNIK VD. Is oesophageal manometry a must before laparoscopic fundoplication? J Minim Access Surg [online] 2011, 7(2):161 [viewed 23 May 2014] Available from: doi:10.4103/0972-9941.78357