Clinical Pearls & Morning Reports
Published September 28, 2022
Gastroesophageal reflux disease (GERD) is a condition in which the reflux of stomach contents causes troublesome symptoms and complications. Read the NEJM Clinical Practice Article here.
Q: Describe the range of manifestations associated with GERD.
A: Although heartburn and regurgitation are considered typical, a broad range of manifestations have been associated with GERD, including chronic cough, a globus sensation, wheezing, posterior laryngitis, dental erosions, and idiopathic pulmonary fibrosis. Risk factors for GERD include an age of 50 years or older, current smoking, use of nonsteroidal antiinflammatory drugs, obesity, low socioeconomic status, and female sex.
Q: Of patients with GERD, who should undergo upper endoscopy?
A: Upper endoscopy is generally limited to patients with GERD who report alarm symptoms (dysphagia, odynophagia, weight loss, anorexia, vomiting, and upper gastrointestinal bleeding), who have no response or an incomplete response to treatment or have recurrent GERD after a successful 8-week course of empirical therapy, who are candidates for antireflux or bariatric surgery, or who are at increased risk for Barrett’s esophagus.
A: Pharmacologic treatment for GERD includes medications taken as needed or daily. The medications that are most frequently used are antacids, histamine2 blockers, and proton pump inhibitors (PPIs). PPIs are the most effective medication for GERD symptom relief, healing of erosive esophagitis, and prevention of disease relapse and complications. In a meta-analysis of randomized, controlled trials of antireflux therapies in patients with erosive esophagitis, the percentage of patients with esophageal healing within 12 weeks after starting treatment was 51.9% with histamine2-receptor antagonists as compared with 83.6% with PPIs, and healing was more rapid with PPIs. Moreover, PPIs were superior to histamine2-receptor antagonists in relieving symptoms (in 77.4% vs. 47.6% of patients), maintaining symptom relief, and preventing complications. PPIs should be used at the lowest dose that controls the patient’s symptoms and esophageal inflammation, and the appropriateness of treatment should be periodically reevaluated.
A: Reflux testing allows for assessment of the degree, height, and type (acidic or weakly acidic) of gastroesophageal reflux and the correlation between symptoms and reflux events. Ambulatory 24-hour pH monitoring is highly sensitive (79 to 96%) and specific (85 to 100%) in patients with erosive esophagitis but less so in patients with nonerosive reflux disease. During reflux testing, a PH catheter is introduced into the nose and placed 5 cm above the proximal margin of the lower esophageal sphincter. The ambulatory 24-hour esophageal impedance–pH monitoring system includes sensors that can detect impedance changes in response to liquid reflux or belched air. An alternative approach is the wireless pH capsule, which provides an extended recording time of up to 96 hours. The capsule is introduced orally by means of a delivery device and attached to the distal esophagus. Appropriate candidates for reflux monitoring include patients who have GERD symptoms despite twice-daily PPI treatment and normal findings on endoscopy. For patients without previous evidence of GERD, any one of the aforementioned reflux tests performed while the patient is not receiving PPI treatment is recommended; the wireless pH capsule is preferred, if available. For patients with previously documented GERD, impedance–pH testing while the patient is receiving PPI treatment is recommended.