© Springer International Publishing Switzerland 2017
Bobby Desai and Alpa Desai (eds.)Primary Care for Emergency Physicians10.1007/978-3-319-44360-7_1111. Gastroesophageal Reflux Disease (GERD)
(1)
Division of Gastroenterology, Department of Internal Medicine, 100277, Gainesville, FL 32610-0277, USA
Keywords
RefluxHiatal herniaHistamine antagonistsProton pump inhibitorsBloating11.1 Introduction
Gastroesophageal reflux disease (GERD) is the reflux of gastric content into the esophagus causing discomfort. It is the most commonly diagnosed GI disorder. The exact prevalence of the disease is unclear as the most common symptom, heartburn, is not ubiquitous which will underestimate the prevalence. Additionally, a large subset of patients will have no subjective symptoms at all but will have objective evidence of reflux disease on endoscopy or pH monitoring and thus are underrepresented on survey-based population studies. An Olmsted County survey found 42 % of people queried had an episode of heartburn in the preceding year while 45 % noted regurgitation. Of this cohort, approximately 5 % visited a physician for the symptoms during this same time period [5].
11.2 History
The diagnosis of GERD can be made by history alone in a patient with the typical symptoms of heartburn and regurgitation, and empiric therapy can be initiated. Given the myriad of over-the-counter (OTC) preparations available, patients have often tried various therapies unsuccessfully prior to seeking medical care. The ineffectiveness of OTC preparations, including proton pump inhibitors (PPIs), does not exclude the diagnosis of GERD, and further investigation is warranted [3].
When chest pain is a presenting symptom, a cardiac etiology should be excluded prior to empiric GERD treatment and/or gastrointestinal work-up. Thought of a cardiac work-up should also be considered for women, who often present with atypical ischemia symptoms, if GERD symptoms are atypical and/or the diagnosis is unclear.
11.3 Risk Factors for GERD
Obesity, particularly central
Hiatal hernia
Pregnancy
Smoking
Acid hypersecretion, such as Zollinger-Ellison syndrome
Lower esophageal dysfunction, such as post myotomy
Dysfunctional esophageal clearance, as with scleroderma
Delayed gastric emptying as seen in gastroparesis
11.4 Symptoms (Red Flags*)
Heartburn
Regurgitation
Dysphagia*
Burping
Dyspepsia
Nausea
Epigastric pain
Bloating
Chest pain
Bronchospasm
Odynophagia*
Sore throat
Hoarseness
Water brash
Chronic cough
Chronic otitis media/sinusitis
Sleep disturbance
Weight loss*
11.5 Physical Exam
As the esophagus is not directly accessible, the physical evaluation for GERD focuses on evaluating for other possible etiologies particularly for extraesophageal symptoms, when present:
Vital signs
Pulse oximetry
GERD is not likely the primary cause of hypoxia but can exacerbate hypoxia in an individual with underlying pulmonary disease.
Head, neck, and throat
Laryngeal and pharyngeal inflammation
Dental enamel erosion
Sinus inflammation
Otitis media
The above symptoms are related to chronic recurrent irritation of regurgitated acid resulting in inflammation and hyperplasia.
Pulmonary
Wheezing and crackles
Severe GERD can result in primary pulmonary disease but more often triggers an exacerbation of an underlying chronic pulmonary disease.
Abdomen
Substernal chest pain or epigastric pain
Possible if GERD is associated with mucosal-based disease like erosive esophagitis or ulceration
Abdominal pain with palpation
Not a common finding. It may indicate alternative diagnosis.
Bowel sounds
If high-pitched or tympanic sounds are present, it may be suggestive of a bowel obstruction, particularly if nausea or vomiting is present.
11.6 Differential Diagnosis
Diagnostic testing is reserved for alarm symptoms, recurrent symptoms, complications, or when the diagnosis remains unclear [7].
Coronary artery disease
Esophageal disease
Esophageal motility disorder
Esophagitis
Functional esophageal dysfunction
Zenker’s diverticulum
Eosinophilic esophagitis
Gastric disease
Gastroparesis
Gastritis
Peptic ulcer disease
Gastric outlet obstruction
