Gastroesophageal reflux disease

Journal of Family Practice, March, 2003 by Colin W. Howden, William D. Chey

* PRACTICE RECOMMENDATIONS

* Heartburn on 2 or more days a week warrants medical attention, as patients are likely to suffer from gastroesophageal reflux disease (GERD). Chronic GERD can lead to the development of complications including erosive esophagitis, stricture formation, and Barrett's esophagus, which increases the risk of esophageal adenocarcinoma.

* A trial with a proton pump inhibitor (PPI) is the quickest and most cost-effective way to diagnose GERD, and is at least as sensitive as 24-hour intraesophageal pH monitoring.

* AS PPIs only bind to actively secreting proton pumps, they should be dosed 30 to 60 minutes before a meal. Despite these recommendations, a recent survey of over 1000 US primary care physicians found that 36% instructed their patients to take a PPI with or after a meal or did not specify the timing of dosing.

* The patients who will have the best response to surgical therapy for GERD are those who had clearly documented acid reflux with typical symptoms, and who have responded to PPI treatment. Unfortunately, the same survey found that most physicians recommend antireflux surgery for patients in whom medical therapy has failed.

Gastroesophageal reflux disease (GERD) is a common, multifactorial condition that often results in decreased quality of life with interruptions of sleep, work, and social activities. Patients have reported that GERD affects emotional well-being to a greater degree than diabetes or hypertension. (1,2) GERD is also associated with well-established complications, including Barrett's esophagus. The role of reflux in carcinogenesis is controversial; the possibility of an association, however, implies that GERD should be treated aggressively and early. (3)

SYMPTOMS OF GERD

The typical symptoms of GERD are heartburn and regurgitation. Heartburn is best defined as a burning retrosternal discomfort starting in the epigastrium or lower chest and moving upwards towards the neck. Regurgitation is the effortless movement of gastric contents up into the esophagus or pharynx.

Most patients with GERD do not have endoscopically visible lesions; a careful analysis of symptoms generally forms the basis of a preliminary diagnosis.

The occurrence of heartburn on 2 or more days a week has been suggested as a basis for further investigation for GERD. (4) However, symptoms vary greatly. Patients may be asymptomatic or experience symptoms that more closely resemble gastric disorders, infectious and motor disorders of the esophagus, biliary tract disease, or even coronary artery disease.

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Extraesophageal manifestations

Adding to the complexity of diagnosis, GERD has been shown to have extraesophageal manifestations, including chronic cough, asthma, recurrent aspiration, chronic sore throat, reflux laryngitis, and paroxysmal laryngospasm or voice changes.

Although the relationship between asthma and GERD remains unclear, it has been estimated that 24% to 98% of patients with asthma also have GERD. (5) Some patients with asthma have been shown to have excess acid reflux into the esophagus. Reflux-like symptoms may precede episodes of asthma that occur after meals or when lying down. (6-8)

Additionally, GERD has been noted in 10% to 50% of patients with noncardiac chest pain (9-10)

DIAGNOSTIC STRATEGIES

Trial of treatment

Diagnosis is usually based on typical symptoms--heartburn or regurgitation--in the clinical history. (The Figure shows a treatment algorithm for both severe and mild symptoms.)

A 2-week trial of treatment with a proton pump inhibitor (PPI) provides the quickest and most cost-effective confirmation of diagnosis and is recommended for the patient whose history suggests uncomplicated GERD. A positive response to PPI treatment in a patient with symptoms suggestive of GERD is at least as sensitive and specific as 24-hour intraesophageal pH monitoring, which is still often considered the "gold standard" for the diagnosis of GERD. Furthermore, complete lack of improvement in response to PPI treatment is highly predictive that the patient does not have GERD and indicates the need for further evaluation and a possible revision of diagnosis. (11,12)

[H.sub.2] receptor antagonists ([H.sub.2]RAs) have also been investigated in empirical trials for usefulness in diagnosing GERD. [H.sub.2]RAs are less effective than PPIs. (13,14)

Endoscopy

No data support routine endoscopy for patients with the recent onset of uncomplicated heartburn who respond to medical therapy. Endoscopy is recommended, however, for patients with severe or atypical GERD symptoms, when other diseases may be present, or when a treatment trial with a PPI is ineffective. (15) Endoscopy is useful for diagnosing complications of GERD, such as Barrett's esophagus, esophagitis, and strictures. Fewer than 50% of patients with GERD symptoms have evidence of esophagitis on endoscopy. (16)

The American Society for Gastrointestinal Endoscopy recommends endoscopy when there are clinical suggestions of severe reflux or other disease. (17) The American College of Gastroenterology recommends further testing