Gastroesophageal reflux disease (GERD) is seen in healthy people. GERD is thought to have a multifactorial etiology rather than a single cause. Contributing factors include the caustic materials that are refluxed, a breakdown in the defense mechanisms of the esophagus and a functional abnormality that results in reflux.
Definition:
Gastroesophageal reflux disease may be defined as symptoms or tissue damage caused by acid reflux of gastric contents with or without esophageal inflammation. However, this definition can blur the distinction between healthy people and those with GERD because a mild degree of esophageal reflux is considered physiologic. Other accepted definitions of GERD include reflux esophagitis identified by endoscopic examination and histologic esophagitis identified by examination of tissue samples.
Clinical Features:
Typical symptoms of GERD and acid reflux are heartburn and regurgitation; atypical symptoms include odynophagia, dysphagia, chest pain, cough, and reactive airway disease. A diagnosis of functional heartburn is made when patients have symptoms of GERD but do not have abnormal acid reflux on 24-hr esophageal pH testing or changes consistent with reflux-induced injury on endoscopic examination.
GERD can usually be diagnosed clinically based on the presentation alone of heartburn and regurgitation, which may also include dysphagia. In the absence of classic symptoms, GERD becomes more difficult to diagnose.
Symptoms of chest pain (possible cardiac causes), dysphagia, odynophagia and weight loss (possible esophageal stricture or cancer), require more extensive investigation before the diagnosis of GERD can be established .
Differential diagnosis:
The differential diagnoses are from other cause of heart burn, dysphagia, and chest pain.
Investigations:
Response to Omeprazole
A recent study demonstrated a potential role for a proton pump inhibitor, omeprazole, in the diagnosis of GERD. The response of symptoms to omeprazole, in a dosage of 40mg per day for 14 days, was shown to be about as the specific and sensitive for the diagnosis of GERD as the results of 24-hour pH monitoring. Because of the efficacy of omeprazole in relieving reflux symptoms, failure to respond to this proton pump inhibitor warrants the investigation of other possible causes for a patient’s symptoms.
Radiologic Findings
Only one-third of patients with GERD have radiologic signs of esophagitis. Findings include erosions and ulcerations, strictures, hiatal hernia, thickening of mucosal folds and poor distensibility. Only a minority of patients with documented abnormal pH have radiographically evident esophagitis. Consequently, a radiographic study is not the test of choice for the diagnosis of GERD.
Endoscopy
Endoscopy is not sensitive for diagnosis of GERD itself. Only 50% of patient with GERD manifest macroscopic evidence on endoscopy. It is useful for diagnosis of the complicated case. Indications for esophageal endoscopy in patients with GERD are:
- dysphagia or odynophagia, persistent or progressive symptoms despite therapy,
- esophageal symptoms in an immunocompromised patient presence of mass,
- stricture or ulcer on upper gastrointestinal barium study,
- evidence of gastrointestinal bleeding or iron deficiency anemia,
- and at least 10 years of GERD symptoms (screen for Barrett’s esophagus).
