Professional Documents
Culture Documents
202 Full
202 Full
Gastroesophageal reflux disease (GERD) is commonly man- esophageal stricture or ring, or to rule out other diagnoses
aged in both primary and secondary care settings, as this such as achalasia [4]. Ambulatory reflux monitoring has
condition occurs in patients of all ages and has a wide vari- the benefit of determining esophageal acid exposure, reflux
ety of clinical presentations. However, evidence suggests frequency, and correlation of reflux to reported symptoms.
that GERD is commonly overdiagnosed and overtreated. Thus, its use is justified when the diagnosis of GERD is
Adherence to guidelines may help reduce the harms of uncertain, when symptoms are refractory, or when surgical
overdiagnosis. management is being considered in the absence of other
objective evidence of GERD [2, 4].
G
Extraesophageal symptoms such as chronic cough,
astroesophageal reflux disease (GERD) is one of the asthma, dental erosions, sinusitis, and laryngitis have been
most frequently encountered and managed diseases attributed to GERD; however, multiple studies have failed
in the primary care setting. In the United States, 18.1% to conclusively demonstrate causality. Indeed, trials in
27.8% of the population report weekly symptoms of GERD, which patients with extraesophageal symptoms are empiri-
and up to 40% of people report occasional symptoms [1]. cally treated with PPIs have no, poor, or mixed evidence
Most patients respond completely to a relatively short for improvement of those symptoms, even in patients with
course of pharmacotherapy and do not require endoscopy; objective evidence of GERD on endoscopy or reflux monitor-
however, GERD is often overdiagnosed and overtreated ing [2].
[2, 3]. Guidelines for diagnosis and treatment of GERD In children aged 15 years, presenting symptoms of GERD
and screening for Barretts esophagus (BE) are available are more likely to include regurgitation, vomiting, abdomi-
from the American College of Gastroenterology (ACG), the nal pain, and cough. Severe symptoms and anorexia or feed
Society of American Gastrointestinal Endoscopic Surgeons refusal should raise clinical suspicion for erosive esophagitis
(SAGES), and the University of Michigan Health System [6, 7]. In infants, normal gastroesophageal reflux may result
[2, 4]. Understanding the indications and recommendations in spitting up 4 or more times per day. GERD is only diag-
regarding the diagnosis and treatment of GERD will help cli- nosed when gastroesophageal reflux symptoms become
nicians identify those in need of endoscopy, minimize the troublesomeincluding spitting, vomiting, back arching,
risks of pharmacotherapy, and reduce costs. feeding difficulties, and coughor when they lead to com-
plications. Barium swallow testing, pH probe testing, and
Diagnosis upper gastrointestinal endoscopy have poor evidence for
The diagnosis of GERD in adults can usually be made establishing GERD as a cause of these symptoms [8].
clinically. Heartburn and regurgitation are the most reliable
symptoms in establishing the diagnosis, identifying up to
Treatment
70% of patients with GERD [5]. Chest pain is also indicative Lifestyle Modification
of GERD once a cardiac cause has been ruled out. In patients Lifestyle modification is often recommended for the
with atypical symptomssuch as dyspepsia, epigastric pain, treatment of GERD symptoms. For nocturnal symptoms,
nausea, bloating, and eructationa good clinical response elevating the head of the bed and avoiding meals 23 hours
to a proton pump inhibitor (PPI) may help establish GERD prior to bedtime may be helpful. For patients with a body
as the diagnosis but should not be considered definitive [2]. mass index above 25 kg/m2 or patients with a normal body
Endoscopy should be reserved for patients with alarm mass index but recent weight gain, weight loss may result in
symptoms, including dysphagia, unintentional weight loss,
and anemia; those with risks for BE; and those whose symp- Electronically published May 6, 2016.
toms have been unresponsive to adequate PPI therapy [2]. Address correspondence to Dr. J. Lane Wilson, 101 Heart Dr, Greenville,
NC 27834 (wilsonjo@ecu.edu).
Barium swallow studies, esophageal biopsy, and esophageal
N C Med J. 2016;77(3):202-205. 2016 by the North Carolina Institute
manometry are not helpful for diagnosis of GERD but may of Medicine and The Duke Endowment. All rights reserved.
help to evaluate the patient for complications, such as an 0029-2559/2016/77312
Hypomagnesemia References
1. El-Serag HB, Sweet S, Winchester CC, Dent J. Update on the epide-
Prolonged PPI use is associated with hypomagnesemia, miology of gastro-oesophageal reflux disease: a systematic review.
which, in turn, is associated with an increased risk for kidney Gut. 2014;63(6):871-880.