Gastroesophageal reflux disease (GERD) and peptic ulcer disease (PUD) are two disorders of the gastrointestinal (GI) tract that can cause tissue damage and unpleasant symptoms. They are both commonly encountered in the primary care and gastroenterology settings and can also significantly decrease a patient’s health-related quality of life if left unmanaged.
GASTROESOPHAGEAL REFLUX DISEASE
GERD is defined as “troublesome symptoms and/or complications” resulting from the abnormal reflux of gastric contents into the esophagus or beyond, including the oral cavity or lungs. Troublesome symptoms are those that have a negative impact on the patient’s well-being and quality of life.
Depending on how the patient presents, GERD syndromes may be classified into two categories: (1) symptoms present but without erosions seen on endoscopic exam or (2) those with esophageal tissue injury. Esophageal erosions occur as a result of repeated exposure to refluxed material for prolonged periods of time.
GERD may occur in all ages, but most commonly occurs in those older than 40 years of age. Patients with mild symptoms do not always seek medical treatment and instead self-treat with lifestyle changes or over-the-counter remedies. As a result, the true prevalence of the disease is difficult to assess. It is estimated that 18% to 28% of adults in the United States suffer GERD symptoms weekly. Prevalence seems to be increasing worldwide, with highest rates in Western countries and lowest rates found in East Asia.
Symptoms and/or tissue damage associated with GERD is caused by exposure of the esophagus to gastric contents. This happens as a result of relaxation of the lower esophageal sphincter (LES) due to increase in intra-abdominal pressure (e.g., obesity, pregnancy), delayed gastric emptying, hiatal hernia, or certain medications or foods as listed in Table 29.1
. Additional risk factors include family history, smoking, alcohol consumption, respiratory diseases, obesity, and reclining or lying down after eating.
Diagnosis is mainly dependent on patient report of symptoms and review of risk factors present. Symptoms are commonly classified as typical, atypical, and extraesophageal and are listed
in Table 29.3
. They tend to occur after meals and may be aggravated by reclining or lying down. Typical symptoms occur more commonly and include acid regurgitation and heartburn. Generally, a diagnosis of GERD is assumed if patients respond to an empiric trial of acid suppression therapy. Diagnosis of patients who present with atypical symptoms is challenging, since their symptoms may be caused by other conditions, such as PUD and gastroparesis. For these patients, further diagnostic evaluation may be considered prior to empiric therapy. Similarly, those presenting with chest pain must be evaluated to rule out cardiac causes.
TABLE 29.3 Symptoms of GERD
Chronic cough/throat clearing
Extraesophageal reflux syndromes are associated with symptoms that occur in organs other than the esophagus. These symptoms should only be associated with GERD if they occur with other GERD symptoms or with evidence of tissue injury since these symptoms are nonspecific and have many other causes.
Diagnostic tests may be helpful in patients who do not respond to therapy or those presenting with extraesophageal syndrome to confirm GERD as a cause, or to detect complications of GERD. Endoscopy (with or without biopsy) may be used to assess mucosal injury or other complications like strictures. Biopsy is necessary to detect esophageal adenocarcinoma or Barrett’s esophagus. Of note, normal endoscopy does not rule out GERD. On the other hand, tissue damage may not be specifically related to GERD. Other tests, such as ambulatory pH monitoring, can help to clarify diagnosis.
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