Speaker A
Gastroesophageal reflux disease, or GERD for short, is a chronic condition in which the lower esophageal sphincter becomes weak or relaxes at the wrong time.
Comprehensive overview of GERD diagnosis, symptoms, and treatment including lifestyle changes, medications, and surgical options.
Key Takeaways
- PPIs are the primary and most effective pharmacologic treatment for GERD.
- Alarm symptoms require urgent evaluation with EGD to rule out complications.
- Lifestyle modifications are foundational in managing GERD symptoms.
- Atypical symptoms may require additional diagnostic testing beyond endoscopy.
- Surgical options exist for refractory GERD when medical therapy fails.
Summary
- GERD is a chronic condition caused by a weak or improperly relaxing lower esophageal sphincter allowing acid reflux.
- Symptoms are categorized as typical (heartburn, acid regurgitation), atypical (chronic cough, hoarseness), and alarm symptoms (anemia, dysphagia).
- Initial patient assessment includes an ABCDE approach to determine stability and continuous vital sign monitoring.
- Management starts with lifestyle modifications and an 8-week trial of proton pump inhibitors (PPIs), which are preferred over H2 blockers.
- Alarm symptoms warrant urgent esophagogastroduodenoscopy (EGD) with biopsy to evaluate for complications like erosive esophagitis or esophageal masses.
- If EGD is normal but symptoms persist, 24-hour esophageal impedance with pH monitoring is recommended to confirm diagnosis.
- Refractory GERD may require surgical interventions such as laparoscopic fundoplication or magnetic sphincter augmentation.
- Physical exam is usually normal but may show subtle signs like dental erosion indicating acid damage.
- Treatment includes acid suppression, lifestyle changes, and in some cases, repeat endoscopy for long-term management.
- Clinical pearls emphasize ruling out other causes for atypical symptoms and tailoring treatment based on symptom response.
Chapters
- 00:00Introduction to GERD and Pathophysiology
- 00:48Initial Patient Assessment and ABCDE Approach
- 01:49Physical Exam and Recognizing Symptoms
- 02:32Stabilization and Management of Unstable Patients
- 03:07Pharmacologic Treatment: PPIs and H2 Blockers
- 03:41Urgent Evaluation for Gastrointestinal Bleeding
- 04:29Complications and Surgical Interventions
- 05:06Typical and Atypical Symptoms of GERD
- 05:44Treatment Trial and Follow-up Diagnostics
- 06:22Clinical Pearls and Advanced Treatment Options
Full Transcript — Download SRT & Markdown
Speaker A
gastric acid can irritate and damage the lining of the esophagus and cause a variety of symptoms, which are commonly grouped into typical, atypical, and alarm symptoms.
Speaker A
This allows acidic content from the stomach to flow back up into the esophagus.
Speaker A
Now, if your patient presents with signs and symptoms suggestive of GERD, you should first perform an ABCDE assessment to determine if your patient is unstable or stable.
Speaker A
Over time, exposure to gastric acid can irritate and damage the lining of the esophagus and cause a variety of symptoms, which are commonly grouped into typical, atypical, and alarm symptoms.
Speaker A
And don't forget to put your patient on continuous vital sign monitoring. Finally, if you identify signs of active gastrointestinal bleeding, such as melena or hematemesis, perform an emergent esophagogastroduodenoscopy, or EGD.
Speaker A
Enjoying our Osmosis videos? Unlock your full potential with an Osmosis subscription.
Speaker A
Individuals with GERD might report classic symptoms like heartburn, also known as pyrosis, acid regurgitation, or sour or bitter taste in the back of the mouth.
Speaker A
Get unlimited access to every Osmosis feature and resource with a free 7-day trial.
Speaker A
On physical exam, findings are usually normal. However, in some cases, you might notice subtle signs of acid damage, such as dental erosion. If your patient reports any of these symptoms, suspect GERD.
Speaker A
Now, if your patient presents with signs and symptoms suggestive of GERD, you should first perform an ABCDE assessment to determine if your patient is unstable or stable.
Speaker A
These include anemia, dysphagia or odynophagia, gastrointestinal bleeding, frequent vomiting, or unintentional weight loss. If one or more alarm signs and symptoms are present, you should suspect a GERD complication and proceed with an urgent EGD with biopsies.
Speaker A
If unstable, stabilize their airway, breathing, and circulation.
Speaker A
Management, of course, includes lifestyle modifications, such as smoking cessation, and reducing foods that trigger reflux symptoms, such as tomatoes and alcohol.
Speaker A
Next, obtain IV access and administer IV fluids.
Speaker A
Although both PPIs and H2 blockers reduce acid secretion, PPIs are the primary treatment because they relieve symptoms more effectively and promote better healing of esophageal damage than H2 blockers.
Speaker A
And don't forget to put your patient on continuous vital sign monitoring.
Speaker A
On the flip side, sucralfate, a non-absorbable mucosal protective agent, is not commonly used in GERD treatment outside of special situations.
Speaker A
Finally, if you identify signs of active gastrointestinal bleeding, such as melena or hematemesis, perform an emergent esophagogastroduodenoscopy, or EGD.
Speaker A
Now, let's go back to EGD and biopsy because in some individuals, erosive esophagitis can progress to more serious conditions. During the procedure, you might detect an esophageal mass or stricture, while biopsy might reveal columnar metaplasia or dysplasia, a
Speaker A
Now, let's go back and take a look at stable patients.
Speaker A
and endoscopic ablation for dysplasia. Sometimes you'll have to consult your surgical team for esophageal resection of a mass.
Speaker A
In this case, start with a focused history and physical examination.
Speaker A
Now that we've covered how to approach individuals with alarm signs and symptoms, let's take a step back and look at what to do when those features are absent. In this case, your first step is to assess the type of GERD
Speaker A
Individuals with GERD might report classic symptoms like heartburn, also known as pyrosis, acid regurgitation, or sour or bitter taste in the back of the mouth.
Speaker A
But sometimes a person may report both typical and atypical GERD symptoms. Atypical symptoms can include chronic cough, hoarseness, frequent throat clearing laryngitis pharyngitis or even sinusitis.
Speaker A
Some might also experience non-specific symptoms, such as chronic cough, hoarseness, or frequent throat clearing.
Speaker A
In this case, you You suspect GERD with both typical and atypical features. In both groups, treatment starts with lifestyle modifications and an 8-week trial of PPIs. After 8 weeks, assess the patient's response to treatment.
Speaker A
On physical exam, findings are usually normal.
Speaker A
On the other hand, if there's an inadequate response, or in other words, if symptoms persist during the trial or return after it ends, proceed with an EGD and biopsy.
Speaker A
However, in some cases, you might notice subtle signs of acid damage, such as dental erosion.
Speaker A
Now, if EGD and biopsies reveal normal esophageal mucosa with no pathology findings, perform a 24-hour esophageal impedance with pH monitoring.
Speaker A
If your patient reports any of these symptoms, suspect GERD.
Speaker A
If the test results are abnormal, diagnose GERD. Similarly, if the EGD and biopsy reveal erosive esophagitis, diagnose GERD.
Speaker A
Next, assess the patient for alarm signs and symptoms that warrant urgent evaluation for GERD complications.
Speaker A
On the flip side, if the EGD with biopsy reveals an esophageal mass, stricture, or columnar metaplasia or dysplasia, diagnose a chronic complication of GERD and move forward with the appropriate treatment.
Speaker A
These include anemia, dysphagia or odynophagia, gastrointestinal bleeding, frequent vomiting, or unintentional weight loss.
Speaker A
If your patient has atypical symptoms only, such as chronic cough, hoarseness, throat clearing, or laryngitis, pharyngitis, or sinusitis, and physical exam reveals wheezing or oropharyngeal changes, such as dental erosions or erythema, suspect GERD with atypical features.
Speaker A
If one or more alarm signs and symptoms are present, you should suspect a GERD complication and proceed with an urgent EGD with biopsies.
Speaker A
For example, if your patient has a chronic cough or wheezing, it's a good idea to rule out lung issues first before heading down the GERD path.
Speaker A
If the biopsy reveals friable, erythematous epithelium with inflammatory cells consistent with erosive esophagitis, the diagnosis is GERD.
Speaker A
If no pathology is found in the EGD and biopsies, follow up with 24-hour esophageal impedance and pH monitoring.
Speaker A
Management, of course, includes lifestyle modifications, such as smoking cessation, and reducing foods that trigger reflux symptoms, such as tomatoes and alcohol.
Speaker A
This includes lifestyle changes and acid-suppressing medications. And if needed, repeat the EGD if a patient requires long-term use of PPIs to control symptoms.
Speaker A
However, the cornerstone of treatment is acid suppression, which typically involves proton pump inhibitors, or PPIs, such as omeprazole, and histamine 2 receptor antagonists, or H2 blockers, such as famotidine.
Speaker A
needed. Here's your last clinical pearl. In patients with refractory GERD, another treatment option is antireflux surgery, most commonly laparoscopic fundoplication.
Speaker A
Although both PPIs and H2 blockers reduce acid secretion, PPIs are the primary treatment because they relieve symptoms more effectively and promote better healing of esophageal damage than H2 blockers.
Speaker A
Another option is magnetic sphincter augmentation or MSA. This involves placing titanium beads with magnetic cores around the distal esophagus, which helps strengthen the sphincter and reduce reflux.
Speaker A
Now, here's a clinical pearl to keep in mind.
Speaker A
If alarm signs and symptoms are not present, the next step depends on the patient's clinical presentation.
Speaker A
For intermittent symptom relief, you can also opt for antacids, such as magnesium hydroxide, which work by neutralizing stomach acid.
Speaker A
If symptoms resolve and are adequate during the trial, diagnose GERD. However, if there's an inadequate response, the next step is to perform an EGD with biopsy. If the EGD shows erosive esophagitis, GERD is confirmed.
Speaker A
On the flip side, sucralfate, a non-absorbable mucosal protective agent, is not commonly used in GERD treatment outside of special situations.
Speaker A
On the flip side, if the EGD and biopsies are normal, then you should proceed with 24-hour esophageal impedance with pH monitoring.
Speaker A
Finally, if your patient experiences recurrent symptoms, or you need to evaluate the healing of the esophageal lining, consider repeating an EGD.
Speaker A
Again, you can diagnose GERD if the EGD reveals erosive esophagitis or if the 24-hour pH monitoring is abnormal.
Speaker A
Now, let's go back to EGD and biopsy because in some individuals, erosive esophagitis can progress to more serious conditions.
Speaker A
Helping current and future clinicians focus, learn, retain, and thrive. Learn more.
Topics:GERDgastroesophageal reflux diseaseheartburnproton pump inhibitorsesophagogastroduodenoscopyacid refluxlaryngitisfundoplicationesophageal biopsyacid suppression
