Approach

Diagnosis is clinical, supported by testing when required. Patients should be queried about the frequency, severity, timing (day time or night time), and duration of symptoms and the presence of any specific triggers (dietary or nondietary).[5]​ Heartburn and regurgitation are the most reliable symptoms.[1] These often occur after meals, especially large or fatty meals. Symptoms may be worse when the patient is lying down or bending over. Relief with antacids is typical. Extraesophageal symptoms include cough, laryngitis, asthma, or dental erosion.[1][6]​ 

Alarm symptoms (anemia, dysphagia, hematemesis, melena, persistent vomiting, or involuntary weight loss) raise the possibility of esophagitis, peptic stricture, or cancer.[9]

Physical exam is generally normal.

While typical patients may be given a therapeutic trial of proton-pump inhibitors (PPIs), those with longstanding or alarm symptoms warrant additional investigation. Those who do not respond to PPIs also merit further evaluation for complications or other conditions.

Routine testing for Helicobacter pylori is not recommended by guidelines.

Typical symptoms

A short trial (about 8 weeks) of a PPI and lifestyle therapy (such as weight loss if needed, and elevation of head of bed for nocturnal features) should be started in patients with typical symptoms, namely heartburn and regurgitation.[1][36]

Symptom relief is presumed to be diagnostic, but failure of PPI treatment does not exclude GERD.

Using endoscopy and ambulatory pH monitoring as a reference standard, a short trial of high-dose PPI has a pooled sensitivity of 78% and specificity of 54%.[1]

Endoscopy for longstanding, unresponsive, or atypical symptoms

Upper endoscopy (esophagogastroduodenoscopy, EGD) is indicated in patients with atypical, relapsing, or persistent symptoms.[1][5][36][37]​​​​ EGD may identify an alternative diagnosis (such as esophageal malignancy or peptic ulcer) or identify complications of GERD (such as Barrett esophagus).

Consider evaluation for nongastrointestinal causes before endoscopy in patients with isolated extraesophageal features (e.g., laryngitis, globus, tooth enamel erosion, halitosis).[6]​ Patients who have extraesophageal features with typical GERD symptoms may have an initial 8-12 week trial of PPI therapy before endoscopy or further testing.[1][6]

If endoscopy is performed to diagnose GERD, PPI therapy should be withheld for 2-4 weeks to assess whether there is excessive esophageal acid exposure in the absence of a PPI.[1]

Barrett esophagus may be found after healing of higher grades of erosive esophagitis. Thus, if endoscopy is performed because of concern for Barrett esophagus (e.g., longstanding symptoms), it may be best to carry out the procedure after an 8-week course of PPI treatment.[37]

Alarm signs and symptoms

Alarm signs and symptoms that suggest complicated disease include weight loss, dysphagia, odynophagia, anemia, bleeding, or evidence of blood in stool.[1][9]​ These patients warrant endoscopy. [Figure caption and citation for the preceding image starts]: Moderate to severe esophagitis with multiple linear, clean-based esophageal ulcersFrom the collection of Dr Douglas G. Adler; used with permission [Citation ends].com.bmj.content.model.Caption@7b9cf2de

Patients with persistent symptoms on therapy with PPIs

Further testing is warranted in patients with persistent symptoms despite PPI therapy. Endoscopy should be performed, if not performed previously.[1][36]

In the absence of erosive esophagitis (Los Angeles grade B and above) or long-segment Barrett esophagus (≥3 cm), prolonged ambulatory pH monitoring should be performed, off drug therapy, to confirm or rule out GERD.[36]

Esophageal manometry should be performed:[1]

  • before antireflux surgery;

  • in patients unresponsive to PPIs where an etiology cannot be determined using impedance-pH monitoring;

  • and in patients with non-cardiac chest pain, especially those unresponsive to PPIs, to assess for motility abnormalities.

Other imaging modalities

Esophageal capsule endoscopy is a less-invasive, safe alternative to upper endoscopy, and a potential screening and diagnostic tool to evaluate esophageal pathology. Studies have shown only moderate sensitivity and specificity for diagnosis of esophageal disorders, and it has a limited role and acceptance in screening for mucosal disease (erosive esophagitis and Barrett esophagus).[38][39][40] Capsule endoscopy is done for patient convenience in select circumstances. It is contraindicated in the presence of suspected (e.g., presence of dysphagia) or known stricture or adhesions. 

Barium swallow may be useful in patients with dysphagia for whom endoscopy is contraindicated or unavailable.[41][42] Barium imaging should not be used solely as a diagnostic test for GERD.[1] The presence of reflux on a barium esophagram has poor sensitivity and specificity for GERD, compared with pH testing.[1]

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