Differentials
Acute coronary syndrome
SIGNS / SYMPTOMS
Cardiac etiology must be ruled out before considering a diagnosis of GERD in people with chest pain.[1]
Typical chest pain is substernal pressure or heaviness that radiates to the jaw, arm, or neck.
Diaphoresis, dyspnea, and syncope may also occur.
INVESTIGATIONS
ECG may show ST changes or Q waves.
Cardiac biomarkers (e.g., troponin) may be elevated.
Stable angina
SIGNS / SYMPTOMS
Cardiac etiology must be ruled out before considering a diagnosis of GERD in people with chest pain.[1]
Stable angina causes chest pain which is typically substernal, precipitated by exertion, and relieved by rest.
INVESTIGATIONS
ECG may show ST changes or Q waves.
Exercise stress testing may show ST-segment elevation and depression.
Cardiac computed tomographic angiography (CCTA) may show >50% luminal narrowing.
Functional esophageal disorder/functional heartburn
SIGNS / SYMPTOMS
No reliable differentiating signs or symptoms.
INVESTIGATIONS
Functional heartburn denotes endoscopy-negative heartburn by definition. A normal esophageal pH study differentiates between nonerosive GERD and functional heartburn. An alternative is a normal impedance-pH study. These studies would usually be done in patients who fail to respond to proton-pump inhibitor (PPI) therapy.
Achalasia
SIGNS / SYMPTOMS
Dysphagia is typically prominent.
INVESTIGATIONS
Esophageal manometry and/or esophagram are abnormal and consistent with achalasia.
Functional (nonulcer) dyspepsia
SIGNS / SYMPTOMS
Dyspepsia symptoms include upper abdominal pain, early satiety, belching, bloating, and nausea.
Symptoms have been investigated with endoscopy and other relevant tests, which have ruled out an organic cause for the symptoms.[52]
INVESTIGATIONS
No definitive differentiating tests. Symptoms may overlap.
Esophagitis and peptic ulcer disease are absent on endoscopy for both nonerosive GERD and functional dyspepsia.
Peptic ulcer disease
SIGNS / SYMPTOMS
Burning pain in the epigastrium, which occurs hours after meals or with hunger.
The pain often wakes the patient at night and is relieved by food and antacids.
INVESTIGATIONS
Endoscopy demonstrates ulcer.
Testing for Helicobacter pylori infection is often positive, although not diagnostic.
Eosinophilic esophagitis
SIGNS / SYMPTOMS
Features of GERD and eosinophilic esophagitis overlap. However, patients with eosinophilic esophagitis may be younger or have symptoms of dysphagia, food impactions, or documented food allergies.[53]
INVESTIGATIONS
Endoscopy may show esophageal rings, linear furrows, white plaques, exudates, absence of a hiatal hernia, and a narrow-caliber esophagus.[53]
Maximum peripheral eosinophil count may be higher than typical for GERD.[53]
Eosinophil count may be ≥15 per high power field in sampled esophageal tissue.
There may be eosinophil degranulation in biopsy specimens.[53]
Proton pump inhibitor-responsive esophageal eosinophilia
SIGNS / SYMPTOMS
International consensus criteria conclude that in many cases proton pump inhibitor-responsive esophageal eosinophilia is indistinguishable from eosinophilic esophagitis (EoE), and that PPIs are better classified as a treatment for esophageal eosinophilia that may be due to EoE than as a diagnostic criteria.[54]
INVESTIGATIONS
Therapeutic response to a PPI.
Doses of PPI should be at least similar to treat GERD-related erosive esophagitis with a duration of 8 weeks continuing until the time of a follow-up endoscopy and biopsy.
Malignancy
SIGNS / SYMPTOMS
Suspected in older adults presenting with alarm symptoms: anemia, acute or progressive dysphagia, hematemesis, melena, persistent vomiting, or involuntary weight loss.[9]
INVESTIGATIONS
Laboratory tests may show anemia or abnormal LFTs.
Esophageal or gastric malignancy may be seen during endoscopy.
Computed tomography of the abdomen may detect pancreatic and hepatobiliary carcinoma.
Tissue biopsies diagnostic.
Laryngopharyngeal reflux
SIGNS / SYMPTOMS
Inflammatory condition of the upper aerodigestive tract tissues related to the direct and indirect effects of gastroduodenal content reflux.[55]
Laryngeal symptoms include dysphonia, cough, globus sensation, persistent throat clearing, and/or dysphagia. Less commonly, patients may exhibit vocal cord polyps or granulomas, laryngospasm, or subglottis stenosis.
Fewer than 50% of patients experience heartburn; esophagitis is present in 25% of patients.[55]
INVESTIGATIONS
Diagnosis is mainly clinical, no single test confirms it.
Laryngoscopy is useful to demonstrate varying degrees of laryngeal edema and erythema.
Dual sensor pH probe is considered the gold standard for diagnosing laryngopharyngeal reflux.
Clinical response to empiric therapy with proton pump inhibitors may be used as a diagnostic tool.[55][56]
Nonacid reflux
SIGNS / SYMPTOMS
Nonacid (pH >4) reflux typically occurs during the postprandial period because gastric acid is buffered by ingested food.[57] This can also occur in patients treated with acid-suppressive drugs.The main causes of nonacid reflux include transient lower esophageal sphincter relaxations and the presence of a hiatal hernia. Nonacid reflux should be suspected in patients with persistent reflux symptoms despite adequate pharmacologic acid suppression.
Bile reflux may occur in the context of previous surgery, intestinal obstruction, or impaired small intestinal motility.[58]
INVESTIGATIONS
Endoscopy typically reveals absence of erosive esophagitis. Alternative conditions such as eosinophilic esophagitis must be ruled out with esophageal biopsies. pH/impedance testing permits accurate diagnosis.[1]
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