Gastroesophageal Reflux Disease Clinical Presentation

  • Author: Marco G Patti, MD; Chief Editor: Julian Katz, MD   more...
 
Updated: Mar 26, 2012
 

History

Gastroesophageal reflux disease (GERD) is associated with a set of typical (esophageal) symptoms, including heartburn, regurgitation, and dysphagia. (However, a diagnosis of GERD based on the presence of typical symptoms is correct in only 70% of patients.) In addition to these typical symptoms, abnormal reflux can cause atypical (extraesophageal) symptoms, such as coughing, chest pain, and wheezing.

The American College of Gastroenterology (ACG) published updated guidelines for the diagnosis and treatment of GERD in 2005. According to the guidelines, for patients with symptoms and history consistent with uncomplicated GERD, the diagnosis of GERD may be assumed and empirical therapy begun. Patients who show signs of GERD complications or other illness or who do not respond to therapy should be considered for further diagnostic testing.[24]

A history of nausea, vomiting, or regurgitation should alert the physician to evaluate for delayed gastric emptying.

Patients with GERD may also experience significant complications associated with the disease, such as esophagitis, stricture, and Barrett esophagus. Approximately 50% of patients with gastric reflux develop esophagitis.

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Physical Examination

Typical esophageal symptoms

Heartburn is the most common typical symptom of GERD. It is felt as a retrosternal sensation of burning or discomfort that usually occurs after eating or when lying supine or bending over.

Regurgitation is an effortless return of gastric and/or esophageal contents into the pharynx. Regurgitation can induce respiratory complications if gastric contents spill into the tracheobronchial tree.

Dysphagia occurs in approximately one third of patients. Patients with dysphagia experience a sensation that food is stuck, particularly in the retrosternal area. Dysphagia can be an advanced symptom and can be due to a primary underlying esophageal motility disorder, a motility disorder secondary to esophagitis, or stricture formation.

Atypical extraesophageal symptoms

Coughing and/or wheezing are respiratory symptoms resulting from the aspiration of gastric contents into the tracheobronchial tree or from the vagal reflex arc producing bronchoconstriction. Approximately 50% of patients who have GERD-induced asthma do not experience heartburn.

Hoarseness results from irritation of the vocal cords by gastric refluxate and is often experienced by patients in the morning.

Reflux is the most common cause of noncardiac chest pain, accounting for approximately 50% of cases. Patients can present to the emergency department with pain resembling a myocardial infarction. Reflux should be ruled out (using esophageal manometry and 24-hour pH testing if necessary; see the image below) once a cardiac cause for the chest pain has been excluded. Alternatively, a therapeutic trial of a high-dose proton pump inhibitor (PPI) can be tried.

Ambulatory pH monitoring indicating episodes of reAmbulatory pH monitoring indicating episodes of reflux correlating with the heartburn experienced by the patient.

Additional atypical symptoms from abnormal reflux include damage to the lungs (eg, pneumonia, asthma, idiopathic pulmonary fibrosis), vocal cords (eg, laryngitis, cancer), ear (eg, otitis media), and teeth (eg, enamel decay).

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Complications of Disease

Esophagitis

Esophagitis (esophageal mucosal damage) is the most common complication of GERD, occurring in approximately 50% of patients (see the images below).

Peptic esophagitis. A rapid urease test (RUT) is pPeptic esophagitis. A rapid urease test (RUT) is performed on the esophageal biopsy sample. The result is positive for esophagitis. Reflux esophagitis is demonstrated on barium esophReflux esophagitis is demonstrated on barium esophagram.

Esophagitis may be diagnosed using endoscopy, although it cannot always be appreciated on endoscopy. As many as 50% of symptomatic patients with GERD demonstrate no evidence of esophagitis on endoscopy. Still, documentation of this complication is important in diagnosing GERD. Degrees of esophagitis are described by the Savary-Miller classification as follows.

  • Grade I – Erythema
  • Grade II – Linear nonconfluent erosions
  • Grade III – Circular confluent erosions
  • Grade IV – Stricture or Barrett esophagus.

Stricture

Strictures are advanced forms of esophagitis and are caused by circumferential fibrosis due to chronic deep injury. Strictures can result in dysphagia and a short esophagus. Gastroesophageal reflux strictures typically occur in the mid-to-distal esophagus and can be visualized on upper GI tract studies and endoscopy. Presence of a stricture with a history of reflux can also help diagnose GERD. Patients present with dysphagia to solid meals and vomiting of nondigested foods.

As a rule, the presence of any esophageal stricture is an indication that the patient needs surgical consultation and treatment (usually surgical fundoplication). When patients present with dysphagia, barium esophagography is indicated to evaluate for possible stricture formation. In these cases, especially when associated with food impaction, eosinophilic esophagitis must be ruled out prior to attempting any mechanical dilatation of the narrowed esophageal region.

Barrett esophagus

The most serious complication of long-standing or severe GERD is the development of Barrett esophagus. Barrett esophagus is present in 8-15% of patients with GERD. Barrett esophagus is thought to be caused by the chronic reflux of gastric juice into the esophagus. It is defined by metaplastic conversion of the normal distal squamous esophageal epithelium to columnar epithelium (see the image below). Histologic examination of esophageal biopsy specimens is required to make the diagnosis. Varying degrees of dysplasia may be found on histologic examination.

Esophagogastroduodenoscopy indicating Barrett esopEsophagogastroduodenoscopy indicating Barrett esophagus.

Barrett esophagus with intestinal type metaplasia has malignant potential and is a risk factor for the development of esophageal adenocarcinoma (see the images below), increasing the risk of adenocarcinoma 30-40 times. The incidence of adenocarcinoma of the esophagus is increasing steadily in Western society. Currently, adenocarcinoma accounts for more than 50% of esophageal cancers in Western industrialized nations.

Gastroesophageal reflux disease (GERD)/Barrett esoGastroesophageal reflux disease (GERD)/Barrett esophagus/adenocarcinoma sequence. Endoscopy demonstrating intraluminal esophageal caEndoscopy demonstrating intraluminal esophageal cancer.

As with esophageal stricture, the presence of Barrett esophagus indicates the need for surgical consultation and treatment (usually surgical fundoplication).

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Contributor Information and Disclosures
Author

Marco G Patti, MD  Professor of Surgery, Director, Center for Esophageal Diseases, University of Chicago Pritzker School of Medicine

Marco G Patti, MD is a member of the following medical societies: American Association for the Advancement of Science, American College of Surgeons, American Gastroenterological Association, American Medical Association, American Surgical Association, Association for Academic Surgery, Pan-Pacific Surgical Association, Society for Surgery of the Alimentary Tract, Society of American Gastrointestinal and Endoscopic Surgeons, Southwestern Surgical Congress, and Western Surgical Association

Disclosure: Nothing to disclose.

Coauthor(s)

Showkat Bashir, MD  Assistant Professor, Department of Medicine, Division of Gastroenterology, George Washington University, Washington, DC

Showkat Bashir, MD is a member of the following medical societies: American College of Gastroenterology, American College of Physicians, American Gastroenterological Association, and American Medical Association

Disclosure: Nothing to disclose.

Jack Bragg, DO  Associate Professor, Department of Clinical Medicine, University of Missouri School of Medicine

Jack Bragg, DO is a member of the following medical societies: American College of Osteopathic Internists and American Osteopathic Association

Disclosure: Nothing to disclose.

Abhishek Choudhary, MD  Resident Physician, Department of Internal Medicine, University Hospital of Missouri-Columbia

Abhishek Choudhary, MD is a member of the following medical societies: American College of Physicians

Disclosure: Nothing to disclose.

Abraham H Dachman, MD, FACR  Professor, Department of Radiology, University of Chicago Division of the Biological Sciences, The Pritzker School of Medicine; Director of CT, Department of Radiology, The University of Chicago Hospitals

Abraham H Dachman, MD, FACR is a member of the following medical societies: Radiological Society of North America

Disclosure: iCAD, Inc. Consulting fee Consulting; GE Healtcare, Inc. Honoraria Speaking and teaching

Gautam Dehadrai, MD  Department Chair, Section Chief, Department of Interventional Radiology, Norman Regional Hospital

Gautam Dehadrai, MD is a member of the following medical societies: American College of Radiology, Medical Council of India, and Radiological Society of North America

Disclosure: Nothing to disclose.

Fernando AM Herbella, MD, PhD, TCBC  Affiliate Professor, Attending Surgeon in Gastrointestinal Surgery, Esophagus and Stomach Division, Department of Surgery, Federal University of Sao Paulo, Brazil; Private Practice; Medical Examiner, Sao Paulo's Medical Examiner's Office Headquarters, Brazil

Fernando AM Herbella, MD, PhD, TCBC is a member of the following medical societies: Society for Surgery of the Alimentary Tract

Disclosure: Nothing to disclose.

Eugene C Lin, MD  Attending Radiologist, Teaching Coordinator for Cardiac Imaging, Radiology Residency Program, Virginia Mason Medical Center; Clinical Assistant Professor of Radiology, University of Washington School of Medicine

Eugene C Lin, MD is a member of the following medical societies: American College of Nuclear Medicine, American College of Radiology, Radiological Society of North America, and Society of Nuclear Medicine

Disclosure: Nothing to disclose.

Mohamed Othman, MD  Resident Physician, Department of Internal Medicine, University of New Mexico School of Medicine

Disclosure: Nothing to disclose.

Praveen K Roy, MD, AGAF  Gastroenterologist, Ochsner Clinic Foundation; Adjunct Associate Research Scientist, Lovelace Respiratory Research Institute; Editor-in-Chief, The Internet Journal of Gasteroenterology; Editorial Board, Signal Transduction Insights; Editorial Board, The Internet Journal of Epidemiology; Editorial Board, Gastrointestinal Endoscopy Review Letter

Praveen K Roy, MD, AGAF is a member of the following medical societies: American College of Gastroenterology, American Gastroenterological Association, and American Society of Gastrointestinal Endoscopy

Disclosure: Nothing to disclose.

Michael AJ Sawyer, MD  Consulting Staff, Department of Surgery, Southwestern Medical Center; Consulting Staff, Department of Surgery, Comanche County Memorial Hospital; Consulting Staff, Great Plains Surgical Clinic, Inc

Michael AJ Sawyer, MD is a member of the following medical societies: American College of Surgeons, Society for Surgery of the Alimentary Tract, Society of American Gastrointestinal and Endoscopic Surgeons, and Society of Laparoendoscopic Surgeons

Disclosure: Nothing to disclose.

Homayoun Shojamanesh, MD  Former Fellow, Digestive Diseases Branch, National Institutes of Health

Homayoun Shojamanesh, MD is a member of the following medical societies: American College of Gastroenterology, American Gastroenterological Association, and American Society for Gastrointestinal Endoscopy

Disclosure: Nothing to disclose.

Manish K Varma, MD  Chief of Interventional Radiology, Department of Radiology, Tripler Army Medical Center

Manish K Varma, MD is a member of the following medical societies: American College of Radiology, American Roentgen Ray Society, and Radiological Society of North America

Disclosure: Nothing to disclose.

Specialty Editor Board

John Gunn Lee, MD  Director of Pancreaticobiliary Service, Associate Professor, Department of Internal Medicine, Division of Gastroenterology, University of California at Irvine School of Medicine

John Gunn Lee, MD is a member of the following medical societies: American College of Gastroenterology, American College of Physicians, American Gastroenterological Association, and American Society for Gastrointestinal Endoscopy

Disclosure: Nothing to disclose.

Francisco Talavera, PharmD, PhD  Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Medscape Salary Employment

Noel Williams, MD  Professor Emeritus, Department of Medicine, Dalhousie University, Halifax, Nova Scotia, Canada; Professor, Department of Internal Medicine, Division of Gastroenterology, University of Alberta, Edmonton, Alberta, Canada

Noel Williams, MD is a member of the following medical societies: Royal College of Physicians and Surgeons of Canada

Disclosure: Nothing to disclose.

David Chelmow, MD  Leo J Dunn Distinguished Professor and Chair, Department of Obstetrics and Gynecology, Virginia Commonwealth University Medical Center

David Chelmow, MD is a member of the following medical societies: American College of Obstetricians and Gynecologists, American Medical Association, American Society for Colposcopy and Cervical Pathology, Association of Professors of Gynecology and Obstetrics, Council of University Chairs of Obstetrics and Gynecology, Phi Beta Kappa, Sigma Xi, Society for Gynecologic Investigation, and Society for Medical Decision Making

Disclosure: Nothing to disclose.

Chief Editor

Julian Katz, MD  Clinical Professor of Medicine, Drexel University College of Medicine

Julian Katz, MD is a member of the following medical societies: American College of Gastroenterology, American College of Physicians, American Gastroenterological Association, American Geriatrics Society, American Medical Association, American Society for Gastrointestinal Endoscopy, American Society of Law, Medicine & Ethics, American Trauma Society, Association of American Medical Colleges, and Physicians for Social Responsibility

Disclosure: Nothing to disclose.

Additional Contributors

The authors and editors of eMedicine gratefully acknowledge the contributions of previous authors Piero Marco Fisichella, MD and Thomas F Murphy, MD, to the development and writing of the source articles.

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Relationship of the phrenoesophageal ligament to the diaphragm and esophagus.
Arterial blood supply and lymphatic drainage of the esophagus.
Barium swallow indicating hiatal hernia.
Ambulatory pH monitoring indicating episodes of reflux correlating with the heartburn experienced by the patient.
Peptic esophagitis. A rapid urease test (RUT) is performed on the esophageal biopsy sample. The result is positive for esophagitis.
Reflux esophagitis is demonstrated on barium esophagram.
Esophagogastroduodenoscopy indicating Barrett esophagus.
Gastroesophageal reflux disease (GERD)/Barrett esophagus/adenocarcinoma sequence.
Endoscopy demonstrating intraluminal esophageal cancer.
The image is a representation of concomitant intraesophageal pH and esophageal electrical impedance measurements. The vertical solid arrow indicates commencement of a nonacid gastroesophageal reflux (GER) episode (diagonal arrow). The vertical dashed arrow indicates the onset of a normal swallow.
Nissen fundoplication.
Laparoscopic Nissen fundoplication.
Hiatal hernia.
 
 
 
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