eMedicine Specialties > Gastroenterology > Esophagus

Gastroesophageal Reflux Disease: Differential Diagnoses & Workup

Author: Piero Marco Fisichella, MD, Assistant Professor of Surgery, Stritch School of Medicine, Loyola University; Director, Esophageal Motility Center, Loyola University Medical Center
Coauthor(s): Marco G Patti, MD, Professor of Surgery, Director, Center for Esophageal Diseases, University of Chicago Pritzker School of Medicine
Contributor Information and Disclosures

Updated: Apr 28, 2009

Differential Diagnoses

Achalasia
Esophagitis
Cholelithiasis
Gastritis, Chronic
Coronary Artery Atherosclerosis
Irritable Bowel Syndrome
Esophageal Cancer
Peptic Ulcer Disease
Esophageal Spasm

Other Problems to Be Considered

Some studies have shown that gastroesophageal reflux disease (GERD) is highly prevalent in patients who are morbidly obese and that a high body mass index (BMI) is a risk factor for the development of this condition.1,2,3,4,5,6

The mechanism by which a high BMI increases esophageal acid exposure is not completely understood. Increased intragastric pressure and gastroesophageal pressure gradient, incompetence of the LES, and increased frequency of transient LES relaxations may all play a role in the pathophysiology of gastroesophageal reflux disease (GERD) in patients who are morbidly obese.

To further support the hypothesis that obesity increases esophageal acid exposure is the documentation of a dose-response relationship between increased BMI and increased prevalence of gastroesophageal reflux disease (GERD) and its complications. Therefore, the pathophysiology of GERD in patients who are morbidly obese might differ from that of patients who are not obese. The therapeutic implication of such a premise is that the correction of reflux in patients who are morbidly obese might be better achieved with a procedure that first controls obesity.

Workup

Laboratory Studies

  • Laboratory tests are seldom useful in establishing a diagnosis of gastroesophageal reflux disease (GERD).

Imaging Studies

  • Barium esophagogram
    • A barium esophagogram is particularly important for patients with gastroesophageal reflux disease (GERD) who experience dysphagia.
    • A barium esophagogram can show the presence and location of a stricture and the presence and shape of a hiatal hernia.
  • Esophagogastroduodenoscopy (EGD)
    • EGD identifies the presence and severity of esophagitis and the possible presence of Barrett esophagus (see Image 1 or below).
      Esophagogastroduodenoscopy indicating Barrett eso...

      Esophagogastroduodenoscopy indicating Barrett esophagus.

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      Esophagogastroduodenoscopy indicating Barrett eso...

      Esophagogastroduodenoscopy indicating Barrett esophagus.

    • EGD also excludes the presence of other diseases (eg, peptic ulcer) that can present similarly to gastroesophageal reflux disease (GERD).
    • Although EGD is frequently performed to help diagnose gastroesophageal reflux disease (GERD), it is not the most cost-effective diagnostic study because esophagitis is present in only 50% of patients with GERD.

Other Tests

  • Esophageal manometry
    • Esophageal manometry defines the function of the LES and the esophageal body (peristalsis).
    • Esophageal manometry is essential for correctly positioning the probe for the 24-hour pH monitoring.
  • Ambulatory 24-hour pH monitoring
    • Ambulatory 24-hour pH monitoring is the criterion standard in establishing a diagnosis of GERD with a sensitivity of 96% and a specificity of 95%.
    • Ambulatory 24-hour pH monitoring quantifies the gastroesophageal reflux and allows a correlation between the symptoms of reflux and the episodes of reflux.
    • Patients with endoscopically confirmed esophagitis do not need pH monitoring to establish a diagnosis of gastroesophageal reflux disease (GERD).
  • Indications for esophageal manometry and prolonged pH monitoring include the following:
    • Persistence of symptoms while taking adequate antisecretory therapy, such as PPI therapy
    • Recurrence of symptoms after discontinuation of acid-reducing medications
    • Investigation of atypical symptoms, such as chest pain or asthma, in patients without esophagitis
    • Confirmation of the diagnosis in preparation for antireflux surgery
  • Radionuclide measurement of gastric emptying
    • Although delayed gastric emptying is present in as many as 60% of patients with gastroesophageal reflux disease (GERD), this emptying is usually a minor factor in the pathogenesis of the disease in most patients (except in patients with advanced diabetes mellitus or connective tissue disorders).
    • Patients with delayed gastric emptying typically experience postprandial bloating and fullness in addition to other symptoms.

More on Gastroesophageal Reflux Disease

Overview: Gastroesophageal Reflux Disease
Differential Diagnoses & Workup: Gastroesophageal Reflux Disease
Treatment & Medication: Gastroesophageal Reflux Disease
Follow-up: Gastroesophageal Reflux Disease
Multimedia: Gastroesophageal Reflux Disease
References
Further Reading
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Further Reading

Additional resources on asthma are available at Medscape’s Gastroesophageal Reflux Disease Resource Center.

Related eMedicine Topics

Clinical Trials

National Guidelines Clearinghouse

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Keywords

gastroesophageal reflux disease, GERD, reflux, heartburn, esophagitis, gastritis, peptic ulcer disease, PUD, lower esophageal sphincter, LES, hiatal hernia, obesity, regurgitation, dysphagia, Barrett esophagus, adenocarcinoma, laryngitis, proton pump inhibitor, PPI, esophagogastroduodenoscopy, EGD, laparoscopic fundoplication, Nissen fundoplication

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Contributor Information and Disclosures

Author

Piero Marco Fisichella, MD, Assistant Professor of Surgery, Stritch School of Medicine, Loyola University; Director, Esophageal Motility Center, Loyola University Medical Center
Piero Marco Fisichella, MD is a member of the following medical societies: American College of Surgeons, American Medical Association, Association for Academic Surgery, Society for Surgery of the Alimentary Tract, and Society of American Gastrointestinal and Endoscopic Surgeons
Disclosure: Nothing to disclose.

Coauthor(s)

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.

Medical Editor

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.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: eMedicine Salary Employment

Managing Editor

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.

CME Editor

Alex J Mechaber, MD, FACP, Associate Dean for Undergraduate Medical Education, Associate Professor of Medicine, University of Miami Miller School of Medicine
Alex J Mechaber, MD, FACP is a member of the following medical societies: Alpha Omega Alpha, American College of Physicians-American Society of Internal Medicine, and Society of General Internal Medicine
Disclosure: Nothing to disclose.

Chief Editor

Julian Katz, MD, Clinical Professor of Medicine, Drexel University College of Medicine; Consulting Staff, Department of Medicine, Section of Gastroenterology and Hepatology, Hospital of the Medical College of Pennsylvania
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 and Ethics, American Trauma Society, Association of American Medical Colleges, and Physicians for Social Responsibility
Disclosure: Nothing to disclose.

 
 
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