Curriculum · Gastroenterology
Gastro-oesophageal reflux disease
What it is
Gastroesophageal reflux disease is defined by its characteristic findings, heartburn and regurgitation. It also causes symptoms outside the esophagus, and it is one of the named causes of chronic laryngitis, meaning laryngitis of more than 2 weeks duration, together with recurrent acute laryngitis, chronic irritants and voice strain, Zenker's diverticulum and hiatus hernia.
How it presents
Heartburn and regurgitation are the characteristic findings. Extraesophageal symptoms may include chest pain, cough, hoarseness, and wheezing. Laryngopharyngeal reflux in this disease gives cough, globus sensation and hoarseness, and on laryngoscopy there is posterior laryngeal edema, true vocal fold edema, and pseudosulcus. Among patients with dyspepsia, GORD is the more likely diagnosis if symptoms of heartburn or regurgitation predominate, and some patients have overlapping GERD and functional dyspepsia.
How it is diagnosed
In a patient without alarm features, meaning no anemia, dysphagia, vomiting or weight loss, symptom relief with PPI therapy confirms the diagnosis. Before ordering an EGD for diagnosis, a once daily PPI is administered, followed by a twice daily PPI for 4 to 8 weeks if there is no symptomatic response. Where symptoms are refractory to empiric PPI therapy the two pages differ. One puts upper endoscopy first, and if it is normal, then ambulatory esophageal pH monitoring, or impedance pH testing while taking a PPI, for symptom-reflux correlation. Dysphagia, odynophagia and weight loss call for upper endoscopy to rule out cancer. The other page gives the next step in management, where heartburn is unresponsive to a PPI taken twice daily, which is the standard for refractory GERD, as 24-hour esophageal pH monitoring rather than upper endoscopy, the aim being to confirm whether acid reflux is truly the cause of the symptoms before considering further treatment. That test is the gold standard for diagnosing pathologic acid reflux: it measures acid exposure in the esophagus over 24 hours, helps differentiate true GERD from non-acid reflux or functional heartburn, and is needed before anti-reflux surgery. EGD is useful where there are alarm symptoms such as dysphagia, weight loss or GI bleeding, but in refractory GERD a normal EGD does not exclude GERD.