Clinical manifestations and diagnosis of gastroesophageal reflux in adults
- Peter J Kahrilas, MD
Peter J Kahrilas, MD
- Professor of Medicine
- Feinberg School of Medicine, Northwestern University
Gastroesophageal reflux disease (GERD) is notable for its prevalence, variety of clinical presentations, under-recognized morbidity, and substantial economic consequences.
This topic review will discuss the clinical features and diagnostic approach to patients with this disorder. The pathophysiology and medical and surgical management of GERD are presented separately. (See "Pathophysiology of reflux esophagitis" and "Medical management of gastroesophageal reflux disease in adults" and "Surgical management of gastroesophageal reflux in adults".)
Some degree of reflux is physiologic . Physiologic reflux episodes typically occur postprandially, are short-lived, asymptomatic, and rarely occur during sleep. Pathologic reflux is associated with symptoms or mucosal injury, often including nocturnal episodes. In general, the term gastroesophageal reflux disease (GERD) is applied to patients with symptoms suggestive of reflux or complications thereof, but not necessarily with esophageal inflammation. Reflux esophagitis describes a subset of patients with GERD who have endoscopic or histopathologic evidence of esophageal inflammation. Among untreated GERD patients, about 30 percent will have endoscopic esophagitis; among those already being treated with acid inhibitors, esophagitis is a relatively unusual finding.
Due to the broad spectrum of conditions attributable to reflux, there is little agreement as to what constitutes typical reflux disease. A consensus statement (the Montreal Classification) defines GERD as a condition that develops when the reflux of stomach contents causes troublesome symptoms and/or complications . According to the Montreal Working Group, heartburn is considered troublesome if mild symptoms occur two or more days a week, or moderate to severe symptoms occur more than one day a week .
There are limitations in the epidemiologic estimates of the prevalence of gastroesophageal reflux disease (GERD) as they are based upon the assumption that heartburn and/or regurgitation are the only indicators of the disease [3-5]. However, patients with objective evidence of GERD (such as esophagitis or Barrett's esophagus) do not always have heartburn and heartburn is not always sufficiently severe to be indicative of GERD .To continue reading this article, you must log in with your personal, hospital, or group practice subscription. For more information on subscription options, click below on the option that best describes you:
- Richter JE. Typical and atypical presentations of gastroesophageal reflux disease. The role of esophageal testing in diagnosis and management. Gastroenterol Clin North Am 1996; 25:75.
- Vakil N, van Zanten SV, Kahrilas P, et al. The Montreal definition and classification of gastroesophageal reflux disease: a global evidence-based consensus. Am J Gastroenterol 2006; 101:1900.
- Nebel OT, Fornes MF, Castell DO. Symptomatic gastroesophageal reflux: incidence and precipitating factors. Am J Dig Dis 1976; 21:953.
- Dent J, El-Serag HB, Wallander MA, Johansson S. Epidemiology of gastro-oesophageal reflux disease: a systematic review. Gut 2005; 54:710.
- Camilleri M, Dubois D, Coulie B, et al. Prevalence and socioeconomic impact of upper gastrointestinal disorders in the United States: results of the US Upper Gastrointestinal Study. Clin Gastroenterol Hepatol 2005; 3:543.
- Zagari RM, Fuccio L, Wallander MA, et al. Gastro-oesophageal reflux symptoms, oesophagitis and Barrett's oesophagus in the general population: the Loiano-Monghidoro study. Gut 2008; 57:1354.
- Vakil NB, Traxler B, Levine D. Dysphagia in patients with erosive esophagitis: prevalence, severity, and response to proton pump inhibitor treatment. Clin Gastroenterol Hepatol 2004; 2:665.
- Kahrilas PJ, Hughes N, Howden CW. Response of unexplained chest pain to proton pump inhibitor treatment in patients with and without objective evidence of gastro-oesophageal reflux disease. Gut 2011; 60:1473.
- Kwiatek MA, Mirza F, Kahrilas PJ, Pandolfino JE. Hyperdynamic upper esophageal sphincter pressure: a manometric observation in patients reporting globus sensation. Am J Gastroenterol 2009; 104:289.
- Brzana RJ, Koch KL. Gastroesophageal reflux disease presenting with intractable nausea. Ann Intern Med 1997; 126:704.
- Dent J. Microscopic esophageal mucosal injury in nonerosive reflux disease. Clin Gastroenterol Hepatol 2007; 5:4.
- Ismail-Beigi F, Horton PF, Pope CE 2nd. Histological consequences of gastroesophageal reflux in man. Gastroenterology 1970; 58:163.
- Orlando RC. Esophageal epithelial defenses against acid injury. Am J Gastroenterol 1994; 89:S48.
- Levine MS. Gastroesophageal reflux disease. In: Radiology of the Esophagus, Levine MS (Ed), WB Saunders, Philadelphia 1989. p.1147.
- Bytzer P, Jones R, Vakil N, et al. Limited ability of the proton-pump inhibitor test to identify patients with gastroesophageal reflux disease. Clin Gastroenterol Hepatol 2012; 10:1360.
- Numans ME, Lau J, de Wit NJ, Bonis PA. Short-term treatment with proton-pump inhibitors as a test for gastroesophageal reflux disease: a meta-analysis of diagnostic test characteristics. Ann Intern Med 2004; 140:518.
- Giannini EG, Zentilin P, Dulbecco P, et al. Management strategy for patients with gastroesophageal reflux disease: a comparison between empirical treatment with esomeprazole and endoscopy-oriented treatment. Am J Gastroenterol 2008; 103:267.
- Moayyedi P, Talley NJ. Gastro-oesophageal reflux disease. Lancet 2006; 367:2086.
- Kahrilas PJ, Shaheen NJ, Vaezi MF, et al. American Gastroenterological Association Medical Position Statement on the management of gastroesophageal reflux disease. Gastroenterology 2008; 135:1383.
- Howard PJ, Maher L, Pryde A, Heading RC. Symptomatic gastro-oesophageal reflux, abnormal oesophageal acid exposure, and mucosal acid sensitivity are three separate, though related, aspects of gastro-oesophageal reflux disease. Gut 1991; 32:128.
- Hemmink GJ, Bredenoord AJ, Weusten BL, et al. Esophageal pH-impedance monitoring in patients with therapy-resistant reflux symptoms: 'on' or 'off' proton pump inhibitor? Am J Gastroenterol 2008; 103:2446.
- DeVault KR, Castell DO. Guidelines for the diagnosis and treatment of gastroesophageal reflux disease. Practice Parameters Committee of the American College of Gastroenterology. Arch Intern Med 1995; 155:2165.
- Sellar RJ, De Caestecker JS, Heading RC. Barium radiology: a sensitive test for gastro-oesophageal reflux. Clin Radiol 1987; 38:303.
- Gonsalves N, Policarpio-Nicolas M, Zhang Q, et al. Histopathologic variability and endoscopic correlates in adults with eosinophilic esophagitis. Gastrointest Endosc 2006; 64:313.
- Monnier P, Savary M. Contribution of endoscopy to gastroesophageal reflux disease. Scand J Gastroenterol 1984; 19(Suppl 106):26.
- Pace F, Bianchi Porro G. Gastroesophageal reflux disease: a typical spectrum disease (a new conceptual framework is not needed). Am J Gastroenterol 2004; 99:946.
- Hirano I, Richter JE, Practice Parameters Committee of the American College of Gastroenterology. ACG practice guidelines: esophageal reflux testing. Am J Gastroenterol 2007; 102:668.
- Kahrilas PJ, Quigley EM. Clinical esophageal pH recording: a technical review for practice guideline development. Gastroenterology 1996; 110:1982.
- Pandolfino JE, Kahrilas PJ. Prolonged pH monitoring: Bravo capsule. Gastrointest Endosc Clin N Am 2005; 15:307.
- Pandolfino JE, Schreiner MA, Lee TJ, et al. Comparison of the Bravo wireless and Digitrapper catheter-based pH monitoring systems for measuring esophageal acid exposure. Am J Gastroenterol 2005; 100:1466.
- Chander B, Hanley-Williams N, Deng Y, Sheth A. 24 Versus 48-hour bravo pH monitoring. J Clin Gastroenterol 2012; 46:197.
- Pandolfino JE, Richter JE, Ours T, et al. Ambulatory esophageal pH monitoring using a wireless system. Am J Gastroenterol 2003; 98:740.
- Garrean CP, Zhang Q, Gonsalves N, Hirano I. Acid reflux detection and symptom-reflux association using 4-day wireless pH recording combining 48-hour periods off and on PPI therapy. Am J Gastroenterol 2008; 103:1631.
- Galmiche P, Scarpignato C. Esophageal pH monitoring. In: Functional Evaluation in Esophageal Disease, Scarpignato C, Galmiche JP (Eds). Front Gastrointest Res 1994; 22:71.
- Charbel S, Khandwala F, Vaezi MF. The role of esophageal pH monitoring in symptomatic patients on PPI therapy. Am J Gastroenterol 2005; 100:283.
- CLINICAL FEATURES
- Clinical manifestations
- Upper gastrointestinal endoscopy findings
- - Histology
- Radiographic findings
- DIFFERENTIAL DIAGNOSIS
- ADDITIONAL EVALUATION
- Upper gastrointestinal endoscopy
- - Esophagitis on esophagoscopy
- Los Angeles classification
- Savary-Miller classification
- Ambulatory esophageal pH monitoring
- Esophageal manometry
- INFORMATION FOR PATIENTS
- SUMMARY AND RECOMMENDATIONS