DIFFRENTIAL DIAGNOSIS

GERD needs to be distinguished from [7]
• Infectious esophagitis (cytomegalovirus, herpes and candida)
• Pill esophagitis
• Eosinophilic esophagitis
• Peptic ulcer disease
• Non-ulcer dyspepsia
• Biliary tract disease
• Coronary artery disease
• Esophageal motor disorders
INVESTIGATIONS

It is neither necessary nor practical to initiate a diagnostic evaluation in every patient with heartburn [1].
• No routine laboratory tests are required.
• Hemoglobin and hematocrit would be helpful to detect anemia, particularly in patients with hematemesis, other signs of gastrointestinal bleeding, or severe, unremitting symptoms.
• Empiric therapy for GERD is reasonable without diagnostic testing. Patients who present with typical symptoms of GERD in the absence of longstanding, frequently recurring, progressive, or alarm symptoms or complicated disease may be started on empiric treatment and rarely need a confirmatory diagnostic test since symptom resolution is the primary clinical end point
• Indications for Further Diagnostic Testing
o Lack of response to therapy
o Need for continuous chronic therapy
o Chronic symptoms in a patient at risk for Barrett’s esophagus
o Alarm symptoms suggesting complicated GERD:
 bleeding
 chest pain
 choking (acid causing coughing, shortness of breath, or hoarseness)
 dysphagia
 weight loss
• If alarm features are present, endoscopy should be performed urgently and time limit for refferal for endoscopy is:
• Anemia (7-10 days)
• Acute onset of total dysphagia (within 1 day)
• Hematemesis (within 1 day if ill)
• Melena (within 1 day if ill)
• Persistent vomiting (7-10 days)
• Weight loss greater than 5% (involuntary) (7-10 days)
• If endoscopy is done and patient has erosions, ulcerations, strictures or intestinal metaplasia (Barrett's esophagus) , they have a positive endoscopy. Patients who have either a normal esophageal examination or only distal esophageal erythema are considered to have a negative endoscopy.
• If patient has acid laryngitis, endoscopy shows erythema or white plaques on the posterior larynx (posterior laryngitis). Some patients have a normal-appearing larynx, just as some patients with serious symptoms of reflux have a normal-appearing esophageal mucosa, viewed endoscopically. In severe cases of acid laryngitis, ulceration or polyp formation is seen on the vocal cords.
• If endoscopy is done biopsy should be taken. Even though the esophagus may appear endoscopically normal, it is not necessarily histologically normal.
• Esophageal capsule endoscopy might be an accurate, safe, and well-tolerated method to screen patients for significant esophageal disorders. Preliminary data seem promising. Recently, Eliakim et al. conducted a multicenter trial at seven sites involving 106 patients (93 GERD, 13 Barrett) undergoing esophageal capsule endoscopy followed by conventional endoscopy. Sixty-six of 106 patients had positive esophageal findings. Esophageal capsule endoscopy identified esophageal abnormalities in 61 (sensitivity, 92%; specificity, 95%) [18].

• 24-hour pH monitoring has been adopted as the diagnostic standard. 24-hour pH monitoring measures longer periods, captures transient pH changes not associated with symptoms, and can be coded into a scientific scoring system yielding acceptable sensitivities [12]
• Esophageal pH recording is indicated to document abnormal esophageal acid exposure in an endoscopy-negative patient being considered for surgical antireflux repair (pH study done after withholding antisecretory drug regimen for one week) [8]
• Esophageal pH recording is indicated to evaluate patients after antireflux surgery who are suspected to have ongoing abnormal reflux (pH study done after withholding antisecretory drug regimen for one week) [8]
• Esophageal pH recording is indicated to evaluate patients with either normal or equivocal endoscopic findings and reflux symptoms that are refractory to proton pump inhibitor therapy (pH study done after withholding antisecretory drug regimen for one week if the study is done to confirm excessive acid exposure or while taking the antisecretory drug regimen if symptom reflux correlation is to be scored) [8]
• Esophageal pH recording is possibly indicated to detect refractory reflux in patients with chest pain after cardiac evaluation using a symptom reflux association scheme, preferably the symptom association probability calculation (pH study done after a trial of proton pump inhibitor therapy for at least four weeks) [8]
• Esophageal pH recording is possibly indicated to evaluate a patient with suspected otolaryngologic manifestations (laryngitis, pharyngitis, chronic cough) of gastroesophageal reflux disease after symptoms have failed to respond to at least four weeks of proton pump inhibitor therapy (pH study done while the patient continues taking the antisecretory drug regimen to document the adequacy of therapy).
• Esophageal pH recording is possibly indicated to document concomitant gastroesophageal reflux disease in an adult onset, nonallergic asthmatic suspected of having reflux-induced asthma (pH study done after withholding antisecretory drugs for one week) [8]
• Impedance-pH monitoring is the most sensitive method for detection and characterization of gastroesophageal reflux episodes but normal values have been lacking.
• Zerbib et al conducted 24-h ambulatory impedance-pH studies in 72 healthy subjects to build a database of gastroesophageal reflux patterns. Most (59%) gastroesophageal reflux episodes were acid, while 28% and 10% were weakly acidic and weakly alkaline, respectively. In addition, the authors showed that 24-h ambulatory impedance-pH monitoring is reproducible [17]
• If patient has acid laryngitis, studies using pH probes just above and just below the upper esophageal sphincter have shown that during some episodes of reflux, gastric acid reaches the level of the larynx [25]
• Esophageal manometry is of minimal use in the diagnosis of GERD. It should not be used for making or confirming a suspected diagnosis of gastroesophageal reflux disease [9]
• Manometry should not be routinely used as the initial test for chest pain or other esophageal symptoms because of the low specificity of the findings and the low likelihood of detecting a clinically significant motility disorder [9]
• The Bernstein test is useful to determine symptom correlation with esophageal acidification in patients without endoscopic evidence of esophagitis [10].
• The test is done by alternately infusing saline or 0.1N HCl at a rate of 6 to 8 mL/min into the mid-esophagus via a nasogastric tube or manometric assembly [10].
• A positive test is defined as reproduction of the patient's symptoms with acid perfusion but not with saline. This test is ideal for determining acid sensitivity [10].
• Double contrast barium swallow examinations can identify early stages of reflux esophagitis by a granular or nodular appearance of the mucosa of the distal third of the esophagus with numerous ill-defined, 1 to 3 mm lucencies (show radiograph 1) [11]. A variety of other changes may also be seen [11]: Thickening of the longitudinally oriented esophageal folds may occur, with folds wider than 3 mm categorized as abnormal. These folds may be quite tortuous, mimicking varices. Shallow ulcers and erosions are recognized on double contrast radiographs as tiny collections of barium in the distal esophagus near the gastroesophageal junction, sometimes surrounded by a radiolucent halo of edematous mucosa
• The water siphon test (sipping water in supine position during a barium esophagram) has a sensitivity of only 60% and a false positive rate of 30% [12]

TREATMENT
• Mild symptomatic GERD can usually be managed empirically; lifestyle and dietary modifications along with antacids and nonprescription histamine-2 (H2) receptor antagonists are usually sufficient.
• Patients with debilitating symptoms usually require more pharmacologic acid-suppressive therapy or antireflux surgery.
• Between these extremes, matching the potency of therapy with disease severity can be achieved either by a "step up" approach (beginning with lifestyle and dietary measures and incrementally increasing the therapeutic intervention over time until symptom control is achieved) or a "step down" approach (beginning with potent antisecretory agents to achieve rapid symptom control and then incrementally decreasing the intervention until break-through symptoms define the therapy necessary for continued symptom control)
NON PHARMACOLOGICAL TREATMENT


Lifestyle modifications are aimed at enhancing esophageal acid clearance, minimizing the incidence of reflux events, or both as with cessation of smoking and avoidance of late meals:
• Head of bed elevation, which can be achieved either by putting 6- to 8-inch blocks under the head end of bed or having more pillows to elevate head. Head of bed elevation is important for individuals with nocturnal or laryngeal symptoms; its necessity in other situations is questionable.
• Dietary modification may be helpful. It is practical to suggest avoidance of a core group of reflux-inducing foods (fatty foods, chocolate, peppermint, and excessive alcohol, which may reduce lower esophageal sphincter pressure) and then to suggest that the patient selectively avoid foods known to cause symptoms. As an example, a number of beverages have a very acidic pH and can exacerbate symptoms. These include colas, red wine, and orange juice (pH 2.5 to 3.9).
• Refraining from assuming a supine position after meals for 2- 3 hours and avoidance of meals before bedtime, both of which will minimize reflux.
• Avoidance of tight fitting garments, which reduces reflux by decreasing the stress on a weak sphincter.
• Obesity is a risk factor for GERD [1]. However, improvement in symptoms following weight loss is not uniform after weight loss. Nevertheless, because of a possible benefit, and because of its other salutary effects, weight loss should be recommended and BMI maintained between 19 – 24.9 kg/m2.
• Promotion of salivation by either chewing gum or use of oral lozenges may also be helpful in mild heartburn. Salivation neutralizes refluxed acid, thereby increasing the rate of esophageal acid clearance.
• Restriction of alcohol use is advised
• Elimination of smoking; smoking is deleterious in part because it diminishes salivation.
• Consider changing medications that can lower the LES pressure (i.e., Theophylline, calcium channel blockers, and barbiturates).