Gastroesophageal reflux disease

Background

• Abbreviation: GERD
• Affects up to 20% of population
• Assume chest pain is cardiac origin until proven otherwise

Causes

• Decreased pressure of lower esophageal sphincter
  • High-fat food
  • Nicotine
  • Ethanol
  • Caffeine
  • Medications (mintrates, calcium-channel blockers, anticholinergics, progesterone/estrogen)
  • Pregnancy
• Decreased esophageal motility
  • Achalasia
  • Scleroderma
  • Diabetes
• Prolonged gastric emptying
  • Anticholinergics
  • Outlet obstruction
  • Diabetic gastroparesis
• High-fat food

Clinical Features

Patients who come to the Emergency may present with various symptoms, both typical and atypical.

• Typical symptoms, may include: heart burn, regurgitation of food or dysphagia.
• Atypical symptoms include noncardiac chest pain, asthma, pneumonia, hoarseness, and aspiration.

• Pain and discomfort with or right after meals
  • typically described as burning pain
  • often worse when lying flat
• Chest pain with features similar to ACS:
  • Exertional, associated with diaphoresis, nausea/vomiting, radiating to arm

Pediatric GERD

• Reflux is physiologic in infants
• Pathologic only if it causes complications, such as:
  • failure to thrive/weight loss
  • esophagitis
  • respiratory disease: refractory asthma, recurrent pneumonia, apnea
  • BRUE

Differential Diagnosis

Epigastric Pain

• Gastroesophageal reflux disease (GERD)
• Peptic ulcer disease with or without perforation
  • Zollinger-Ellison syndrome
• Gastritis
• Pancreatitis
• Gallbladder disease
  • Acute cholecystitis
  • Cholangitis
  • Symptomatic cholelithiasis
  • Acalculous cholecystitis
• Myocardial Ischemia
• Splenic Infarctionenlargement/rupture/aneurysm
• Pericarditis/Myocarditis
• Aortic dissection
• Hepatitis
• Pyelonephritis
• Pneumonia
• Pyogenic liver abscess
• Fitz-Hugh-Curtis Syndrome
• Hepatomegaly due to CHF
• Bowel obstruction
• SMA syndrome
• Pulmonary embolism
• Bezoar
• Ingested foreign body

Management

• Avoid GERD exacerbating agents (ETOH, caffeine, nicotine, chocolate, fatty foods)
• Sleep with head of bed elevated
• Avoid eating within 3hr of sleep
• PPI or H2 blocker
• Infants: small frequent feeds, avoid semi-supine position (e.g. carseat, carrier) right after feeds
  • medications only if significant complications

Disposition

• Home (outpatient treatment)

See Also

• Abdominal Pain