Gastroesophageal Reflux Disease: Diagnosis and Treatment

Diagnosis

Initial assessment should include a thorough history and physical examination to rule out a cardiac source of chest pain. Focused diagnostic testing may be necessary, including an EKG and cardiac enzymes.

In most cases, diagnosis can be made on the basis of the patient’s clinical response to proton pump inhibitors (eg, omeprazole). A therapeutic trial of lifestyle changes (see below), antacids, or H2 (Histamine–2) receptor blockers (eg, cimetidine) may also be attempted, although these are less reliable for diagnostic purposes.

Further diagnostic testing may include the following:

Upper GI endoscopy. Permits direct inspection of the inflamed mucosa and biopsy to rule out Barrett’s esophagus or malignancy.

Barium esophagram. Evaluates for anatomic causes and complications of gastroesophageal reflux disease (eg, hiatal hernia, strictures).

24–hour pH monitoring. Correlates esophageal pH to symptom onset in order to diagnose reflux.

Esophageal manometry. Measures pressure within the esophagus to evaluate esophageal sphincter function or esophageal dysmotility.

Treatment

Lifestyle modification is the initial therapy for mild–to–moderate disease. Along with weight loss, this may include dietary changes to eliminate or minimize predisposing agents, such as avoiding alcohol, caffeine, chocolate, peppermint, spicy foods, fatty foods, and other dietary triggers, and refraining from eating within 2 to 4 hours of bedtime. Other modifications include smoking cessation, avoiding postprandial recumbancy, elevation of the head of one’s bed by 6 to 8 inches, avoidance of tight–fitting clothing that may increase intra–abdominal pressure, and elimination of medications that decrease esophageal sphincter tone (eg, calcium channel blockers).

Medications are usually effective for symptomatic relief. Oral antacids or H2 receptor blockers (eg, cimetidine, ranitidine) are used when symptoms are mild and intermittent.

Proton pump inhibitors (eg, omeprozole) are generally reserved for severe or recurrent symptoms.

Severe reflux may require surgical fundoplication, which involves wrapping the distal end of the esophagus with the fundus of the stomach to restore the competence of the lower esophageal sphincter.

Patients who have been diagnosed with Barrett’s esophagus require regular screening endoscopies to monitor for esophageal carcinoma.

Attaining or maintaining a healthy body weight may be helpful. Compared with individuals with a body mass index (BMI) below 25 kg/m2, those with a BMI between 25 and 30 kg/m2 have roughly 1.5 times the risk for gastroesophageal reflux disease, while persons with a BMI > 30 have approximately double the risk for this disease.¹ Available evidence is limited, but suggests that weight loss may bring symptomatic improvement.^2,3

In addition, psychological distress, caused by either major life events^4,5 or overt psychiatric disease,⁶ is associated with GERD symptoms. Limited evidence suggests that stress–reduction techniques (ie, relaxation training) may reduce symptoms in many persons.⁷