The 15-Minute Visit

A guide to patient encounters in the real world of office practice

Gastroesophageal reflux disease

PROBLEM

A 28-year-old man presents with a history of indigestion and heartburn that has occurred several times a week for the past 2 years. He also complains of a 1-month history of a nonproductive cough, particularly at night. He has smoked 1 pack of cigarettes a day for the last 10 years, and he drinks a 6-pack of beer on weekends. He takes ibuprofen twice daily for a burning sensation in his throat.

APPROACH

This man has gastroesophageal reflux disease (GERD), which is characterized by reflux of acidic stomach contents into the esophagus. In this very common disorder (approximately 10%-20% of adults suffer from heartburn), reflux causes burning chest pain and indigestion, as well as a feeling that food is passing up from the patient's stomach into the chest. Any medication (such as theophylline, anticholinergics, or calcium channel blockers), food (such as fatty foods, chocolate, or peppermint), or condition (such as pregnancy or use of nasogastric tube) that decreases the lower esophageal sphincter pressure can cause GERD. In this patient, other conditions to consider include NSAID gastropathy and/or alcohol-induced gastropathy. In immunocompromised patients, infectious esophagitis (attributable to candidal, herpes simplex, or cytomegalovirus pathogens) would be another consideration.

GERD is associated with many extraesophageal manifestations, including laryngitis, aspiration pneumonia, vocal cord granulomas, tooth decay, and asthma. This patient's nocturnal cough may indicate the presence of asthma and requires further pulmonary evaluation with spirometry, in addition to treatment for GERD.

Complications of GERD include erosive esophagitis, Barrett's esophagus (intestinal metaplasia on pathologic examination), esophageal stricture, and increased risk of esophageal adenocarcinoma. As the duration of GERD symptoms increases, so does the patient's risk of adenocarcinoma, though the overall risk is quite low.

Management

Although there is no strong evidence to support lifestyle measures to treat GERD, most clinicians provide the following common sense recommendations: Avoid dietary triggers; eat small, frequent meals rather than 3 large ones; avoid large meals after 6 pm; avoid tight-fitting clothes, bending, or stooping; elevate the head of the bed; lose weight if necessary; and stop smoking. This patient should be advised to significantly limit or eliminate alcohol and NSAID use.

After counseling the patient on the these measures, it is reasonable to empirically prescribe proton pump inhibitors (PPIs) or histamine-2 blockers. The former are preferred because they have been shown to be more effective, but in patients for whom cost is an issue, histamine-2 blockers may be initially tried and the clinical response monitored. Remember that PPIs should be administered before breakfast (and before dinner if the patient is taking medicine twice daily). These drugs are not as effective when used on a prn basis. Patients for whom empiric PPI therapy fails or who have "alarm" symptoms that are suggestive of GERD complications (such as dysphagia or weight loss) should be referred for upper endoscopy. Older patients (older than 40) who have chronic symptoms (lasting 3-5 years) should also be considered for endoscopic screening.

Common reasons for refractoriness to therapy include nonadherence to the medical regimen, incorrect diagnosis, and improper administration (for example, taking the medication with food). Patients diagnosed with Barrett's esophagus will need periodic endoscopic surveillance (the frequency is controversial) as determined by a gastroenterologist. Controversy also exists regarding how long to treat GERD. Most patients will have recurrent symptoms if medications are stopped, and they therefore receive indefinite therapy.

Although surgery has been shown to be effective for GERD, long-term benefits are uncertain. Most symptoms of GERD can be controlled with medication, and patients are thus able to avoid the potential complications associated with surgery (dysphagia, bloating, and diarrhea in up to 20% of patients).

This patient was persuaded to avoid alcohol and limit the use of NSAIDs such as ibuprofen. He was also given a prescription for a PPI, omeprazole (Prilosec), 20 mg/d, and a patient education handout on GERD. He was also encouraged to quit smoking. At his follow-up visit 2 weeks later, the patient reported resolution of his GERD symptoms.

 

What would you do if . . . 1. The patient is pregnant? 2. The patient develops anginalike chest pain? 3. The patient does not respond to initial PPI therapy? Answers 1. Review conservative measures (see "Management"). Several PPIs and histamine-2 blockers are listed as Category B drugs in pregnancy and appear safe to use. 2. Assess the risk factors for coronary syndromes (history of hypertension, diabetes, smoking, dyslipidemia, family history of MI), and make necessary diagnostic interventions (exercise tolerance test versus cardiac catheterization) before assuming the symptoms are related to GERD. 3. Make sure the patient is taking the maximum dose of the PPI on an empty stomach. If symptoms persist, refer the patient for upper endoscopy.

 

For more on this topic . . . DeVault KR, Castell DO, Practice Parameters Committee of the American College of Gastroenterology. ACG Treatment Guideline: Updated Guidelines for the Diagnosis and Treatment of Gastroesophageal Reflux Disease, 1999. Available at: http://www.acg.gi.org/physicianforum/guides/gerdabs.html . Accessed June 22, 2004. Ofman JJ. Decision making in gastroesophageal reflux disease: what are the critical issues? Gastroenterol Clin North Am. 2002;31(suppl 4):S67-S76. Richter JE. Medical management of patients with esophageal or supraesophageal gastroesophageal reflux disease. Am J Med. 2003;115(suppl 3A):179S-187S.

CONTRIBUTOR

DEAN GIANAKOS, MD, Clinical Associate Professor of Family Medicine, Director of Internal Medicine and Critical Care Education, Lynchburg Family Practice Residency, Lynchburg, Va; member, Patient Care Board of Editors.

REVIEWER

LAWRENCE S. FRIEDMAN, MD, Associate Professor of Medicine, Harvard Medical School; Physician, Massachusetts General Hospital, GI Unit, Boston, Mass; and member, Patient Care Subspecialty Board of Editors.

 

The 15-Minute Visit. Patient Care July 2004;38:14.