In gastroesophageal reflux disease, stomach acid flows back into the esophagus often enough to cause troublesome symptoms or damage. Over time it can lead to esophagitis, strictures or Barrett esophagus, a change in the lining that can rarely turn into cancer.
Key symptoms
- Burning heartburn behind the breastbone, worse after meals or lying down
- Sour or bitter regurgitation into the mouth
- Chronic cough, hoarseness or throat clearing
- Chest pain that can mimic heart pain
- Worse at night, with large meals, alcohol or late eating
What you find on exam
- Often a normal exam
- Mild epigastric tenderness
- Weight and BMI; obesity worsens reflux
- Look for dental erosion and signs of anemia or weight loss
Tests
- Diagnosis is usually clinical, with a trial of a proton pump inhibitor
- ECG and troponin first if chest pain could be cardiac
- Upper endoscopy for alarm features or poor response to treatment
- Ambulatory pH monitoring when the diagnosis is unclear or before surgery
Treatment basics
- Weight loss, raise the head of the bed, no meals 2 to 3 hours before bed
- Proton pump inhibitor such as omeprazole once daily before breakfast for 8 weeks
- H2 blocker such as famotidine or antacids for mild, occasional symptoms
- Step down to the lowest dose that controls symptoms
- Surgery (fundoplication) for selected patients who do not respond or prefer it
Red flags
- Trouble or pain when swallowing
- Vomiting blood, black stools or anemia
- Unintended weight loss, or chest pain with exertion
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Sources: NCCPA PANCE Content Blueprint; NBOME COMLEX-USA clinical presentations; AAMC Core Entrustable Professional Activities (Core EPAs). Written by Making Synapses. Making Synapses is not affiliated with these organizations.