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Sun 3 Jun 2007 03:01 PM

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Diagnosing atypical manifestations of GERD

If a patient has a persistent sore throat, asthma, chest pain, or hoarseness, physicians shouldn’t rule out reflux.

Gastroesophageal reflux disease (GERD), already widespread, may be on the rise as it is exacerbated by common behaviors such as stress, smoking cigarettes, and drinking strong coffee. Normally, when stomach acid backs up into the esophagus it causes heartburn, making the condition relatively easy to diagnose and treat. But around 10% of people with GERD don't have heartburn. Instead, their symptoms mimic disorders of the ear, nose, and throat. Some have upper respiratory symptoms, such as asthma or wheezing, while others report sore throat, chest pain, recurrent laryngitis, hoarseness, or the sensation of choking or a lump in the throat.

In many of these patients the symptoms persist for years and standard treatments fail to provide any relief. "These patients should be referred to a gastroenterologist for an assessment," says Dr. Douglas Pleskow, co-Director of GI endoscopy at Beth Israel Deaconess Medical Center (BIDMC) in Boston, and assistant clinical professor at Harvard Medical School.

In this "In Practice" article, Pleskow discusses these extraesophageal symptoms of GERD and illuminates the current approaches to diagnosis and treatment of a condition that he says "is often under-diagnosed or misdiagnosed."

No telltale signs

Over the past decade or so, scientists have begun to recognise the link between extraesophageal problems and GERD. Still, patients frequently experience symptoms for years before they are referred to a gastroenterologist. Pleskow cited a recent case from his own practice as an example. "I just saw a woman who was diagnosed with asthma and treated with a variety of inhalers over the past three years with no results. After performing a few tests, I discovered that her condition was caused by GERD," he said. "She's perplexed because she has no symptoms of heartburn. That is the characteristic response of these patients."

The fact that there are few telltale signs that the problem is GERD makes it difficult to identify the condition, he adds. But once reflux is suspected there are several ways of making a diagnosis. Generally, a diagnosis of atypical manifestations of GERD begins with a detailed history and physical exam. The treating physician, says Pleskow, should find out when symptoms occur, the type of symptoms, and what other types of therapy have they had.

Some subtle clues of reflux include refluxlike symptoms preceding an asthma attack, or breathlessness after meals or when lying down. The majority of (but not all) patients with GERD have some of these reflux-like symptoms.

During the physical exam, the treating physician should look for signs of potential reflux: loss of tooth enamel, erythema, redness in the back of the throat, dry cough, bad breath, tight throat, and difficulty swallowing.

Once reflux is suspected, the patient should be referred to a gastroenterologist who will perform invasive and non-invasive diagnostic studies.

Diagnostic studies

A barium swallow may be helpful in eliciting whether a patient has reflux or a hiatal hernia. Upper endoscopy is used to identify signs of reflux and determine whether a patient has esophagitis, a hiatal hernia, ulcers, or complications of reflux, such as strictures or Barrett's esophagus. If direct inspection of the esophageal mucosa appears normal, then an esophageal biopsy may provide evidence of microscopic esophagitis, and help to establish a link between asthma and GERD.

Esophageal pH studies are another important tool in identifying whether or not there is reflux -- at least acidic type. In these studies, small probes are placed in the esophagus at the time of the endoscopy to quantify the amount of acid that refluxes into the esophagus over a 24- or 48-hour period. During this time period, the probe transmits a signal to a recording device worn on the patient's belt. At the end, the probe falls off and passes through the GI tract.

In the past, the probes were left in for 24 hours, but Pleskow says in recent years most physicians have opted for the 48-hour approach in order to more effectively diagnose reflux that occurs intermittently. "Recently, when we've compared 24-hour study to 48-hour Bravo probe studies, we found that the 24-hour studies were less accurate because they occasionally missed an occurrence during the second 24-hour period," he said. The 48-hour study has been available for over three years, and is becoming more widely used in the U.S.

For some patients, even the 48-hour pH study reveals no acid. Moreover, acid-reducing medications have no effect on the patient's symptoms. Pleskow says that in these cases, GERD may still be the cause, because there is a growing line of evidence to suggest that some reflux is non-acid reflux.

These patients should receive impedance testing, a technique that can detect reflux of non-acid contents and assess whether swallowed food passes through the esophagus in a normal manner. It works by measuring changes in electrical current as substances pass through the esophagus.

This test is particularly important if a patient presents with asthma or another otolarygologic disorder. If the test reveals that the patient has nonacid reflux, they should be given a mechanical approach to therapy.

Last, esophageal manometry is used to measure esophageal motility. A probe with multiple pressure sensors is placed in the esophagus, and the patient is asked to swallow sips of water. The test is especially useful for diagnosing GERD in patients who present with non-cardiac chest pain, and is crucial for patients being considered for surgical treatment of GERD.

Pleskow emphasizes that for patients with recurrent chest pain, the treating physician needs to rule out cardiac, pulmonary, and musculoskeletal causes.

Treating atypical manifestations of GERD

Therapy for atypical manifestations of GERD is directed at dealing with the cause of the reflux. Typically, the problem is acid-induced and requires lifestyle modification: smoking cessation, elimination from the diet of caffeine, citrus, and chocolate; weight loss; and avoiding late-night dining. In addition, acid-suppression medication may be recommended. Pleskow says that typically, patients fare best on proton pump inhibitors (PPIs) prescribed at double the amount used for someone with classic heartburn symptoms. These medications may be combined with a prokinetic agent, such as metoclopramide.

Antacids are rarely strong enough to alleviate symptoms in people with atypical manifestations of GERD. Some patients benefit from high-dose histamine2 (H2)-receptor antagonists, such as cimetadine, famotidine, nizatidine, or ranitidine hydrochoride. However, generally these drugs are not as effective as PPIs.

If medication doesn't work, anti-reflux surgery may be needed to prevent the reflux from entering the esophagus. Surgical approaches include laparascopic Nissen fundoplication or endoluminal fundoplication.

Endoscopic therapy represents a relatively new approach to therapy. Pleskow suggests that patients interested in this therapy should talk to a specialist about the specific advantages and disadvantages of the various approaches. The bottom line, he says, is that when patients with upper respiratory symptoms are not responding to standard therapy, physicians should consider GERD as a potential cause.

This article is provided courtesy of Harvard Medical International. © 2007 President and Fellows of Harvard College.

At a glance: symptoms of atypical manifestations of GERD

Non-allergic asthma

• Chronic nighttime coughing

• Hoarseness

• Laryngitis

• Vocal nodules

• Fluid in the vocal cords

• Abnormal narrowing of the larynx

• Spasms of the larynx

• Narrowing of the throat below the vocal chords

• Lump in the throat

• Sinusitis

• Non-cardiac chest pain

• Chronic hiccups

• Loss of dental enamel

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