Outpatient Evaluation of GERD

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Welcome back to Run the List, a medical education podcast in internal medicine. As a quick disclaimer, this podcast is made for educational and informational purposes only, and should not be understood as medical advice under any circumstances. Welcome back to Run the List. We're so excited to be back after a long hiatus. Some of us have graduated medical school, started residency or fellowship, and become attendings. We're looking forward to bringing you new episodes on new topics we haven't yet covered, updates to our older episodes, as well as deeper dives into subjects you may want to learn about in more detail. Today, I'm here with Navine Kumar, attending GI at Brigham & Women's Hospital, and fellow core RTL member. Hi, Navine. Hi, Emily. It's so good to hear your voice again. You too. I feel like it's been a long time and I'm just so happy that we're back recording another episode. It's funny. I was just telling you before we started that Run the List just keeps on coming back into our lives from students who and residents and trainees who've been using it, and so I'm just so excited to be back recording new episodes and doing such great content as you've been doing once again. So before we start, I wanted you. I know what you been up to, but I think our listeners would love an update on where you are in your training career, and then we can get into it. That sounds great. So since we last recorded, I finished up my internal medicine residency at Mount Sinai, New York, and I'm now in my second year of rheumatology fellowship at NYU. I'm having a really great time. I know I initially started this RTL journey thinking I was going to fall in your footsteps and go into GI, but rheumatology kind of became my calling, and I hope we can get into some room episodes here as well. That's great, and there's always there's always some overlap between rheumatology and gastroenterology, so it's still yeah, it still works. Awesome. So today we're going to start off with an episode about GERD, and we're going to focus on its diagnosis on the outpatient side. So without further ado, let's go ahead and run the list. Mr. S is a 52-year-old male with a history of hypertension who presents to primary care clinic with six months of retro-sternal burning discomfort after meals. His symptoms are worse at night and improved with an antaphid. There's no exertional component, and the symptoms have been occurring at rest. So Naveen, what are you thinking about in terms of a diagnosis for this patient? Yeah, Emily, so this sounds like a pretty classic presentation of gastroesophageal reflux disease or GERD. You know, GERD is a clinical diagnosis, so the primary symptom is heartburn, which we define as retro-sternal burning discomfort, and then there's a lot of features that are commonly associated with this symptom of heartburn. So those include the fact that it's post-prandial or after meals. There's a postural component, so it's typically worse when laying down and better when sitting upright just because of the fact that gravity can help keep the acid down in the stomach, but you lose that benefit when you lay down. There is the fact that it can be alleviated by ant acids, which we saw was the case for our patient in this clinical vignette, and then also that there's several dietary triggers, and we'll get into these later a bit further on in this episode. So just to review, this is again a clinical diagnosis, and the definition of GERD is the fact of patients having symptoms or tissue injury due to reflux of gastric contents. I think the important piece here is that it's not reflux of acidic contents, it's reflux of gastric contents, and there are gastric contents that are non-acidic. So we'll talk about this in our next episode, but the symptoms of GERD can be either acidic or non-acidic, and there's ways that we can actually determine the acidity of the reflux using some more invasive approaches that we can order from our GI clinic. So this patient meets the typical presentation of GERD. Are there any atypical symptoms we should consider as well? Yeah, absolutely, and the way I like to think about atypical symptoms is that I use kind of a bucket approach by system. So the first bucket is the cardiac non-cardiac bucket, and that's patients who are having chest pain that's due to GERD as opposed to some other cause, which first and foremost will always want to rule out a cardiac cause. There's then the pulmonary bucket where atypical symptoms of GERD include chronic coughing or wheezing, and then the third big bucket is the ear, nose, and throat category, and within that category we can think of the symptoms of globus, which is the sensation of having something in the back of your throat that you can just cannot clear, and then also the symptom of waterbrush, which is an interesting phenomenon where due to acid refluxing into the oral pharynx, it stimulates the salivary glands to secrete a great deal of saliva. So some people, and this often happens when patients who are having reflux overnight wake up, they notice that there's a sour taste in their back of their mouth, and sometimes because of the excess saliva, their mouth is actually full of saliva. And so that's another atypical symptom of GERD. Now what's important to note is that whereas the classic symptoms, which include, we already talked about heartburn, the other classic symptom is regurgitation. So if a patient has heartburn and or regurgitation, that essentially makes the diagnosis of GERD, but with these atypical symptoms, the presence of those are not sufficient to make the diagnosis. And that makes sense because if you imagine you see your seeing a patient in clinic and they're reporting to you that they're having chest pain, you wouldn't then just go ahead and say that that is a diagnosis of GERD. You would want to rule out the other possible causes first and then say that okay, if all these other possible causes are not at play, then GERD is the most likely cause. So I think when we are seeing these patients who are presenting atypically, again, remember first you need to rule out the other possible causes before you rule in the possibility that it could be from GERD. Okay, so we have atypical and typical symptoms of GERD to elicit when we're taking a history. Do you have any other questions in mind when evaluating a patient with GERD in the clinic? I do, Emily, when I'm seeing a patient in clinic, of course I'm going to take a full history, but thinking more specifically about their presentation with GERD, what I really want to know is if they are experiencing any alarm symptoms. And by alarm symptoms, I mean the following. So we're going to go through a list right now. So the first alarm symptom is age and so your patient is 60 years or older and they're having new onset, GERD or dysbeptic symptoms. That's considered an alarm symptom. The next category or the next alarm symptom to mention is one of dysphasia or odinophasia. So dysphasia refers to difficulty swallowing, odinophasia refers to pain on swallowing. If either these are present, that would be considered an alarm symptom. Next is GI bleeding. So let's first think about evidence of overt GI bleeding that being hematemesis or are they actually vomiting, red blood or coffee grounds from their upper GI tract or are they reporting dark, black, tarystools or melanin that would suggest bleeding from the upper GI tract as well. On labs, you may find that they have iron deficiency anemia as a manifestation of GI bleeding. So that would also be an alarm symptom. And then in terms of other things, the patients might report. You have to ask about weight loss, persistent vomiting, and this is one that's often forgotten is having a family history of upper GI malignancy. So the question is, why are these lists of symptoms alarming? Well, the main point is that if any of these symptoms are present, it suggests that there could be a more concerning underlying diagnosis aside from gastrosophageal reflux disease or girds. So most notably, we're concerned for there being an occult cancer. But there's also the possibility that they have severe esophageitis that is causing these symptoms, the peptic ulcer disease, or they have an esophageal stricter or even eosinophilic esophageitis, all of which would need an upper endoscopy for diagnosis. So when you ask your patients, these alarm symptoms, and if any of them are present, know that the next step is going to be that they need an upper endoscopy for further evaluation. And we're going to get into the endoscopy side of things in a later episode as well. So just to remind all of us about our patient, he's a 52 year old gentleman with history of hypertension, and he's coming in with six months of retrosjournal burning discomfort after meals, worse at night, better with an antacid and non-exertional and occurring at rest. Just to review your alarm symptoms that you just went over, he does not have any of those concerning symptoms, but also reports to you that he's actually gained weight about 15 pounds since these symptoms started. And he notices that he's drinking more caffeine. He's curious why all these symptoms have developed now when he never had them before. Yeah, this question of why now comes up often in GI clinic? And what I do with patients is I like to use an anatomical framework to help explain the pathophysiology of GERD in a way that our patients can understand easily. So what I do is I say, let's start with the upper GI tract, and we're going to move from the proximal location, and then we're going to move downwards more distally. So after you swallow your meal, the first place the food finds itself is within the esophagus or esophageal body. And so at the level of the esophageal body, if you have ineffective esophageal clearance, if ascetic or non-acidic any gastric contents reflux upwards into the esophagus, with ineffective esophageal clearance, they will not get removed effectively, and that itself will lead to reflux symptoms. Now most commonly, we see this with patients who have dysmotility or usually from underlying connective tissue disorders like scleroderma. So that is one thing to think about when you're valuing your patient, you're absolutely explaining to them why they may be experiencing these GERD symptoms. So moving from the esophageal body more distally will then meet the lower esophageal sphincter, that sphincter that's in between the esophagus and the stomach that controls the passage of food from the esophagus into the stomach. So as you can imagine, when you swallow, the lower esophageal sphincter will eventually open to allow the food bolus to pass through, and then it closes so that whatever left in the stomach will not reflux upwards. Now in just a moment, we'll talk a lot more about the lower esophageal sphincter because that is the area that is most commonly involved with GERD symptoms, and so we'll get back to that in just a bit. Now moving further distally, we get into the proximal stomach, and it's there that you can have a hydrohernia. And there's two reasons why a hydrohernia can lead to GERD. One is that you weaken the lower esophageal sphincter because you don't have the diaphragmatic support around the LES when your stomach herniates upwards. And then two is that the hydrohernia actually forms a small sac, and that sac can end up holding onto the gastric reflux contents, and with the stasis of those contents in the sac, that will lead to more symptoms as well. Moving more distally, we're now in the gastric body, and you can imagine if there's anything that's compressing the stomach from the outside, that's going to push the contents upwards into the esophagus. So this is commonly from conditions such as obesity or pregnancy where you get that extrinsic compression, forcing gastric contents up into the esophagus. And then lastly, I move down to the pylorus where I think about the stomach emptying, and anything that slows gastric emptying is going to allow for more chances of reflux to occur. So for example, the patient has gastroparesis, and then now more commonly with patients on GLP1 agonist that delay gastric emptying, we're seeing a lot of these patients experience heartburn for the first time, or worsening of heartburn that was previously well controlled, because those stomach contents are just sitting in the stomach longer, leading to more opportunities for those stomach contents to reflux upward into esophagus and cause symptoms. So it's really important to think about the entire GI tract, which really can help us figure out exactly why these gourd symptoms are coming on now. Let's return to the lower esophageal sphincter, because as you said, it appears to be the cause of issues for a lot of people with gourd. Absolutely. Anyway, I completely agree. So the lower esophageal sphincter again is the is that area that anatomical location that demarcates the esophagus from the stomach, and a very normal phenomenon that occurs at the lower esophageal sphincter is the transient lower esophageal sphincter relaxation, or TLESR. Now this is a normal reflex to allow the release of air from the stomach. Whenever we eat, we will always swallow some degree of air. And so what these TLESRs allow is the release of that air from the stomach into esophagus so that we can actually remove that air from our GI tract. Now the problem is, in the majority of patients who have gourd, these sphincter relaxations occur at an increased frequency, or with increased proportion of gastric contents, thereby causing gourd symptoms. So if your lower esophageal sphincter is relaxing too often, that's going to allow the opportunity for gastric contents to reflex upward, or whenever your sphincter is relaxing that some gastric contents are reflexing upwards during that moment, that's also going to lead to more symptoms. So think about the lower esophageal sphincter as almost the gatekeeper of what gets into the stomach, and then what is allowed to come back up when it's relaxed. The reason why this is so important is that so many dietary triggers are actually working at the level of the LES or the lower esophageal sphincter. So caffeine, alcohol, smoking, chocolate, peppermint, fats, they all relax the lower esophageal sphincter, which will allow the opportunity for gastric contents to reflex upwards. There's also many medications that work at this level as well, calcium channel blockers, anticholinergics, nitrates, opioids, so those will all relax this sphincter and allow for more reflex to occur. And then lastly, hormones such as estrogen and progesterone, another reason why patients who are pregnant have such a high risk of a reflex disease. That's a great list of triggers that I'm sure we're going to get back to in our next episode on treatment of GERD. But before we go, Naveen, can you just summarize the most important takeaways for our listeners? Yes, I'd love to. So number one, let's all remember GERD is a clinical diagnosis. When we meet again next time, we're going to talk about all the different diagnostic tools available to confirm the diagnosis of GERD. But this is really a diagnosis that you should be making in clinic based on those classic symptoms, heartburn and or regurgitation. And remember that atypical symptoms, we went through the buckets of cardiac, noncardiac, chest pain, pulmonary, and ENT. Those atypical symptoms are insufficient for diagnosis. So you have to rule out the other possible causes before you rule in GERD. Number two, I want you all to remember the alarm symptoms of GERD. We went through a nice list of those. And if any of those are present, we do have to proceed to an upper endoscopy for diagnosis because the possibility that a more severe underlying diagnosis most notably cancer, but other more severe GI manifestations such as peptic ulcer disease or GERD with severe esophageitis may be at play. And then lastly, try out this anatomical framework with your patients and when you're teaching to identify the underlying cause of GERD. And I should say it's even more than just with your patients and your teaching should be for yourself when you're reasoning through why your patients may be experiencing GERD at this time. Because if you can identify the one or two potential causes, that's going to lead to influencing how you may treat them to improve their symptoms in the long term. Awesome. Thank you for that. So we really hope that you enjoyed this comeback episode on diagnosing GERD in the office. And we hope you're going to join us again next time when we cover GERD in the endoscopy suite as well as treatment options. Thanks, Naveen. Thanks, Emily. It was so fun to record again and can't wait to do this again just a few weeks.