- 1 Gastrointestinal Reflux Disease
- 1.1 Main symptoms
- 1.2 Other possible symptoms
- 1.3 Red flags
- 1.4 Lifestyle factors
- 1.5 For doctors
- 1.6 Medications
- 1.7 Which symptom is unresponsive?
- 2 References
Gastrointestinal Reflux Disease
This is an extremely common disease. Normally, a diagnosis is made after serious diseases are considered and ruled out by your doctor.
Unfortunately, if you are diagnosed with this disease, you must understand that it is a chronic disease (AKA long term). It tends to wax and wane with time, and will be triggered when the lifestyle factors are overlooked again.
Some of the information in this article is meant for family physicians. Patients can try to read the top portion only.
- Burning sensation behind the chest. Can sometimes be a dull or even pulling sensation (heartburn)
- Perception or feeling of stomach contents in the throat (regurgitation)
- Painful or abnormal swallowing sensation (dysphagia)
Other possible symptoms
- Unusual chest pain sensation (make sure it’s not due to a heart problem first)
- Lump or the feeling of something in the throat (globus). Rather common symptom in the local setting
- Unexplained nausea
- Chronic persistent cough that cannot be explained by other symptoms
The doctor must make sure that there is none of the following red flags that can be a sign of something more dangerous.
- Loss of weight
- Bleeding from stools, malena (black tarry stools) or hematochezia (red stools)
- Low blood count (anaemia)
- Painful swallowing (dysphagia)
- Chest pain (make sure it is not due to a lung or heart problem first)
There are numerous lifestyle factors that are associated with this condition.
- Poor quality of sleep/insufficient sleep
- Irregular eating habits
Protein Pump Inhibitors
Comes in many names and brands, like omeprazole, esomeprazole (nexium), lansoprazole, dexlansoprazole (dexilant) and many others.
Extremely effective drugs to reduce the stomach acid. Doubling the dose of the medication has limited benefits. It is reasonable to empirically start the patient on a course of PPI and if the symptoms are resolved, no further testing is required.
Instructions to follow: best taken before the meal, before breakfast.
“RAFT- forming agents”
Refers to alginate based medications such as Gaviscon, which forms a “raft” or protective layer over the stomach.
Adding these agents has some additional benefit in selected patients.
Adding a H2 antagonist such as ranitidine or famotidine or prokinetic agents such as domperidone or maxolon is no longer recommended.
Duration of treatment?
What if it doesn’t respond after that?
Consider if the patient has been taking the medication faithfully as prescribed. If the patient has, perhaps it is time to consider other possible causes. (Time for referral to a specialist or further testing)
Which symptom is unresponsive?
This symptom is the most responsive to the PPI medications.
A scope (gastroscopy/OGD) should be done to look for an alternative diagnosis (eosinophilic esophagitis, infection, pill injury and achalasia). Also can find out reflux esophagitis and complications. Most will be diagnosed with non-erosive reflux disease (NERD).
pH probe is something similar to a nasogastric tube (NGT) to wear for a day, to check if the reflux is correlating with the symptoms. If the patient shows normal acid exposure on the pH probe but complains of a lot of symptoms, consider starting TCA (tricyclic antidepressants) or SSRI (selective serotonin reuptake inhibitor).
For example: Amitriptyline low dose 10mg every evening. Takes about 2-3 weeks minimum before seeing effects, KIV increase dose if diagnosis is correct and responding.
Alternatively consider wireless pH monitoring (instead of pH probe) : more expensive and require endoscopy to place the probe.
Generally less responsive to PPI. Consider surgical treatment: fundoplication.
- Vomiting, has forceful abdominal contractions or nausea, unlike in regurgitation which does not have.
- Rumination syndrome: is a habit, never occurs during sleep, begins right after meals, not preceeded by belching. Treatment is by behavioral therapy via diaphragmatic breathing.
Gastric VS Supragastric.
Supragastric belch: stops during sleep, “Volitational”: patient has learnt to subconsciously swallow the air and burp it out: “supragastric” : send for behavioural therapy via diaphragmatic breathing.
Differentials: achalasia and esophageal dysmotility
Is not a symptom of GERD. Consider irritable bowel syndrome (IBS) <link required>
1. Dr Vikneswaran Namasivayam’s lecture at Singapore General Hospital 10 February 2017.
2. Clinical manifestations and diagnosis of gastroesophageal reflux in adults. Uptodate.com. Topic 2265 Version 19.0. Accessed 6 March 2017.