Jay W. Marks, MD, is a board-certified internist and gastroenterologist. He graduated from Yale University School of Medicine and trained in internal medicine and gastroenterology at UCLA/Cedars-Sinai Medical Center in Los Angeles.
Dr. Charles "Pat" Davis, MD, PhD, is a board certified Emergency Medicine doctor who currently practices as a consultant and staff member for hospitals. He has a PhD in Microbiology (UT at Austin), and the MD (Univ. Texas Medical Branch, Galveston). He is a Clinical Professor (retired) in the Division of Emergency Medicine, UT Health Science Center at San Antonio, and has been the Chief of Emergency Medicine at UT Medical Branch and at UTHSCSA with over 250 publications.
Symptoms and response to treatment (therapeutic trial)
The usual way that GERD is diagnosed—or at least suspected—is by its
characteristic symptom, heartburn. Heartburn is most frequently described as a
sub-sternal (under the middle of the chest) burning that occurs after meals and
often worsens when lying down. To confirm the diagnosis, physicians often treat
patients with medications to suppress the production of acid by the stomach. If
the heartburn then is diminished to a large extent, the diagnosis of GERD is
considered confirmed. This approach of making a diagnosis on the basis of a
response of the symptoms to treatment is commonly called a therapeutic trial.
There are problems with this approach, however, primarily because it does not
include diagnostic tests. For instance, patients who have conditions that can
mimic GERD, specifically duodenal or gastric (stomach) ulcers, also can actually
respond to such treatment. In this situation, if the physician assumes that the
problem is GERD, he or she will not look for the cause of the ulcer disease. For
example, a type of infection called Helicobacter pylori, or non-steroidal
anti-inflammatory drugs (for example, ibuprofen), can also cause ulcers and these
conditions would be treated differently from GERD.
Moreover, as with any treatment, there is perhaps a 20% placebo effect, which
means that 20% of patients will respond to a placebo (inactive) pill or, indeed,
to any treatment. This means that 20% of patients who have causes of their
symptoms other than GERD (or ulcers) will have a decrease in their symptoms
after receiving the treatment for GERD. Thus, on the basis of their response to
treatment (the therapeutic trial), these patients then will continue to be
treated for GERD, even though they do not have GERD. What's more, the true
cause of their symptoms will not be pursued further.
Endoscopy
Upper gastrointestinal endoscopy
(also known as esophago-gastro-duodenoscopy
or EGD) is a common way of diagnosing GERD. EGD is a procedure in which a tube
containing an optical system for visualization is swallowed. As the tube
progresses down the gastrointestinal tract, the lining of the esophagus,
stomach, and duodenum can be examined.
The esophagus of most patients with symptoms of reflux looks normal. Therefore, in most patients, endoscopy will not help in the diagnosis of GERD. However, sometimes the lining of the esophagus appears inflamed (esophagitis). Moreover, if erosions (superficial breaks in the esophageal lining) or ulcers (deeper breaks in the lining) are seen, a diagnosis of GERD can be made confidently. Endoscopy will also identify several of the complications of GERD, specifically, ulcers, strictures, and Barrett's esophagus. Biopsies also may be obtained.
Finally, other common problems that may be causing GERD like symptoms can be diagnosed (for example ulcers, inflammation, or cancers of the stomach or duodenum)
with EGD.
Biopsies
Biopsies of the esophagus that are obtained through the endoscope are not considered very useful for diagnosing GERD. They are useful, however, in diagnosing cancers or causes of esophageal inflammation other than acid reflux, particularly infections. Moreover, biopsies are the only means of diagnosing the cellular changes of Barrett's esophagus. More recently, it has been suggested that even in patients with GERD whose esophagi appear normal to the eye, biopsies will show widening of the spaces between the lining cells, possibly an indication of damage. It is too early to conclude, however, that seeing widening is specific enough to conclude confidently that GERD is present.
X-rays
Before the introduction of endoscopy, an X-ray of the esophagus (called an
esophagram) was the only means of diagnosing GERD. Patients swallowed barium
(contrast material), and X-rays of the barium-filled esophagus were then taken.
The problem with the esophagram was that it was an insensitive test for
diagnosing GERD. That is, it failed to find signs of GERD in many patients who
had GERD because the patients had little or no damage to the lining of the
esophagus. The X-rays were able to show only the infrequent complications of
GERD, for example, ulcers and strictures. X-rays have been abandoned as a means
of diagnosing GERD, although they still can be useful along with endoscopy
in the evaluation of complications.
Examination of the throat and larynx
When GERD affects the throat or larynx and causes symptoms of cough,
hoarseness, or sore throat, patients often visit an ear, nose, and throat (ENT)
specialist. The ENT specialist frequently finds signs of inflammation of the
throat or larynx. Although diseases of the throat or larynx usually are the
cause of the inflammation, sometimes GERD can be the cause. Accordingly, ENT
specialists often try acid-suppressing treatment to confirm the diagnosis of
GERD. This approach, however, has the same problems that, as discussed above,
result from using the response to treatment to confirm GERD.
Esophageal acid testing
Esophageal acid testing is considered a "gold standard" for diagnosing GERD. As discussed previously, the reflux of acid is common in the general population. However, patients with the symptoms or complications of GERD have reflux of more acid than individuals without the symptoms or complications of GERD. Moreover, normal individuals and patients with GERD can be distinguished moderately well from each other by the amount of time that the esophagus contains acid.
The amount of time that the esophagus contains acid is determined by a test called a 24-hour esophageal pH test. (pH is a mathematical way of expressing the amount of acidity.) For this test, a small tube (catheter) is passed through the nose and positioned in the esophagus. On the tip of the catheter is a sensor that senses acid. The other end of the catheter exits from the nose, wraps back over the ear, and travels down to the waist, where it is attached to a recorder. Each time acid refluxes back into the esophagus from the stomach, it stimulates the sensor and the recorder records the episode of reflux. After a 20 to 24 hour period of time, the catheter is removed and the record of reflux from the recorder is analyzed.
There are problems with using pH testing for diagnosing GERD. Despite the fact that normal individuals and patients with GERD can be separated fairly well on the basis of pH studies, the separation is not perfect. Therefore, some patients with GERD will have normal amounts of acid reflux and some patients without GERD will have abnormal amounts of acid reflux. It requires something other than the pH test to confirm the presence of GERD, for example, typical symptoms, response to treatment, or the presence of complications of GERD. GERD also may be confidently diagnosed when episodes of heartburn correlate with acid reflux as shown by acid testing.
pH testing has uses in the management of GERD other than just diagnosing GERD. For example, the test can help determine why GERD symptoms do not respond to treatment. Perhaps 10 to 20 percent of patients will not have their symptoms substantially improved by treatment for GERD. This lack of response to treatment could be caused by ineffective treatment. This means that the medication is not adequately suppressing the production of acid by the stomach and is not reducing acid reflux. Alternatively, the lack of response can be explained by a wrong diagnosis of GERD. In both of these situations, the pH test can be very useful. If testing reveals substantial reflux of acid while medication is continued, then the treatment is ineffective and will need to be changed. If testing reveals good acid suppression with minimal reflux of acid, the diagnosis of GERD is likely to be wrong and other causes for the symptoms need to be sought.
pH testing also can be used to help evaluate whether reflux is the cause of symptoms (usually heartburn). To make this evaluation, while the 24-hour ph testing is being done, patients record each time they have symptoms. Then, when the test is being analyzed, it can be determined whether or not acid reflux occurred at the time of the symptoms. If reflux did occur at the same time as the symptoms, then reflux is likely to be the cause of the symptoms. If there was no reflux at the time of symptoms, then reflux is unlikely to be the cause of the symptoms.
Lastly, pH testing can be used to evaluate patients prior to endoscopic or surgical treatment for GERD. As discussed above, some 20% of patients will have a decrease in their symptoms even though they don't have GERD (the placebo effect). Prior to endoscopic or surgical treatment, it is important to identify these patients because they are not likely to benefit from the treatments. The pH study can be used to identify these patients because they will have normal amounts of acid reflux.
A newer method for prolonged measurement (48 hours) of acid exposure in the esophagus utilizes a small, wireless capsule that is attached to the esophagus just above the LES. The capsule is passed to the lower esophagus by a tube inserted through either the mouth or the nose. After the capsule is attached to the esophagus, the tube is removed. The capsule measures the acid refluxing into the esophagus and transmits this information to a receiver that is worn at the waist. After the study, usually after 48 hours, the information from the receiver is downloaded into a computer and analyzed. The capsule falls off of the esophagus after 3-5 days and is passed in the stool. (The capsule is not reused.)
The advantage of the capsule over standard pH testing is that there is no discomfort from a catheter that passes through the throat and nose. Moreover, with the capsule, patients look normal (they don't have a catheter protruding from their noses) and are more likely to go about their daily activities, for example, go to work, without feeling self-conscious. Because the capsule records for a longer period than the catheter (48 versus 24 hours), more data on acid reflux and symptoms are obtained. Nevertheless, it is not clear whether obtaining additional information is important.
Capsule pH testing is expensive. Sometimes the capsule does not attach to the esophagus or falls off prematurely. For periods of time the receiver may not receive signals from the capsule, and some of the information about reflux of acid may be lost. Occasionally there is pain with swallowing after the capsule has been placed. Use of the capsule is an exciting use of new technology although it has its own specific problems.
Esophageal motility testing
Esophageal motility testing determines how well the muscles of the esophagus are working. For motility testing, a thin tube (catheter) is passed through a nostril, down the back of the throat, and into the esophagus. On the part of the catheter that is inside the esophagus are sensors that sense pressure. A pressure is generated within the esophagus that is detected by the sensors on the catheter when the muscle of the esophagus contracts. The end of the catheter that protrudes from the nostril is attached to a recorder that records the pressure. During the test, the pressure at rest and the relaxation of the lower esophageal sphincter are evaluated. The patient then swallows sips of water to evaluate the contractions of the esophagus.
Esophageal motility testing has two important uses in evaluating GERD. The
first is in evaluating symptoms that do not respond to treatment for GERD. The
abnormal function of the esophageal muscle sometimes causes symptoms that
resemble the symptoms of GERD. Motility testing can identify some of these abnormalities
and lead to a diagnosis of an esophageal motility disorder. The second use is
evaluation prior to surgical or endoscopic treatment for GERD. In this
situation, the purpose is to identify patients who also have motility disorders
of the esophageal muscle. The reason for this is that in patients with motility
disorders, some surgeons will modify the type of surgery they perform for GERD.
Gastric emptying studies
Gastric emptying studies are studies that determine how well food empties
from the stomach. As discussed above, about 20 % of patients with GERD have slow emptying of the stomach that may be contributing to the reflux of acid. For
gastric emptying studies, the patient eats a meal that is labeled with a
radioactive substance. A sensor that is similar to a Geiger counter is placed
over the stomach to measure how quickly the radioactive substance in the meal
empties from the stomach.
Information from the emptying study can be useful for managing patients with
GERD. For example, if a patient with GERD continues to have symptoms despite
treatment with the usual medications, doctors might prescribe other medications
that speed-up emptying of the stomach. Alternatively, in conjunction with GERD
surgery, they might do a surgical procedure that promotes a more rapid emptying
of the stomach. Nevertheless, it is still debated whether a finding of reduced
gastric emptying should prompt changes in the surgical treatment of GERD.
Symptoms of nausea, vomiting, and regurgitation may be due either to abnormal
gastric emptying or GERD. An evaluation of gastric emptying, therefore, may be
useful in identifying patients whose symptoms are due to abnormal emptying of the stomach rather than to GERD.
Acid perfusion test
The acid perfusion (Bernstein) test is used to determine if
chest pain is
caused by acid reflux. For the test, a thin tube is passed through one nostril,
down the back of the throat, and into the middle of the esophagus. A dilute,
acid solution and a physiologic (normal) salt solution are alternately poured
(perfused) through the catheter and into the esophagus. The patient is unaware
of which solution is being infused. If the perfusion with acid provokes the
patient's usual pain and perfusion of the salt solution produces no pain, it is
likely that the patient's pain is caused by acid reflux.
The acid perfusion test, however, is used only rarely. A better test for correlating pain and acid reflux is a 24-hour esophageal pH or pH capsule study during which patients note when they are having pain. It then can be determined from the pH recording if there was an episode of acid reflux at the time of the pain. This is the preferable way of deciding if acid reflux is causing a patient's pain. It does not work well, however, for patients who have infrequent pain, for example every two-three days, which may be missed by a one or two day pH study. In these cases, an acid perfusion test may be reasonable.
GERD - Proton Pump InhibitorsQuestion: Heartburn symptoms caused by GERD are usually relieved by drugs called proton pump inhibitors (Prilosec, Prevacid, Aciphex, Protonix, Nexium, Zegerid); however, proton pump inhibitors sometimes do not work well. If your symptoms were not relieved by treatment with proton pump inhibitors, can you please describe your GERD symptoms that did not improve? If you have other treatments that have been effective, please comment on those.
Abdominal pain is pain in the belly and can be acute or chronic. Causes include inflammation, distention of an organ, and loss of the blood supply to an organ. Abdominal pain can reflect a major problem with one of the organs in the abdomen such as the appendix, gallbladder, large and small intestine, pancreas, liver, colon, duodenum, and spleen.
There are many symptoms involved in the 1st, 2nd and 3rd trimesters of pregnancy. The first early pregnancy symptom is typically a missed period, but others include breast swelling and tenderness, nausea and sometimes vomiting, fatigue and bloating. Second trimester symptoms include backache, weight gain, itching, and possible stretch marks. Third trimester symptoms are additional weight gain, heartburn, hemorrhoids, swelling of the ankles, fingers, and face, breast tenderness, and trouble sleeping. Read more to learn about recommended procedures and tests for each stage of a healthy pregnancy.
Bronchitis is a disease of the respiratory system in which the bronchial passages become inflamed. There are two types of bronchitis, acute and chronic. Symptoms of acute bronchitis include frequent cough with mucus, lack of energy, wheezing, and possible fever. Treatment may require medication such as bronchial inhalers and predinsone. Supportive treatment is focused on relieving the symptoms with fever reducers, cough suppressants, and rest. Treatment may be more aggressive in patients with pre-existing conditions such as empyema, COPD, or cigarette smoking.
Allergic rhinitis symptoms include an itchy, runny nose, sneezing, itchy ears, eyes, and throat. Seasonal allergic rhinitis (also called hay fever) is usually caused by pollen in the air. Perennial allergic rhinitis is a type of chronic rhinitis and is a year–round problem, often caused by indoor allergens, such as dust, animal dander, and pollens that may exist at the time. Treatment of chronic rhinitis and post nasal drip are dependant upon the type of rhinitis condition.
A hiatal hernia is an anatomical abnormality in which part of the stomach protrudes through the diaphragm and up into the chest. Causes of hiatal hernia are a larger than normal esophageal hiatus. There are two types of hiatal hernias, sliding, or para-esophageal. When symptoms of hiatal hernia appear, they are similar to GERD symptoms. Hiatal hernia treatment is generally surgery.
Sjögren's syndrome is an autoimmune disease involving the abnormal production of extra antibodies that attack the glands and connective tissue. Sjögren's syndrome with gland inflammation (resulting dry eyes and mouth, etc.) that is not associated with another connective tissue disease is referred to as primary Sjögren's syndrome. Sjögren's syndrome that is also associated with a connective tissue disease, such as rheumatoid arthritis, systemic lupus erythematosus, or scleroderma, is referred to as secondary Sjögren's syndrome. Though there is no cure for Sjögren's syndrome, the symptoms may be treated by using lubricating eye ointments, drinking plenty of water, humidifying the air, and using glycerin swabs. Medications are also available to treat dry eye and dry mouth.
Chronic cough is a cough that does not go away and is generally a symptom of another disorder such as asthma, allergic rhinitis, sinus infection, cigarette smoking, GERD, postnasal drip, bronchitis, pneumonia, medications, and less frequently tumors or other lung disease. Treatment of chronic cough is dependant upon the cause.
Esophageal cancer is a disease in which malignant cells form in the esophagus. Risk factors of cancer of the esophagus include smoking, heavy alcohol use, Barrett's esophagus, being male and being over age 60. Severe weight loss, vomiting, hoarseness, coughing up blood, painful swallowing, and pain in the throat or back are symptoms. Treatment depends upon the size, location and staging of the cancer and the health of the patient.
Chest pain is a common complaint by a patient in the ER. Causes of chest pain include broken or bruised ribs, pleurisy, pneumothorax, shingles, pneumonia, pulmonary embolism, angina, heart attack, costochondritis, pericarditis, aorta or aortic dissection, and reflux esophagitis. Diagnosis and treatment of chest pain depends upon the cause and clinical presentation of the patient's chest pain.
Dyspepsia (indigestion) is a functional disease in which the gastrointestinal organs, primarily the stomach and first part of the small intestine, function abnormally. It is a chronic disease in which the symptoms fluctuate infrequency and intensity. Symptoms of dyspepsia include upper abdominal pain, belching, nausea, vomiting, abdominal bloating, early satiety, and abdominal distention (swelling). These symptoms are most often provoked by eating.
Scleroderma is an autoimmune disease of the connective tissue. It is characterized by the formation of scar tissue (fibrosis) in the skin and organs of the body, leading to thickness and firmness of involved areas. Scleroderma is also referred to as systemic sclerosis, and the cause is unknown. Treatment of scleroderma is directed toward the individual features that are most troubling to the patient.
Laryngitis is an inflammation of the voice box (vocal cords). The most common cause of acute laryngitis is infection, which inflames the vocal cords. Symptoms may vary from degree of laryngitis and age of the patient. Common symptoms include croup, hoarse cough, fever, cold, runny nose, dry cough, and loss of voice. Chronic laryngitis generally lasts more than three weeks. Causes other than infection include smoking, excess coughing, GERD, and more. Treatment depends on the cause of laryngitis.
Asthma is a common disorder in which
chronic inflammation of the bronchial tubes (bronchi) makes them swell, narrowing the airways. Signs and symptoms include shortness of breath, chest tightness,
cough and wheezing.
Eosinophilic esophagitis is an inflammation of the esophagus. Eosinophilic esophagitis has many causes including acid reflux, heartburn, viruses, medications that become stuck in the esophagus, allergy, asthma, hay fever, allergic rhinitis, and atopic dermatitis. Eosinophilic esophagitis symptoms include difficulty swallowing food, abdominal pain, chest pain, and heartburn.
Dysphagia or difficulty in swallowing, swallowing problems. Dysphagia is due to problems in nerve or muscle control. It is common, for example, after a stroke. Dysphagia compromises nutrition and hydration and may lead to aspiration pneumonia and dehydration.
Esophagitis is caused by an infection or irritation of the esophagus. Infections that cause esophagitis include candida yeast infection of the esophagus as well as herpes.
Barrett's esophagus occurs as a complication of chronic gastroesophageal reflux disease (GERD), primarily in white males. GERD refers to the reflux of acidic fluid from the stomach into the esophagus (the swallowing tube), and is classically associated with heartburn.
Chronic bronchitis is a cough that occurs daily with production of sputum that lasts for at least three months, two years in a row. Causes of chronic bronchitis include cigarette smoking, inhaled irritants, and underlying disease processes (such as asthma, or congestive heart failure). Symptoms include cough, shortness of breath, and wheezing. Treatments include bronchodilators and steroids. Complications of chronic bronchitis include COPD and emphysema.
Hoarseness (abnormal deep, harsh, raspy voice) is caused by a variety of conditions in which the larynx (voice box and vocal chords) are irritated or injured. Examples of causes of hoarseness include: laryngitis, straining the vocal cords by yelling or screaming, infections, GERD, allergies, and more. Treatment of hoarseness depends on the cause.
Insomnia is the perception or complaint of inadequate or poor-quality sleep because of difficulty falling asleep; waking up frequently during the night with difficulty returning to sleep; waking up too early in the morning; or unrefreshing sleep. Secondary insomnia is the most common type of insomnia. Treatment for insomnia include lifestyle changes, cognitive behavioral therapy, and medication.
Connective tissue diseases are disorders featuring abnormalities involving the collagen and elastin.
Connective tissue diseases that are strictly inheritable include Marfan syndrome and Ehlers-Danlos syndrome. The classic immune-related connective tissue diseases include systemic lupus erythematosus, rheumatoid arthritis, scleroderma, polymyositis, and dermatomyositis. Treatment is often directed at suppressing the inflammation present in the tissues by using anti-inflammatory and immunosuppressive medications.
Hiccups are a sudden, involuntary contraction of the diaphragm muscle. In general hiccups are just a temporary condition. Some of the causes of hiccups include certain medications, surgery, eating or drinking too much, spicy foods, diseases or conditions that irritate the nerves controlling the diaphragm, strokes, brain tumors, liver failure, and noxious fumes.
Asthma, the main cause of chronic illness in children, has signs and symptoms in children that include frequent coughing spells, low energy while playing, complaints of chest "hurting," wheezing while breathing, shortness of breath, and feelings of tiredness. Treatment will involve a doctor creating an asthma action plan which will describe the use of asthma medications and when to seek emergency care for the child.
Burning mouth syndrome (BMS) is a condition that causes pain in the mouth. BMS may be caused by menopause, dry mouth or allergies. Signs and symptoms include tingling or numbness of the tip of the tongue, bitter or metallic taste, and dry or sore mouth. Treatment depends upon the cause of your burning mouth syndrome.
Iron is a mineral our bodies need. Iron deficiency is a condition resulting from not enough iron in the body. It is the most common nutritional deficiency and the leading cause in the US. Iron deficiency is caused due to increased iron deficiency from diseases, nutritional deficiency, or blood loss and the body's inability to intake or absorb iron. Children, teen girls, pregnant women, and babies are at most risk for developing iron deficiency. Symptoms of iron deficiency include feeling weak and tired, decreased work or school performance, slow social development, difficulty maintaining body temperature, decreased immune function, and an inflamed tongue. Blood tests can confirm an iron deficiency in an individual. Treatment depends on the cause of the deficiency. Proper diet that includes recommended daily allowances of iron may prevent some cases of iron deficiency.
Schatzki (Schatzki's) ring, is a narrow ring of tissue located just above the junction of the esophagus and stomach. The cause of Schatzki ring is not clearly known, however, some doctors believe they are caused by long term acid reflux. The symptoms of a Schatzki ring is primarily poorly chewed food that stays in chunks becoming stuck in the esophagus. Diagnosis of Schatzki's ring is barium x-ray or endoscopy. Treatment is generally a procedure to stretch or fracture the rings.
Heartburn is a burning sensation experienced from acid reflux (GERD). Symptoms of heartburn include chest pain, burning in the throat, difficulty swallowing, the feeling of food sticking in the throat, and a burning feeling in the chest. Causes of heartburn include dietary habits, lifestyle habits, and medical causes. Treatments for heartburn include lifestyle changes, OTC medication, prescription medication, and surgery.
There are many unusual symptoms of asthma, including sighing, difficulty sleeping, anxiety, chronic cough, recurrent walking pneumonia, and rapid breathing. These symptoms may vary from individual to individual. These asthma complexities make it difficult to accurately diagnose and treat asthma.
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