Investigating a patient with GERD

Gastro oesophageal reflux disease is a common medical condition affecting a significant adult population. Studies have shown that about 10 to 40 percent of adults will have some degree of symptoms.Investigating a patient with GERD

The principal symptom of the condition is “Heartburn” which is burning sensation at central chest. Regurgitation and belching are other symptoms associated with this condition.
During the initial evaluation of a patient with suspected GERD, it is important to consider other conditions which may present with similar symptoms. Some of them include

  • Coronary Artery disease
  • Gall stone disease
  • Peptic ulcer disease
  • Oesophageal & Gastric cancers

Detailed evaluation of the patient’s clinical history will aid in differentiation of these conditions.

The clinician will definitely look for “Alarming Symptoms and Signs”. Presence of these symptoms or signs mandates urgent investigations.

These are,

  • Difficulty in swallowing (Dysphagia)
  • Weight loss
  • Loss of Appetite
  • Evidence of Anaemia (Low Haemoglobin)

Upper Gastrointestinal Endoscopy (UGIE) for GERD

 UGIE is the most important first line investigation in a patient presenting with symptoms suggestive of GERD. Patients presenting with alarming symptoms and signs must have endoscopic examination without a delay. Other patients can be booked for endoscopic evaluation after a trial of Proton pump inhibitor(PPI) treatment for two weeks.

The endoscopy test may show evidence of reflux as esophagitis or as ulceration in the inner lining of the oesophageal wall.  It might demonstrate another problem such as an ulcer in the stomach which might be responsible for the symptoms.

If the patient was on PPI up to the time of examination the test might become negative.

The other most important advantage of early endoscopy is that any suspicious area can be biopsied for pathological evaluation.

 

Investigating a patient with GERD-endoscopy Investigating a patient with GERD-endoscopy-2

Endoscopy




Barrett’s Oesophagus

24- Hour oesophageal PH Monitoring

The changes of the PH value occurring in the lower oesophagus with each reflux episode can be recorded by a special catheter placed in the lower oesophagus. This test is carried out for 24 hours and it is considered as the gold standard test for diagnosing GERD. The test will record the number of reflux episodes and their durations with the changes of PH with each episode. A final score will be calculated form the 24 hours data.

This test can be used,

  • To confirm GERD in patients with typical symptoms
  • To establish diagnosis in patients with atypical symptoms
  • When symptoms are suggestive but endoscopy is negative
  • Also to monitor objective response to PPI
  • May also used for investigating chest pain of non-cardiac origin

With the advancement in technology a new wireless monitoring device is available for the ease of patients. Patient does not have to have a tube through the nose to the oesophagus.

When the test is done to diagnose the condition, patient should be off PPI for at least 10 days. This will result in return of the normal acidity of the stomach.

During the procedure the patient is allowed to eat and drink and can involve in day to day activities.

Patients who need surgery for GERD are nowadays routinely evaluated with 24 hour PH study prior to the antireflux surgical procedure.

Dr Udaya Samarajeewa MBBS, MD- Surgery, MRCS (Eng.)

Consultant General Surgeon

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