Investigations in Heartburn Mary Yeboah Afihene, MD Department of Medicine Komfo Anokye Teaching Hospital Kumasi, Ghana Heartburn and regurgitation are classic symptoms of gastroesophageal reflux disease (GERD). Investigating GERD remains a challenge as both invasive methods and symptom-based strategies have limitations. A large number of tests is available for evaluating patients with GERD. Many times, these tests are unnecessary because the classic symptoms of heartburn and acid regurgitation are sufficiently specific to identify reflux disease and begin medical treatment. However, this is not always the case and, on occasion, the clinician must decide which test to choose to make a diagnosis in a reliable, cost-effective and timely manner. Questionnaires Current international guidelines recommend symptom-based diagnosis and therapy unless alarm symptoms such as dysphagia, weight loss or hemorrhage mandate prompt endoscopy. Consequently, there is a need for optimizing the management of GERD patients by implementing symptom based management algorithms, preferably facilitated by a patient-completed questionnaire. Several different questionnaires have been developed to facilitate the diagnosis of GERD, but many of them lack proper validation or lack the simplicity required to be an integrated part of routine care. The GerdQ is a self-administered six-item questionnaire that was recently developed by combining six questions from three different validated patient reported outcome (PRO) questionnaires (GERD Impact Scale – GIS; Gastrointestinal Symptom Rating Scale – GSRS; Reflux Disease Questionnaire – RDQ) to improve and standardize symptom-based diagnosis and evaluation of treatment response in patients with GERD. Endoscopy Upper endoscopy is commonly used in the diagnosis and management of GERD. Evidence demonstrates that it is indicated only in certain situations; inappropriate use generates unnecessary costs and exposes patients to harm without improving outcomes. After a review of evidence regarding the indications for, and yield of, upper endoscopy in GERD, the Clinical Guidelines Committee of the American College of Physicians recommended that upper endoscopy is indicated for: 1. Heartburn and alarm symptoms (dysphagia, bleeding, anemia, weight loss, recurrent vomiting). 2. Typical GERD symptoms that persist despite a therapeutic trial of 4 to 8 weeks of twice-daily proton-pump inhibitor (PPI) therapy. Severe erosive esophagitis after a 2-month course of PPI therapy to assess healing and rule out Barrett’s esophagus. Recurrent endoscopy after this follow-up examination is not indicated in the absence of Barrett’s esophagus. A history of esophageal stricture with recurrent symptoms of dysphagia. 3. Men >50 years with chronic GERD symptoms (>5 years) and additional risk factors (nocturnal reflux symptoms, hiatal hernia, elevated body mass index, tobacco use, intra-abdominal distribution of fat) to detect esophageal adenocarcinoma and Barrett’s esophagus. Surveillance evaluation in men and women with a history of Barrett’s esophagus. In the absence of dysplasia, surveillance examinations should occur at intervals no more frequently than 3 to 5 years. More frequent intervals are indicated in patients with Barrett’s esophagus and dysplasia. Histology Like endoscopy, the role of esophageal biopsies in evaluating GERD has evolved over the years. There is little value for histologic examination of normal-appearing squamous mucosa to diagnose GERD; however, this dictum must now be tempered by the need to differentiate eosinophilic esophagitis from GERD, Variable Frequency score (points) for symptom Question 0 day 1 day 2–3days 4–7 days 1. How often did you have a burning feeling behind your breastbone (heartburn)? 0 1 2 3 2. How often did you have stomach contents (liquid or food) moving upwards to your throat or mouth (regurgitation)? 0 1 2 3 3. How often did you have a pain in the center of the upper stomach? 3 2 1 0 4. How often did you have nausea? 3 2 1 0 5. How often did you have difficulty getting a good night’s sleep because of your heartburn and ⁄ or regurgitation? 0 1 2 3 6. How often did you take additional medication for your heartburn and ⁄ or regurgitation, other than what the 0 1 2 3 physician told you to take? (such as Tums, Rolaids, Maalox?) GERDQ Table GerdQ symptom scores: GerdQ < 8: low probability for GERD GerdQ ≥ 8 and ≤ 3 on questions 5 and 6 (impact questions): GERD with low impact on daily life GerdQ ≥ 8 and ≥ 3 on questions 5 and 6 (impact questions): GERD with high impact on daily life World Digestive Health Day WDHD May 29, 2015 WGO HANDBOOK HEARTBURN: A GLOBAL PERSPECTIVE 6
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