GERD & Dyspepsia!

WHICH IS WHICH?!

GERD is a disease; dyspepsia is a symptom!

  • GERD = symptoms or complications resulting from the reflux of gastric contents into the esophagus or beyond (e.g. oral cavity, larynx, lung)
  • dyspepsia = nonspecific epigastric discomfort

GERD has many symptoms: 

  • typical: retrosternal burning (i.e. heartburn), regurgitation
  • less common: cough, chest pain, sore throat
  • atypical (may suggest overlapping condition): dyspepsia, nausea, bloating, belching

DDx for dyspepsia is extensive! 

  • common: functional dyspepsia, H.pylori infection, PUD, GERD, multiple meds (see below), gastric cancer
    • meds: NSAIDs, CCB, methylxanthines, alendronate, orlistat, oral potassium, acarbose, dabigatran, iron, vitamin D, SSRI, sildenafil, sulfonylureas, and certain antibiotics, including erythromycin
  • less common: biliary pain, gastroparesis, pancreatitis, malabsorption, infiltrative disease (e.g. Crohn’s), metabolic (e.g. hypercalcemia), ischemic bowel disease, celiac artery compression syndrome, SMA syndrome, systemic disorders (e.g. DM, thyroid/parathyroid disease), connective tissue disease, parasitic infection, other cancers (HCC, pancreatic cancer), etc

ALARM FEATURES!

Alarm features are similar for both GERD and dyspepsia, but the work-up differs! 

  • Alarm features
    • age of onset >60yo
    • unintentional weight loss (>5-10% over 6-12 months)
    • overt GI bleeding
    • dysphagia or odynophagia
    • unexplained iron deficiency anemia
    • persistent vomiting or hematemesis
    • palpable mass or lymphadenopathy
    • family history of upper gastrointestinal cancer in first-degree relative

Work-up differences

  • GERD: endoscopy is generally recommended for adult pts in the presence of alarm features
  • dyspepsia: endoscopy is generally not recommended in pts <60yo even in the presence of alarm symptoms because the risk of malignancy remains <1%; nevertheless, consider endoscopy in the presence of prominent alarm symptoms (e.g. significant weight loss or rapidly progressive dysphagia) and always on a case-by-case basis (i.e. lower threshold to perform endoscopy for alarm feature in 58yo pt vs 28yo pt)
        • note: studies of alarm features have only looked at single features as opposed to combinations of them

H.PYLORI!

Key literature: 2017 ACG guideline

Variable prevalence: generally higher prevalence outside the US (especially in Asia, Africa, Central America, and South America)

Testing indications

  • definite: confirmed PUD, MALT lymphoma, dyspepsia, and s/p endoscopic resection of early gastric cancer
  • less-established but recommended by ACG: unexplained iron deficiency anemia, ITP 
  • controversial: chronic NSAID/ASA use, first-degree FHx of gastric ca 
  • key point: GERD is not an indication for H.pylori testing

Diagnosis: fecal antigen test (sensitivity = 94%, specificity = 97%) or urea breath test (sensitivity = 88-95%, specificity = 95-100%)

  • false negatives are common for both testing modalities in 3 situations: recent use of antibiotics/bismuth (must be off for 4wk), recent use of PPI (must be off for 1-2wk), or actively bleeding peptic ulcer

Treatment: triple therapy (avoid clarithromycin if pt has any prior macrolide use); otherwise quadruple therapy

  • triple therapy = PPI BID + clarithromycin 500mg BID + amoxicillin 1000mg BID 
  • quadruple therapy = PPI BID + bismuth subsalicylate 300mg QID + metronidazole 500mg QID + tetracycline 500mg QID

Follow-up: eradication testing should be performed ≥4wk after completing initial treatment because ~25% of pts fail initial therapy