Epigastric Discomfort: Differentiating Between GERD and Dyspepsia

Gastroesophageal reflux disease (GERD) is common in the United States, and refractory GERD is the number 1 reason primary care providers refer their patients to gastroenterologists, according to this afternoon’s presentation at Practical Updates in Primary Care 2020.

Speaker Joel J. Heidelbaugh, MD, is a clinical professor in the Department of Family Medicine at the University of Michigan Medical School in Ann Arbor, Michigan.

He started his session by discussion common etiologies for epigastric discomfort. He said historically, GERD is thought to be a disorder of the stomach acid—either too much or too little in the stomach. However, transient lower esophageal sphincter relaxations (TLESRs) are also thought to play a role in the pathophysiology of GERD. Other triggers might be smoking, alcohol use, caffeine consumption, stress, or large, fatty, or spicy meal consumption. Other practice recommendations are listed in Figure 1 (click the image to enlarge).

“Alarm” Symptoms and Extraesophageal Manifestations of GERD

According to Dr Heidelbaugh, alarm symptoms include black or bloody stools, choking, chronic cough, dysphagia, early satiety, hematemesis, hoarseness, iron deficiency anemia, odynophagia, and weight loss.

“Certainly, if any of these [symptoms] are present, it should prompt you to think about an upper GI evaluation,” Dr Heidelbaugh said.

The most common extraesophageal manifestations of GERD include asthma (82%), hoarseness (78%), and chest pain (50%), among others.

GERD, Dyspepsia, and Related Conditions

Dyspepsia is intermittent gnawing or aching epigastric pain that may improve with meals. GERD is heartburn and regurgitation. Dr Heidelbaugh said patients with GERD should not experience bloody regurgitation. Patients with dyspepsia might experience bloody regurgitation if their condition progresses to peptic ulcer disease.

“GERD and dyspepsia can be very challenging to differentiate,” Dr Heidelbaugh said. “About 40% of cases are what we call ‘functional dyspepsia.’ Diagnosis is made in the absence of any organic cause.”

Patients with GERD should not be tested for H pylori infection, but patients with dyspepsia should be. The ELISA IgG test is the preferred first test to use; but once positive, always positive. So, down the road, if you need to retest for H pylori, you can use the stool antigen test or the 13C/ 14C urea breath test, Dr Heidelbaugh suggested. He also discussed treatment options for H pylori (see Figure 2, click the image to enlarge).

Antisecretory Therapy and Other Treatment Options

Over the years, treatment options for GERD have become simpler, with H2-receptor antagonists and proton-pump inhibitors becoming available over the counter. Many patients begin with a self-directed trial of over-the-counter antisecretory therapy. Then, when their symptoms persist, patients consult their primary care provider for prescribed antisecretory therapy.

Long-term use of proton-pump inhibitors is controversial, with some research pointing to serious adverse outcomes such as increased risk for community-acquired pneumonia, bone fractures, and renal failure. Lifestyle modification plays an important role in the treatment regimen (see Figure 3, click the image to enlarge).

—Amanda Balbi

Reference:

Heidelbaugh JJ. Evaluation and management of epigastric discomfort. Talk presented at: Practical Updates in Primary Care 2020; December 4-5, 2020; Virtual.