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Gastroesophageal reflux disease

Gastroesophageal Reflux Disease (GERD; or GORD when spelling oesophageal, the BE form) is defined as chronic symptoms or mucosal damage produced by the abnormal reflux of gastric contents into the esophagus. . more...

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This is commonly due to transient or permanent changes in the barrier between the esophagus and the stomach. This can be due to incompetence of the lower esophageal sphincter (LES), transient LES relaxation, or association with a hiatal hernia. Gastric regurgitation is an extension of this process with retrograde flow into the pharynx or mouth.


Heartburn is the symptom of acid in the esophagus, characterized by a burning discomfort behind the breastbone (sternum). Findings in GERD include esophagitis (reflux esophagitis) – inflammatory changes in the esophageal lining (mucosa) – strictures, difficulty swallowing (dysphagia), and chronic chest pain. Patients may have only one of those findings. Atypical symptoms of GERD include cough, hoarseness, changes of the voice, chronic ear ache, or sinusitis. Complicatons of GERD include stricture formation, Barrett's esophagus, esophageal ulcers and possibly even lead to esophageal cancer.

Occasional heartburn is common but does not necessarily mean one has GERD. Patients that have heartburn symptoms more than once a week are at risk of developing GERD. A hiatal hernia is usually asymptomatic, but the presence of a hiatal hernia is a risk factor for development of GERD.


The most prominent symptom of GERD is heartburn, the sensation of burning pain in the chest coming upward towards the mouth caused by reflux of acidic contents from the stomach to the esophagus.

Patients with GERD also tend to get the feeling of a sour or salty taste at the back of their throats due to regurgitation. This can sometimes happen even if the pain of heartburn is absent.

Less common symptoms:

  • Chest pain without any of the above
  • Dysphagia (difficulty swallowing)
  • Halitosis (bad breath)
  • Regurgitation (vomit-like taste in the mouth)
  • Repeated throat clearing
  • Water brash (the sensation of a large amount of non-acid liquid due to sudden hypersecretion of saliva)


  • Strictures or scarring of esophagus (especially young children).
  • Barrett's esophagus (sometimes referred to as Barrett's Disease)
  • Esophageal cancer

Important Warning symptoms:

  • Trouble swallowing Dysphagia requires immediate medical attention
  • Vomiting blood or partially-digested blood (looks like coffee grounds) requires immediate medical attention as does digested blood in the stools.

GERD in Children

GERD is commonly overlooked in infants and children. Symptoms may vary from typical adult symptoms. GERD in children may cause repeated vomiting, effortless spitting up, coughing, and other respiratory problems. Inconsolable crying, failure to gain adequate weight, refusing food and bad breath are also common. Children may have one symptom or many - no single symptom is universally present in all children with GERD.


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Diagnosis and treatment of cough-related GERD - Tips from Other Journals gastroesophageal reflux disease
From American Family Physician, 10/15/03 by Karl E. Miller

One of the most common etiologies of chronic cough is gastroesophageal reflux disease (GERD). In up to 75 percent of patients with GERD, chronic cough is the only presenting symptom. In addition, chronic cough caused by other etiologies may lead to GERD. Cough related to GERD can be diagnosed using a 24-hour ambulatory esophageal pH monitor, although this procedure is expensive and may be poorly tolerated by patients. In one study, GERD-related cough improved with the use of a high-dose proton pump inhibitor. Poe and Kallay evaluated the use of proton pump inhibitor therapy, with or without the addition of a prokinetic agent, in the diagnosis and treatment of GERD-related cough.

The study included all patients with chronic cough who were referred to a university-based pulmonary clinic. Chronic cough was defined as a cough lasting three or more weeks. Patients with normal results on chest radiography were evaluated for the three most common causes of cough--postnasal drip syndrome, asthma, and GERD. The evaluation was performed using an anatomic diagnostic protocol. When symptoms other than cough were present, the initial evaluation was based on those symptoms. If no symptoms suggested a cause of chronic cough, investigators used a methacholine challenge test and an empiric trial of an antihistamine-decongestant to diagnose asthma or postnasal drip syndrome.

The remainder of patients thought to have GERD-related cough were placed on a once-daily dosage of a proton pump inhibitor. Patients who were thought to have esophageal dysfunction or who had an inadequate response to the proton pump inhibitor received a prokinetic agent. Those who did not respond to this treatment plan underwent a 24-hour esophageal pH-monitoring test.

Of the 183 patients with chronic cough, 56 were identified as having GERD-related chronic cough. In this trial, 43 percent of patients with GERD-related cough had GERD as the only cause of chronic cough. In addition, 43 percent of patients with GERD-related chronic cough had cough as their only presenting symptom. The majority of patients responded to proton pump inhibitor therapy alone or in combination with a prokinetic agent. The chronic cough was eliminated or improved dramatically in 86 percent of patients after four weeks of therapy. The 12 patients who did not respond were evaluated with 24-hour esophageal pH monitoring; nine patients were found to have some cough episodes during reflux, while three patients had reflux unrelated to their chronic cough. Six of the nonresponders had aspiration diagnosed by bronchoscopy.

The authors conclude that four to six weeks of therapy with a proton pump inhibitor, with or without the addition of a prokinetic agent, successfully diagnoses and treats the vast majority of patients with GERD-related cough. In patients who do not respond to this therapy, 24-hour esophageal pH monitoring can be used to establish reflux as the cause of chronic cough. Nonresponders are also at a higher risk of aspiration.

Poe RH, Kallay MC. Chronic cough and gastroesophageal reflux disease. Experience with specific therapy for diagnosis and treatment. Chest March 2003;123:679-84.

COPYRIGHT 2003 American Academy of Family Physicians
COPYRIGHT 2003 Gale Group

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