GERD's Atypical Symptoms

Sara Marlow, MSN, RN, PHN, FNP-C
Wednesday February 28, 2018
Acid reflux and regurgitation are increasingly common symptoms of industrialized nations, and they can lead to patient-restricted activity and missed work.1 About 20% to 40% of the adult popu- lation in the Western world experiences these symptoms,1 accounting for 9 million gastroesophageal reflux disease (GERD) primary care visits annually.1 Fortunately, for many people, GERD can be safely managed by activity changes, diet, and medication. However, if left untreated, GERD can lead to Barrett esophagus, esophagitis, strictures, and esophageal cancer.2 Esophagitis occurs in nearly 50% of patients with GERD, while Barrett esophagus occurs in only about 15%. Very rarely, GERD can progress to esophageal cancer.2 

Early, accurate diagnosis of GERD is imperative in preventing progressive inflammatory changes of the esophagus that can lead to cancer, but patients may require assistance when identifying symptoms. Typical symptoms of GERD include heartburn and regurgitation, and many patients who experience these may not seek medical treatment; instead they self-treat with OTC medications.3 Therefore, they could go years without knowing that their GERD could be better controlled to prevent progressive damage to the esophagus. 

According to a population-based study, 44% of US adults experience heartburn and regurgitation symptoms at least once a month, 14% experience them weekly, and 7% experience them daily.3 So it seems that though a large percentage of Americans may be able to identify typical symptoms of acid reflux, they may not know the atypical signs. These patients may not seek treatment or may receive a misdiagnosis. Typical symptoms, heartburn and regurgitation, are absent in 40% to 60% of patients with asthma; 57% to 94% of patients with ear, nose, and throat symptoms; and 43% to 75% of those with a chronic cough.3 Atypical symptoms include belching, chest pain, coughing, dental erosion, globus, granuloma, halitosis, hoarseness, sore throat, voice changes, and wheezing.3 Severe symptoms that suggest complicated GERD are black or bloody stools, choking, chronic cough, dysphagia, early satiety, hematemesis, iron deficiency anemia, odynophagia, and weight loss.Remembering these atypical symptoms will broaden and increase the accuracy of differential diagnoses. 

CHRONIC COUGH

Interestingly, asthma, postnasal drip, and GERD account for 94% of all chronic cough cases.3 About 50% to 80% of patients with asthma have GERD, and up to 75% have abnormal 24-hour pH levels. Because of this strong association, GERD should be high on the differential list when evaluating chronic cough. If GERD is the primary cause of the cough, no other gastrointestinal complaints are present in 75% of these cases.3 To complicate matters more, asthma and GERD can affect the other’s disease course. 

Asthma can create negative intrathoracic pressure and thus weaken the lower esophageal sphincter. Simultaneously, GERD can exacerbate asthma symptoms in various ways. It is thought that when acid is refluxed, small amounts aspirate into the larynx and upper bronchial tree, leading to irritation and a cough.3 It is also thought that the acid stimulation of the vagal afferent neurons in the distal esophagus can cause bronchospasm and chest pain.3 

PATIENT EDUCATION

Primary care providers may be well versed in the basic pathophysiology of acid reflux and GERD but can forget that patients may not understand their condition. In addition to counseling about prescription medications, such as proton pump inhibitors and H2 antagonists, providers should spend time helping patients understand their condition and things that they can do to minimize symptoms. Below is a summary of modifiable and unmodifiable risk factors for acid reflux and GERD. 

FOODS THAT WORSEN GERD 
• Acidic foods, such as Buddha’s hand, citron, grapefruit, kinnow, lemon, lime, orange, pineapple, pomelo, rangpur, salsa, tangelo, tangerine, tomato, vinegar, vinaigrette, and yuzu 
•    Alcohol 

•    Carbonated beverages, such as energy drinks, soda, sparkling 
water, and sparkling wine 

•    Chocolate 

•    Coffee 

•    Dairy 

•    Fatty foods, such as bacon, butter, cheese, cream, fried food, 
garlic, hot dogs, oil, pepperoni, and sausage 

•    High-salt foods 

•    Mint 

•    Onions 

•    Spicy foods, such as black pepper, hot-flavored chips and 
snacks, hot salsa, and spicy curry 


MEDICATIONS AND SUPPLEMENTS THAT WORSEN GERD4
•    Anticholinergics prescribed for irritable bowel syndrome and overactive bladder 

•    Antibiotics (tetracycline) 

•    Bisphosphonates taken orally, such as alendronate (Fosamax), 
ibandronate (Boniva), and risedronate (Actonel) 

•    Calcium channel blockers and nitrates 

•    Iron supplements 

•    Narcotics (opioids) 

•    Pain relievers, such as aspirin and ibuprofen 

•    Potassium supplements 

•    Progesterone 

•    Quinidine 

•    Sedatives or tranquilizers, such as diazepam (Valium) or 
temazepam (Restoril)

•    Theophylline (Elixophyllin or Theochron)

•    Tricyclic antidepressants, such as amitriptyline and doxepin 

HABITS THAT WORSEN GERD 

• Being overweight. There is convincing evidence to support weight loss for patients with a body mass index higher than 25. This should improve GERD symptoms and esophageal pH.5
• Drinking or eating before bedtime or before lying supine
• Eating before working out or intense physical activity. Jostling the stomach up and down or leaning forward, such as in yoga, can cause the stomach contents to naturally flow upward into
the esophagus.

• Eating too much food at once

• Tobacco use. Cessation of tobacco use is always recommended to improve health, but it may not necessarily improve GERD symptoms.5 Nonetheless, quitting smoking has countless benefits, such as lowering the risk of several types of cancer; having a low-birth-weight baby; heart disease; infertility in women; lung disease, such as chronic obstructive pulmonary disease; miscarriage; peripheral vascular disease; and stroke.6
• Wearing tight clothing 

UNMODIFIABLE RISK FACTORS

• Being older than 40 years
• Having the GERD1 gene7
• Hiatal hernia 


Sara Marlow, MSN, RN, PHN, FNP-C, is a licensed and board-certified family nurse practitioner, public health nurse, and adjunct assistant professor of health policy. She was the spring 2015 health policy fellow at the American Association of Nurse Practitioners’ Government Affairs Office in Washington, DC. In addition, she is a DNP candidate at the University of California, San Francisco. 

References
 
1. Cohen E, Bolus R, Khanna D, et al. GERD Symptoms in the General Population: Prevalence and Severity Versus Care-Seeking Patients. Digestive diseases and sciences. 2014;59(10):2488-2496. doi:10.1007/s10620-014-3181-8.
2. Gastroesophageal Reflux Disease - UChicago Medicine. Uchospitalsedu. 2018. Available at: http://www.uchospitals.edu/specialties/gi/esophageal/gerd/. Accessed January 1, 2018.
3.  Heidelbaugh J, Gill A, Harrison V, Nostrant T. Atypical presentations of gastroesophageal reflux disease. American Family Physician. 2018;78(4):483-488. Available at: https://www.aafp.org/afp/2008/0815/p483.html. Accessed January 1, 2018.
4.  Picco M. GERD: Can certain medications increase severity?. Mayo Clinic. 2015. Available at: https://www.mayoclinic.org/diseases-conditions/gerd/expert-answers/heartburn-gerd/faq-20058535. Accessed January 1, 2018.
5. Katz P, Gerson L, Vela M. Diagnosis and Management of Gastroesophageal Reflux Disease. American College of Gastroenterology. 2013. Available at: http://gi.org/guideline/diagnosis-and-managemen-of-gastroesophageal-reflux-disease/. Accessed January 1, 2018. 
6. CDC - Fact Sheet - Smoking Cessation - Smoking & Tobacco Use. Centers for Disease Control and Prevention. 2017. Available at: https://www.cdc.gov/tobacco/data_statistics/fact_sheets/cessation/quitting/index.htm. Accessed January 1, 2018.
7. Post J, Ehrlich G. Genetics of pediatric gastroesophageal reflux. US National Library of Medicine National Institutes of Health. 2005; 5(1): 5-9. Available at: https://www.ncbi.nlm.nih.gov/pubmed/15643337. Accessed January 2, 2018.




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