Firing the Esophagus - GERD in ED

GERD is often listed as a part of Chest Pain differentials in ED. It is caused due to the reflux of gastric contents into the oesophagus and can cause a multitude of symptoms and it can be challenging to differentiate from ACS. A weak lower esophageal sphincter is frequently responsible for reflux. However, asymptomatic reflux several times a day is a normal physiologic phenomenon. 

Causes of GERD

Dysmotiliy

• Achalasia
• Scleroderma

Prolonged Emptying

• Anti-cholinergics
• Gastric Outlet Obstruction
• Diabetic Gastroparesis
• Fat rich diet

Low LES tone

• Ethanol
• Caffeine, Chocolate
• Tobacco Smoking
• Medications (CCBs, Nitrates, Progesterone, Oestrogen)
• Pregnancy

Symptoms
Pain and discomfort with meals indicate GERD. Symptoms might be exacerbated with a head-down position or an increase in intra-abdominal pressure. and are transiently alleviated by antacids. GERD may be accompanied by diaphoresis, pallor, and nausea and vomiting which makes it hard to differentiate from cardiac pain. 

• Heartburn
• Diaphoresis, pallor, and nausea and vomiting (Always rule out Cardiac etiology)
• Odynophagia, dysphagia, Acid regurgitation, and hyper-salivation (Water brash) 
• Asthma exacerbations
• Sore throat and other ENT symptoms
• Dental erosions, gingivitis, halitosis, vocal cord ulcers and granulomas, laryngitis with hoarseness and repeated throat clearing
• Chronic sinusitis
• Chronic cough

Long standing GERD may lead to strictures, dysphagia, and inflammatory esophagitis.  

Radiation into both arms is rarely seen in reflux, whereas it may be present in approximately one quarter of patients with ischemic heart disease. 

Management

GERD is a very common problem. ED management focuses on ruling out the life threats, proving symptomatic relief and arranging follow up care. 

• H2 Blockers or PPIs (PPIs are more effective than H2-blockers in eliminating symptoms and healing mucosal damage)
• Antacids
• Pro kinetics 
• Lifestyle advice (Weight loss, avoid ethanol, caffeine,nicotine, chocolate, fatty foods, sleep with the head of the bed elevated, and avoid eating within 3 hours of going to bed at night)
• Follow up care (esophageal pH monitoring, an upper GI radiographic series, esophageal manometry, or esophagoscopy may be necessary, especially for patients who fail to respond to all of the preceding measures

Further Reading:
https://coreem.net/podcast/episode-74-0/

Posted by:

              

     Lakshay Chanana

     

     Speciality Doctor

     Northwick Park Hospital

     Department of Emergency Medicine

     England

     @EMDidactic