Alarm symptoms of GERD
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Corresponding author John M. Wo, MD Division of Gastroenterology/Hepatology, University of Louisville, 550 S. Jackson Street, ACB 3rd Floor, Louisville, KY 40202, USA. E-mail: [email protected] Current GERD Reports 2007, 1:215–219 Current Medicine Group LLC ISSN 1934-967X Copyright © 2007 by Current Medicine Group LLC
Heartburn is very common. In the United States, about 20% of adults report experiencing heartburn at least once a week. The practice guidelines for gastroesophageal reflux disease (GERD) recommend diagnostic testing in the presence of alarm symptoms, which include dysphagia, odynophagia, weight loss, gastrointestinal bleeding, and anemia. A detailed history of the pattern, severity, and duration of alarm symptoms is essential. What are the benefits of identifying alarm symptoms in patients with GERD? Does identifying patients with alarm symptoms improve the treatment outcome? The goals of this review are to define the alarm symptoms of GERD, determine their ability to predict reflux complications and upper gastrointestinal malignancy, and develop a management strategy for patients with alarm symptoms.
Introduction Heartburn is very common. In the United States, about 20% of adults report experiencing heartburn at least once a week [1]. The prevalence of heartburn is greater in North America and Europe than in Asia [2]. Most heartburn sufferers do not seek medical attention. Individuals are more likely to seek medical care if their symptoms are severe [3]. There is a general international consensus among the practice guidelines for gastroesophageal reflux disease (GERD) that empiric acid suppression can be implemented first in patients with heartburn in the absence of the alarm symptoms of GERD, as listed in Table 1 [4–7]. Dysphagia and odynophagia are symptoms that are specific to the esophagus. Weight loss, gastrointestinal bleeding, and anemia are also alarm symptoms of dyspepsia [8,9]. These alarm symptoms are present in about 11% of patients with suspected GERD in the primary care office [10]. According to surveys of general practitioners, alarm symptoms are the most common reasons for referral to a specialist [11•,12]. However, there are major discrepancies between physicians’ actual practices and the guideline recom-
mendations for GERD [10]. Primary care physicians are influenced more by the patient’s symptom severity than by the type of symptoms [10]. What are the benefits of identifying alarm symptoms in patients with GERD? It is often assumed that alarm symptoms are good predictors for complicated GERD. For example, patients with dysphagia may have a reflux stricture. Weight loss, with or without dysphagia, may be a sign of upper gastrointestinal malignancy. Odynophagia and gastrointestinal bleeding may represent a mucosal complication of erosive esophagitis. Another assumption is that identifying the reflux complications by alarm symptoms may improve treatment outcome. For instance, endoscopic dilation can relieve dysphagia caused by a reflux stricture. Antireflux therapy can be maintain
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