Heartburn differential diagnosis: Difference between revisions

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{{CMG}} {{AE}} {{Jose}}
{{CMG}} {{AE}} {{Jose}}


==Overview==
[[Heartburn]] must be differentiated from other diseases that cause [[chest pain]], such as [[acute coronary syndromes]].<br>
[[Heartburn]] may also be differentiated from other diseases that cause [[dysphagia]] such as [[esophageal cancer]], [[achalasia]] and [[eosinophilic esophagitis]] in high risk individuals.
==Differentiating Heartburn from other Diseases==
==Differentiating Heartburn from other Diseases==
 
*[[Heartburn]] must be differentiated from other diseases that cause [[chest pain]], such as [[acute coronary syndromes]].</br>
[[Heartburn]] must be differentiated from other causes of [[chest pain]]. Cardiac causes must be excluded since they can be life-threatening and may present with similar symptoms. In order to facilitate this, there's a table below which describes the life-threatening causes which must be differentiated:
*[[Heartburn]] may also be differentiated from other diseases that cause [[dysphagia]] in high risk individuals.</br>
*Cardiac causes must be excluded since they can be life-threatening and may present with similar symptoms. In order to facilitate this, there's a table below which describes the life-threatening causes which must be differentiated:
</br>
</br>
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</br>
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While evaluating heartburn and considering [[gastroesophageal reflux disease]] ([[GERD]]) its most probable diagnosis, there's a diagnostic approach that must be performed in order to exclude other causes, especially in high risk patients:
While evaluating heartburn and considering [[gastroesophageal reflux disease]] ([[GERD]]) its most probable diagnosis, there's a diagnostic approach that must be performed in order to exclude other causes, especially in high risk patients, according the the American Journal of Gastroenterology guidelines<ref name="pmid23419381">{{cite journal| author=Katz PO, Gerson LB, Vela MF| title=Guidelines for the diagnosis and management of gastroesophageal reflux disease. | journal=Am J Gastroenterol | year= 2013 | volume= 108 | issue= 3 | pages= 308-28; quiz 329 | pmid=23419381 | doi=10.1038/ajg.2012.444 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=23419381  }} </ref> :
</br>
</br>
</br>
{{familytree/start |summary=PE diagnosis Algorithm.}} {{familytree | | | | A01 |~| A02 | A01='''Classic symptoms of GERD''' <br>(heartburn and regurgitation)|A02= If there are '''warning [[signs]]*''':<br> upper [[endoscopy]] during the initial evaluation}}
{{familytree/start |summary=PE diagnosis Algorithm.}} {{familytree | | | | A01 |~| A02 | A01='''Classic symptoms of GERD''' <br>(heartburn and regurgitation)|A02= If there are '''warning [[signs]]*''':<br> upper [[endoscopy]] during the initial evaluation}}
Line 42: Line 47:
{{familytree | | C01 | | C02 | C01= If better: [[GERD]] probable| C02= If refractory, proceed to refractory [[GERD]] algorithm}}  
{{familytree | | C01 | | C02 | C01= If better: [[GERD]] probable| C02= If refractory, proceed to refractory [[GERD]] algorithm}}  
{{familytree/end}}
{{familytree/end}}
<nowiki>*</nowiki> [[Dysphagia]], [[bleeding]], [[anemia]], [[weight loss]] and recurrent [[vomiting]] are considered warning signs and should be investigated with [[upper endoscopy]].
*[[Dysphagia]], [[bleeding]], [[anemia]], [[weight loss]] and recurrent [[vomiting]] are considered warning signs and should be investigated with [[upper endoscopy]]. [[Esophageal cancer]], and other severe diseases including [[esophagitis]] may be considered, the latter especially in [[HIV]] patients.<br>
<br>


{{familytree/start}}
{{familytree/start}}
Line 70: Line 76:
**[[Tobacco]] use
**[[Tobacco]] use
**Intra-abdominal distribution of fat
**Intra-abdominal distribution of fat
</br>
* Heartburn must be differentiated from other diseases such as [[GERD]], [[gastritis]], [[peptic ulcer]], [[crohn's disease]], [[gastric adenocarcinoma]], and [[gastrinoma]].<ref name="pmid6710074">{{cite journal| author=Sugimachi K, Inokuchi K, Kuwano H, Ooiwa T| title=Acute gastritis clinically classified in accordance with data from both upper GI series and endoscopy. | journal=Scand J Gastroenterol | year= 1984 | volume= 19 | issue= 1 | pages= 31-7 | pmid=6710074 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=6710074  }} </ref><ref name="pmid25901896">{{cite journal| author=Sipponen P, Maaroos HI| title=Chronic gastritis. | journal=Scand J Gastroenterol | year= 2015 | volume= 50 | issue= 6 | pages= 657-67 | pmid=25901896 | doi=10.3109/00365521.2015.1019918 | pmc=4673514 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=25901896  }} </ref><ref name="pmid16819502">{{cite journal| author=Sartor RB| title=Mechanisms of disease: pathogenesis of Crohn's disease and ulcerative colitis. | journal=Nat Clin Pract Gastroenterol Hepatol | year= 2006 | volume= 3 | issue= 7 | pages= 390-407 | pmid=16819502 | doi=10.1038/ncpgasthep0528 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16819502  }} </ref><ref name="pmid2789799">{{cite journal| author=Sipponen P| title=Atrophic gastritis as a premalignant condition. | journal=Ann Med | year= 1989 | volume= 21 | issue= 4 | pages= 287-90 | pmid=2789799 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=2789799  }} </ref><ref name="pmid25133039">{{cite journal| author=Badillo R, Francis D| title=Diagnosis and treatment of gastroesophageal reflux disease. | journal=World J Gastrointest Pharmacol Ther | year= 2014 | volume= 5 | issue= 3 | pages= 105-12 | pmid=25133039 | doi=10.4292/wjgpt.v5.i3.105 | pmc=4133436 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=25133039  }} </ref><ref name="pmid17956071">{{cite journal| author=Ramakrishnan K, Salinas RC| title=Peptic ulcer disease. | journal=Am Fam Physician | year= 2007 | volume= 76 | issue= 7 | pages= 1005-12 | pmid=17956071 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=17956071  }} </ref><ref name="pmid17985090">{{cite journal| author=Banasch M, Schmitz F| title=Diagnosis and treatment of gastrinoma in the era of proton pump inhibitors. | journal=Wien Klin Wochenschr | year= 2007 | volume= 119 | issue= 19-20 | pages= 573-8 | pmid=17985090 | doi=10.1007/s00508-007-0884-2 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=17985090  }} </ref><ref name="pmid15621988">{{cite journal| author=Dicken BJ, Bigam DL, Cass C, Mackey JR, Joy AA, Hamilton SM| title=Gastric adenocarcinoma: review and considerations for future directions. | journal=Ann Surg | year= 2005 | volume= 241 | issue= 1 | pages= 27-39 | pmid=15621988 | doi= | pmc=1356843 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=15621988  }} </ref><ref name="pmid21390139">{{cite journal| author=Ghimire P, Wu GY, Zhu L| title=Primary gastrointestinal lymphoma. | journal=World J Gastroenterol | year= 2011 | volume= 17 | issue= 6 | pages= 697-707 | pmid=21390139 | doi=10.3748/wjg.v17.i6.697 | pmc=3042647 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=21390139  }} </ref>
 
{| style="border: 0px; font-size: 90%; margin: 3px;" align="center"
| colspan="13" style="background: #4479BA; text-align: center;" | {{fontcolor|#FFF|'''Differential Diagnosis'''}}
|+
| rowspan="3" style="background:#4479BA; padding: 5px 5px;" align="center" |{{fontcolor|#FFF|'''Disease'''}}
| rowspan="3" style="background:#4479BA; padding: 5px 5px;" align="center" |{{fontcolor|#FFF|'''Cause'''}}
| colspan="9" style="background:#4479BA; padding: 5px 5px;" align="center" |{{fontcolor|#FFF|'''Symptoms'''}}
| style="background:#4479BA; padding: 5px 5px;" align="center" |{{fontcolor|#FFF|'''Diagnosis'''}}
| rowspan="3" style="background:#4479BA; padding: 5px 5px;" align="center" |{{fontcolor|#FFF|'''Other findings'''}}
|-
| colspan="3" style="background:#4479BA; padding: 5px 5px;" align="center" |{{fontcolor|#FFF|'''Pain'''}}
| rowspan="2" style="background:#4479BA; padding: 5px 5px;" align="center" |{{fontcolor|#FFF|'''Nausea & Vomiting'''}}
| rowspan="2" style="background:#4479BA; padding: 5px 5px;" align="center" |{{fontcolor|#FFF|'''Heartburn'''}}
| rowspan="2" style="background:#4479BA; padding: 5px 5px;" align="center" |{{fontcolor|#FFF|'''Belching or Bloating'''}}
| rowspan="2" style="background:#4479BA; padding: 5px 5px;" align="center" |{{fontcolor|#FFF|'''Weight loss'''}}
| rowspan="2" style="background:#4479BA; padding: 5px 5px;" align="center" |{{fontcolor|#FFF|'''Loss of Appetite'''}}
| rowspan="2" style="background:#4479BA; padding: 5px 5px;" align="center" |{{fontcolor|#FFF|'''Stools'''}}
| rowspan="2" style="background:#4479BA; padding: 5px 5px;" align="center" |{{fontcolor|#FFF|'''Endoscopy findings'''}}
|-
| rowspan="1" style="background:#4479BA; padding: 5px 5px;" align="center" |{{fontcolor|#FFF|'''Location'''}}
| rowspan="1" style="background:#4479BA; padding: 5px 5px;" align="center" |{{fontcolor|#FFF|'''Aggravating Factors'''}}
| rowspan="1" style="background:#4479BA; padding: 5px 5px;" align="center" |{{fontcolor|#FFF|'''Alleviating Factors'''}}
|-
| style="padding: 5px 5px; background: #DCDCDC;" |[[GERD]]
| style="padding: 5px 5px; background: #F5F5F5;" |
* Lower esophageal sphincter abnormalities
* [[Hiatal hernia]]
* Abnormal esophageal contractions
* Prolonged emptying of [[stomach]]
* [[Gastrinomas]]
|
* [[Epigastric pain]]
|
* Spicy food
* Tight fitting clothing
|
* [[Antacids]]
* Head elevation during sleep
|✔


* [[Angina]] / ischemia
(Suspect delayed gastric emptying)
* [[Ascites]]
|✔
* [[Asthma]]
|<nowiki>-</nowiki>
* [[Barrett's esophagus]]
|<nowiki>-</nowiki>
* Cardiotomy
|<nowiki>-</nowiki>
* Caustic agent ingestion with resultant mucosal injury
|<nowiki>-</nowiki>
* [[Chagas disease]]
|
* [[Cholelithiasis]]
* [[Esophagitis]]
* Clothes (elevated internal stomach pressure)
* [[Barrette's esophagus]]
* [[Constipation]]
* [[Strictures]]
* [[Coronary artery disease]]
|Other symptoms:
* [[Coughing]]
* [[Dysphagia]]
* [[CREST syndrome]] (Calcinosis Raynaud's phenomenon Esophagus Sclerodactyly Telangiectasias)
* [[Regurgitation]]
* Direct irritation of esophagus:
* [[Cough|Nocturnal cough]]
**[[Aspirin]]
* [[Hoarseness]]
**[[Cigarette smoke]]
Complications
**Citrus fruits, juice
* [[Esophagitis]]
**[[Ibuprofen]]
* [[Strictures]]
**Spicy foods
* Barrette esophagus
**Tomatoes
|-
**Tomato sauce
| style="padding: 5px 5px; background: #DCDCDC;" |[[Acute gastritis]]
* [[Diabetes]]
| style="padding: 5px 5px; background: #F5F5F5;" |
* [[Drugs]]:
* ''[[H. pylori]]''
**[[Albuterol]]
* [[NSAIDS]]
**[[Anticholinergic]]s
* [[Corticosteroids]]
**[[Caffeine]]
* [[Alcohol]]
**[[Calcium channel blockers]]
* Spicy food
**[[Cigarette smoking]]
* Viral infections
**[[Nitrates]]
* [[Crohn's disease]]
**[[Progesterone]]
* [[Autoimmune diseases]]
**[[Theophylline]]  
* Bile reflux
* [[Cocaine]] use
* Breathing machine or ventilator
* Ingestion of [[corrosive|corrosives]]
|
* [[Epigastric pain]]
|Food
|[[Antacids]]
|✔
|✔
|✔
|<nowiki>-</nowiki>
|✔
|[[Melena|Black stools]]
|
* [[Pangastritis]] or antral [[gastritis]]
* [[Gastric erosion|Erosive]] (Superficial, deep, hemorrhagic)
* Nonerosive (''[[H. pylori]]'')
|<nowiki>-</nowiki>
|-
| style="padding: 5px 5px; background: #DCDCDC;" |[[Gastritis|Chronic gastritis]]
| style="padding: 5px 5px; background: #F5F5F5;" |
* ''[[H. pylori]]''
* [[Alcohol]]
* Medications
* [[Autoimmune diseases]]  
* Chronic stress
|
* [[Epigastric pain]]
|Food
|[[Antacids]]
|✔
|✔
|✔
|✔
|✔
|<nowiki>-</nowiki>
|''[[H. pylori]] [[gastritis]]''
* [[Atrophy]]
* Intestinal [[metaplasia]]
Lymphocytic gastritis
* Enlarged folds
* Aphthoid erosions
|<nowiki>-</nowiki>
|-
| style="padding: 5px 5px; background: #DCDCDC;" |[[Atrophic gastritis]]
| style="padding: 5px 5px; background: #F5F5F5;" |
* ''[[H. pylori]]''
* [[Autoimmune disease]]
|[[Epigastric pain]]
|<nowiki>-</nowiki>
|<nowiki>-</nowiki>
|✔
|<nowiki>-</nowiki>
|
|✔
|✔
|<nowiki>-</nowiki>
|''[[H. pylori]]''
* Mucosal [[atrophy]]
[[Autoimmune]]
* Mucosal [[atrophy]]
|
* [[Iron deficiency anemia]]
*Autoimmune gastritis diagnosis includes:
**Antiparietal and anti-IF antibodies
**[[Achlorhydria]] and hypergastrinemia
**Low serum [[vitamin B12|cobalamine]]
|-
| style="padding: 5px 5px; background: #DCDCDC;" |[[Crohn's disease]]
| style="padding: 5px 5px; background: #F5F5F5;" |
* [[Autoimmune disease]]
|
* [[Abdominal pain]]
|<nowiki>-</nowiki>
|<nowiki>-</nowiki>
|<nowiki>-</nowiki>
|<nowiki>-</nowiki>
|<nowiki>-</nowiki>
|✔
|✔
|
* Chronic [[diarrhea]] often bloody with [[pus]] or [[mucus]]
* [[Rectal bleeding]]
|
* Mucosal nodularity with cobblestoning
* Multiple [[aphthous ulcers]]
* Linier or serpiginous ulcerations
* Thickened antral folds
* Antral narrowing
* Hypoperistalsis
* Duodenal strictures
|
* [[Fever]]
* [[Fatigue]]
* [[Anemia]] ([[pernicious anemia]])
|-
| style="padding: 5px 5px; background: #DCDCDC;" |[[Peptic ulcer disease]]
| style="padding: 5px 5px; background: #F5F5F5;" |
* ''[[H. pylori]]''
* [[Smoking]]
* [[Alcohol]]
* [[Radiation therapy]]
* Medications
* Zollinger-ellison syndrome
|
* [[Epigastric pain]] sometimes extending to back
* [[Right upper quadrant pain]]
|
'''[[Duodenal ulcer]]'''
*Pain aggravates with empty stomach
'''[[Gastric ulcer]]'''
*Pain aggravates with food
|
* [[Antacids]]


* Esophageal atresia or fistula
* [[Duodenal ulcer]]
* [[Esophageal carcinoma]]
:*Pain alleviates with food
* [[Esophageal diverticulum]]
|✔
* [[Esophageal varices]]
|✔
* Foods:
|<nowiki>-</nowiki>
**[[Alcohol]]
|<nowiki>-</nowiki>
**Chocolate
|<nowiki>-</nowiki>
**Coffee
|
**Fatty foods
* [[Melena|Black stools]]
**Peppermint
|'''Gastric ulcers'''
**Soft drinks with caffeine
* Discrete mucosal lesions with a punched-out smooth ulcer base with whitish fibrinoid base
**Tea
* Most [[ulcers]] are at the junction of [[fundus]] and antrum
* 0.5-2.5cm
'''Duodenal ulcers'''
* Well-demarcated break in the [[mucosa]] that may extend into the [[muscularis propria]] of the [[duodenum]]
* Found in the first part of [[duodenum]]
* <1cm
|'''Other diagnostic tests'''
* Serum [[gastrin]] levels
* [[Secretin]] stimulation test
* [[Biopsy]]
|-
| style="padding: 5px 5px; background: #DCDCDC;" |[[Gastrinoma]]
| style="padding: 5px 5px; background: #F5F5F5;" |
* Associated with [[MEN type 1]]
|
* [[Abdominal pain]]
|<nowiki>-</nowiki>
|<nowiki>-</nowiki>
|✔


* Fundectomy (postoperative)
(suspect [[gastric outlet obstruction]])
* [[Gastrectomy]] (postoperative)
|✔
* [[Gastritis]]
|<nowiki>-</nowiki>
* [[Gastroesophageal reflux disease]] ([[GERD]])
|<nowiki>-</nowiki>
* [[Hiatal hernia]]
|<nowiki>-</nowiki>
* Infectious [[esophagitis]]
|
* Lifting
* [[Melena|Black stools]]
* [[Mallory-Weiss tear]]
|Useful in collecting the tissue for [[biopsy]]
* Motility disorders
|
* Muscle strain
* May present with symptoms of [[GERD]] or [[peptic ulcer disease]]
* [[Myasthenia gravis]]
* Associated with [[MEN type 1]]
* [[Myocardial infarction]]
'''Diagnostic tests'''
* [[Obesity]]
* Serum [[gastrin]] levels
* [[Peptic ulcer disease]]
* [[Somatostatin]] receptor [[scintigraphy]]
* [[Pericardial disease]]
* [[CT]] and [[MRI]]
* [[Pregnancy]]
|-
* Primary reflux [[esophagitis]]
| style="padding: 5px 5px; background: #DCDCDC;" |[[Gastric Cancer|Gastric Adenocarcinoma]]
* [[Pulmonary embolism]]
| style="padding: 5px 5px; background: #F5F5F5;" |
* [[Raynaud's phenomenon]]
* ''[[H. pylori]]'' infection
* [[Scleroderma]]
* Smoked and salted food
* Strictures, webs or rings
|
* [[Vagotomy]] (postoperative)
* [[Abdominal pain]]
|<nowiki>-</nowiki>
|<nowiki>-</nowiki>
|✔
|✔
|✔
|✔
|✔
|
* [[Melena|Black stools]], or blood in stools
|'''Esophagogastroduodenoscopy'''
* Multiple biopsies are taken to establish the diagnosis
|'''Other symptoms'''
* [[Dysphagia]]
* Early [[satiety]]
* Frequent [[burping]]
|-
| style="padding: 5px 5px; background: #DCDCDC;" |[[Gastric lymphoma|Primary gastric lymphoma]]
| style="padding: 5px 5px; background: #F5F5F5;" |
* ''[[H. pylori]]'' infection
|
* [[Abdominal pain]]
* [[Chest pain]]
|<nowiki>-</nowiki>
|<nowiki>-</nowiki>
|<nowiki>-</nowiki>
|<nowiki>-</nowiki>
|<nowiki>-</nowiki>
|✔
|<nowiki>-</nowiki>
|<nowiki>-</nowiki>
|Useful in collecting the tissue for [[biopsy]]
|'''Other symptoms'''
* Painless swollen [[lymph nodes]] in neck and armpit
* Night sweats
* [[Fatigue]]
* [[Fever]]
* [[Cough]] or trouble breathing
|}


==References==
==References==
{{Reflist|2}}
{{Reflist|2}}
{{WH}}
 
{{WS}}


[[Category:General practice]]
[[Category:General practice]]
[[Category:Gastroenterology]]
[[Category:Gastroenterology]]
[[Category:Digestive disease symptoms]]
[[Category:Digestive disease symptoms]]
[[Category:Needs overview]]

Latest revision as of 17:42, 17 September 2020

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1] Associate Editor(s)-in-Chief: José Eduardo Riceto Loyola Junior, M.D.[2]

Overview

Heartburn must be differentiated from other diseases that cause chest pain, such as acute coronary syndromes.
Heartburn may also be differentiated from other diseases that cause dysphagia such as esophageal cancer, achalasia and eosinophilic esophagitis in high risk individuals.

Differentiating Heartburn from other Diseases

  • Heartburn must be differentiated from other diseases that cause chest pain, such as acute coronary syndromes.
  • Heartburn may also be differentiated from other diseases that cause dysphagia in high risk individuals.
  • Cardiac causes must be excluded since they can be life-threatening and may present with similar symptoms. In order to facilitate this, there's a table below which describes the life-threatening causes which must be differentiated:


Differentiating heartburn from angina [1] [2]
Heartburn (GERD) Angina or Heart Attack
Burning chest pain, begins at the breastbone Tightness, pressure, squeezing, stabbing or dull pain, most often in the center
Pain that radiates towards the throat Pain radiates to the shoulders, neck or arms
Sensation of food coming back to the mouth Irregular or rapid heartbeat
Acid taste in the back of the throat Cold sweat or clammy skin
Pain worsens when patient lie down or bend over Lightheadedness, weakness, dizziness, nausea, indigestion or vomiting
Appears after large or spicy meal Shortness of breath
Symptoms appears with physical exertion or extreme stress


While evaluating heartburn and considering gastroesophageal reflux disease (GERD) its most probable diagnosis, there's a diagnostic approach that must be performed in order to exclude other causes, especially in high risk patients, according the the American Journal of Gastroenterology guidelines[3] :

 
 
 
Classic symptoms of GERD
(heartburn and regurgitation)
 
If there are warning signs*:
upper endoscopy during the initial evaluation
 
 
 
 
 
 
 
 
 
 
 
 
 
 
PPI 8-week trial
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
If better: GERD probable
 
If refractory, proceed to refractory GERD algorithm


 
 
 
 
 
 
Treat GERD:
Start a 8-week course of PPI
 
If there are warning signs*:
upper endoscopy during the initial evaluation
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Refractory GERD
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Optimize PPI therapy
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
No response:
Exclude other etiologies
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Typical symptoms:
Upper endoscopy
 
 
 
 
 
Atypical symptoms:
Referral to ENT, pulmonary, allergy specialist
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Abnormal:
(eosinophilic esophagitis, erosive esophagitis, other)
Specific treatment
 
NORMAL
 
Abnormal:
(ENT, pulmonary, or allergic disorder)
Specific treatment
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
REFLUX MONITORING
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Low pre test probability of GERD
 
High pre test probability of GERD
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Test off medication with pH or impedance-pH
 
Test on medication with impedance-pH
 
 
 
 
Differential Diagnosis
Disease Cause Symptoms Diagnosis Other findings
Pain Nausea & Vomiting Heartburn Belching or Bloating Weight loss Loss of Appetite Stools Endoscopy findings
Location Aggravating Factors Alleviating Factors
GERD
  • Spicy food
  • Tight fitting clothing

(Suspect delayed gastric emptying)

- - - - Other symptoms:

Complications

Acute gastritis Food Antacids - Black stools -
Chronic gastritis Food Antacids - H. pylori gastritis

Lymphocytic gastritis

  • Enlarged folds
  • Aphthoid erosions
-
Atrophic gastritis Epigastric pain - - - - H. pylori

Autoimmune

Crohn's disease - - - - -
  • Mucosal nodularity with cobblestoning
  • Multiple aphthous ulcers
  • Linier or serpiginous ulcerations
  • Thickened antral folds
  • Antral narrowing
  • Hypoperistalsis
  • Duodenal strictures
Peptic ulcer disease

Duodenal ulcer

  • Pain aggravates with empty stomach

Gastric ulcer

  • Pain aggravates with food
  • Pain alleviates with food
- - - Gastric ulcers
  • Discrete mucosal lesions with a punched-out smooth ulcer base with whitish fibrinoid base
  • Most ulcers are at the junction of fundus and antrum
  • 0.5-2.5cm

Duodenal ulcers

Other diagnostic tests
Gastrinoma - -

(suspect gastric outlet obstruction)

- - - Useful in collecting the tissue for biopsy

Diagnostic tests

Gastric Adenocarcinoma - - Esophagogastroduodenoscopy
  • Multiple biopsies are taken to establish the diagnosis
Other symptoms
Primary gastric lymphoma - - - - - - - Useful in collecting the tissue for biopsy Other symptoms

References

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