Internal Medicine

0521779407-08 CUNY1086/Karliner 0 521 77940 7 June 13, 2007 7:47

Gastroesophageal Reflux Disease 611

■>80% of patients with esophagitis have hiatal hernia that dissociates

the LES from the crural diaphragm

■Large hiatal hernias (>3cm) are associated with weak LES, poor

esophageal peristalsis, severe acid reflux and esophagitis

Symptoms

■Heartburn

■Acid regurgitation

■Dysphagia

■Extra-esophageal symptoms: asthma, recurrent pneumonia, chro-

nic cough, angina-like chest pain, laryngitis (hoarseness), dental ero-

sions, chronic hiccups

Physical Signs

■Usually absent

tests

Basic Tests

■CBC: rule out anemia from blood loss

Specific Diagnostic Tests

■Endoscopy with biopsy

➣Best diagnostic study for evaluating mucosal injury and identi-

fying hiatal hernia, peptic strictures, and Barrett’s esophagus; it

allows dilation of peptic strictures and surveillance for dysplasia

and cancer in Barrett’s esophagus

■Esophageal manometry

➣Used to assess LES pressure and peristalsis; performed before

anti-reflux surgery to identify patients with poor esophageal

body peristalsis

■Ambulatory esophageal pH monitoring

➣Evaluation of patients with atypical reflux symptoms or failed

antireflux therapy; % time with pH <4 most useful measure to dis-

criminate between physiologic and pathologic esophageal acid

exposure

Other Tests

■Barium swallow/UGI

➣May identify hiatal hernia, strictures and dysmotility

■Barium tablet study

➣Useful in identifying areas of subtle stenosis and explain dyspha-

gia