SS and DD of GERD

Gastroesophageal Reflux Disease [GERD]

DDx
• Peptic ulcer disease, gastritis, nonulcer dyspepsia, or cholelithiasis
• Angina pectoris - chest pain
• Infectious esophagitis: Candida, herpes simplex virus, cytomegalovirus
• Pill-induced esophagitis - dysphagia, odynophagia
• Esophageal motility disorders, eg, achalasia, esophageal spasm, scleroderma
• Radiation esophagitis - dysphagia, odynophagia
• Zollinger-Ellison syndrome (gastrinoma) - heartburn, dysphagia
Typical Presentation
Heartburn - often occurs 30–60 minutes after meals and upon reclining/ relief from taking antacids or baking soda, symptom is dominant, the diagnosis is established with a high degree of reliability.
Concomitant nausea, vomiting or early satiety – Gastroparesis is suspected.
Overall, a clinical diagnosis of gastroesophageal reflux has a sensitivity of 80% but a specificity of only 70%.
Regurgitation - the spontaneous reflux of sour or bitter gastric contents into the mouth.
Dysphagia or Odynophagia - occurs in one-third of patients and may be due to erosive esophagitis, abnormal esophageal peristalsis, or the development of an esophageal stricture.
It is necessary to undergo gastroscopy if find weight loss, anemia, family history of Upper GI cancer, GI bleed or advanced age.
Atypical Presentation
• Asthma – microaspiration causes initiation of asthma, adult onset asthma KIV.
• Otitis Media – children, with effusion results hearing loss
• Chronic cough
• Chronic laryngitis
• Sore throat
• Chest pain
In the absence of heartburn or regurgitation, atypical symptoms are unlikely to be related to gastroesophageal reflux.
Physical examination and laboratory data are normal in uncomplicated disease.

Differential Diagnosis

Superficial thrombophlebitis
Superficial vein thrombophlebitis is a common inflammatory-thrombotic process that may occur spontaneously or as a complication of medical or surgical interventions. Sterile thrombophlebitis limited to the superficial veins rarely is life threatening, but a thorough diagnostic evaluation is mandatory because many patients with superficial phlebitis also have occult deep vein thrombosis (DVT), which carries high rates of morbidity and mortality.
Patients with superficial thrombophlebitis often give a history of a gradual onset of localized tenderness, followed by the appearance of an area of erythema along the path of a superficial vein. A history of local trauma, prior similar episodes, varicose veins, prolonged travel, hormone use, tobacco use, family history of blood coagulopathies, or enforced stasis may be given. Asking about these risk factors for hypercoagulability should be done, but the absence of identifiable risk factors has no prognostic value.
• Traumatic thrombophlebitis: Ask about trauma, needlesticks, indwelling IV catheters, drug (eg, phenytoin) or hypertonic (10% calcium chloride) solution infusion and sclerotherapy.
• Thrombosed varicose veins: Ask about history of varicose veins


Varicose veins
Varicose veins and telangiectasia (spider veins) are the visible surface manifestations of an underlying problem with reverse venous flow, which is also termed venous insufficiency syndrome. Venous insufficiency syndromes describe venous blood deviating from a normal flow path and flow in a retrograde direction so that fluid accumulates, causing a "congested" leg.
Mild forms of venous insufficiency are merely uncomfortable, annoying, or cosmetically disfiguring, but severe venous disease can produce serious systemic consequences and can lead to loss of life or limb.
Most patients with venous insufficiency have subjective symptoms that may include pain, soreness, burning, aching, throbbing, cramping, muscle fatigue, and restless legs. Over time, chronic venous insufficiency leads to cutaneous and soft tissue breakdown that can be debilitating.


Cellulitis
The word cellulitis literally means inflammation of the cells. It generally indicates an acute spreading infection of the dermis and subcutaneous tissues resulting in pain, erythema, edema, and warmth.
Skin and subcutaneous tissues are involved when microorganisms, typically gram-positive bacteria, invade disrupted skin.

The skin disruption may be obvious, such as a laceration, fissure, or puncture wound. However, cellulitis frequently occurs in areas where no apparent injury exists. This is common in dry and irritated skin where microscopic breaks allow penetration of bacteria.

The infection triggers an inflammatory response that results in the clinically apparent pain, redness, warmth, and swelling.

Muscle Injury/Compartment Syndrome
Compartment syndrome (CS) is a condition in which the perfusion pressure falls below the tissue pressure in a closed anatomic space, with subsequent compromise of tissue circulation and function. Each muscle or muscle group is enclosed in a compartment bound by relatively rigid walls of bone and fascia. The compartments of the lower leg and the volar forearm are particularly prone to developing elevated compartment pressures.

As many as 45% of all cases of CS are caused by tibial fractures. Other causes include any long-bone fracture, vascular injury, compression in the setting of a crush injury, drug overdose, and a tight cast or dressing. Late manifestations of CS include the absence of a distal pulse, extremity paresis, and hypoesthesia. Compartment syndrome (CS) may be the result of either externally applied compressive forces or internally expanding forces. Fractures, vascular injuries, DVT, overexertion, fluid sequestration, or prolonged compression (as from a cast or other cause) may lead to CS. DVT rarely leads to CS, except in the most severe form of DVT, phlegmasia cerulea dolens.

Others:
Achilles tendonitis
Arterial insufficiency
Arthritis
Asymmetric peripheral edema secondary to CHF, liver disease, renal failure, or nephrotic syndrome
Cellulitis, lymphangitis
Extrinsic compression of iliac vein secondary to tumor, hematoma, or abscess
Hematoma
Lymphedema
Muscle or soft tissue injury
Neurogenic pain
Postphlebitic syndrome
Prolonged immobilization or limb paralysis
Ruptured Baker cyst
Stress fractures or other bony lesions
Superficial thrombophlebitis
Varicose veins

Differential Diagnosis for Asthma

1.Cystic fibrosis

Differential symptoms/signs:

Chronic, sometimes productive cough with a possible family history of CF. Nasal polyposis at or before age 12 and symptoms related to other organ involvement, such as diarrhoea, malabsorption or failure to thrive.

Test:

Sweat chloride testing: level of sweat chloride >67.

Consider repeat testing.

2.Tracheomalacia

Differential signs/symptoms:

Symptoms are usually positionally dependent and occur within the first weeks or months of life.

Expiratory stridor and a barking brassy cough, wheezing respiratory distress with additional breath sound at the end of expiration (the bagpipe sign) are accompanied by the occasional extension of the neck with breathing, inspiratory stridor, episodes of holding of breath, anoxia, recurrent respiratory infections, retraction of intercostal and subcostal muscles, failure to thrive and respiratory and cardiac arrest.

Test:

The sensitivity of plain radiographs is 62%, using microlaryngoscopy and bronchoscopy as the reference standards.

In addition to CXR, barium oesophagography is useful for evaluating associated disease processes, such as tracheo-oesophageal fistula and reflux disease.

3.Vascular ring

Differential signs/symptoms:

Wheezing, shortness of breath, occasional stridor.

Test:

CT chest with contrast: double aortic arch, abnormal take-off of the innominate artery, anomaly of left pulmonary artery, right aortic arch, aberrant right subclavian, enlarged pulmonary veins.

4.Foreign body aspiration

Differential signs/symptoms:

Wheezing, shortness of breath, occasional stridor are common.

If the foreign body is in the peripheral airway, localised one-sided wheezing or collapse of the distal lung tissue is found.

Test:

CXR, CT chest or bronchoscopy shows the foreign body.

5.Vocal cord dysfunction

Differential Signs/symptoms:

Inspiratory and expiratory wheezing is often difficult to differentiate. Should be considered in steroid-resistant asthma patients.

Test:
Direct visualisation of the vocal cords with rhinolaryngoscopy during a spell. Inspiratory flow volume loop is helpful when abnormal (flattened).

6.Alpha-1 antitrypsin deficiency

Differential signs/symptoms:

Wheezing, resistant to management. May have family history of parents or grandparents dying of lung disease.

Test:
Testing for the alpha-1 antitrypsin phenotype.

7.COPD

Differential signs/symptoms:

Dyspnoea occurs with or without wheezing and coughing.

Examination may show barrel chest, hyper-resonance to percussion and distant breath sounds.

Test:
PFTs with residual volume (RV), total lung capacity (TLC) and a flow volume loop with bronchodilator showing an obstructive pattern with an increase in TLC and RV and a reduction in forced expiratory flow at one second (FEV1), FEV1/forced vital capacity (FVC) ratio with no response to bronchodilator.

CXR showing hyper-inflation of the lungs.

8.Bronchiectasis

Differential signs/symptoms:

Dyspnoea, cough and wheezing and, if severe, recurrent pulmonary infections.

Test:
High resolution CT chest: dilated airways, bronchial wall thickening.

Can occasionally be seen on CXR.

9.Pulmonary embolism

Differential signs/symptoms:

Patients have a wide variety of presentations but most common is shortness of breath and pleuritic pain.

Test:
Pulmonary angiogram is the preferred test, but carries risks. An acceptable alternate test is CT angiogram of the lung, which, if not available, can be replaced with the less sensitive V/Q scan.

10.Congestive heart failure

Differential signs/symptoms:

History of CAD or uncontrolled HTN; examination showing dependent oedema, elevated jugular venous pressure, and basal pulmonary crepitations.

Test:
CXR may show increased alveolar markings, fluid in fissures and pleural effusions.

Echocardiogram: reduced left ventricular ejection fraction.

11.Common variable immunodeficiency

Differential sign/symptoms:

History of recurrent, usually sinopulmonary, infections.

Test:
Serum IgG level below 5g/L (500 mg/dL).