When to Refer Patients with Symptoms of GERD or IBS

Symptoms of gastroesophageal reflux disease and irritable bowel syndrome are common presentations in primary care that may or may not require evaluation by a gastroenterologist. The authors lay out an approach to patients with these problems designed to ensure appropriate specialist involvement and cost-effective use of various diagnostic tools.

By Enrique Valdivia, MD, and Ronald Fogel, MD

 
Gastroesophageal reflux disease (GERD) and irritable bowel syndrome (IBS) are prevalent medical conditions treated by both primary physicians and gastroenterologists. The symptoms of GERD prompt four to five million physician office visits annually, and those of IBS account for 12% of primary care physician visits and 28% of gastroenterologist office visits.

The diagnosis and treatment of these ailments require both generalist and specialist skills, and our purpose in this article is to clarify the role that each plays. The quality of care, the cost of care, and the physician's satisfaction with the consultation process are influenced by the extent of the initial investigation, the choice of patients referred for consultation, the workup performed by the consultant, and the communication between the physicians.

A broad outline of the process is that the primary physician completes an appropriate initial diagnostic evaluation and treatment plan that will direct the investigations of the gastroenterologist after referral, and the gastroenterologist provides the primary physician with the diagnosis, initiates treatment, and outlines the long-term management of these patients.
 

UNDERSTANDING THE NATURE OF
GASTROESOPHAGEAL REFLUX DISEASE

Gastroesophageal reflux disease is caused by one or more of three factors: reduced pressure in the lower esophageal sphincter (the barrier that prevents backflow of gastric contents into the esophagus), inappropriate transient relaxations of the lower esophageal sphincter (the cause of reflux in the majority of cases), and hiatal hernia with a low sphincter pressure (responsible for reflux in approximately 20% of cases). Although the pathogenesis of GERD is diminished sphincter barrier, the symptoms result from gastric acid irritating the esophageal mucosa.

For clinical management purposes, GERD symptoms fall into three categories: those that are localized to the epigastrium and lower esophagus, those that are supraesophageal or atypical, and those that should be regarded as "alarm symptoms." In the first category are the typical symptoms of reflux: heartburn and regurgitation of food. Supraesophageal or atypical manifestations range from asthma to dental caries (see table below). Proper diagnosis of supraesophageal symptoms can often be elusive since many patients with atypical complaints lack concurrent problems of heartburn or regurgitation. Clinical acumen is necessary to remember that GERD is one of the various possible etiologies for these symptoms, which can require extensive investigation.

Alarm symptoms (see table below) are those complaints that can occur with esophageal reflux but also can be manifestations of other potentially more serious conditions. For example, dysphagia for solids can result solely from the acute inflammation related to GERD, but may also indicate the development of an esophageal stricture. Less frequently, dysphagia may be the result of an esophageal carcinoma. Weight loss can indicate the presence of a neoplasm. Vomiting is an unusual presentation for GERD and raises the possibility of a motility disorder (either gastric or esophageal) or a mechanical obstruction. Anemia, gastrointestinal bleeding, and early satiety likewise are not prevalent symptoms of GERD. The presence of these complaints should raise suspicion of other conditions such as neoplasm or ulcer disease.

PRIMARY CARE OF PATIENTS WITH GERD

Patients whose symptoms are consistent with GERD (heartburn and regurgitation) usually do not present a diagnostic dilemma. The diagnosis of GERD can be based on the clinical symptoms and the response to therapy, as we will explain. Patients with a classic GERD presentation should have complete resolution of symptoms with appropriate treatment. Failure to become symptom-free mandates that the patient be referred to a gastroenterologist for additional tests to exclude other conditions.

Unfortunately, many patients do not understand the meaning of the term "heartburn" or are unable to describe their symptoms to the physician. Consequently, the primary physician may be uncertain about the actual cause of the symptoms. Depending on the degree of diagnostic uncertainty and the severity of symptoms, an empiric trial of acid inhibitory treatment can be considered. Again, if such treatment fails to completely resolve symptoms, a consultation is indicated.

Patients with atypical symptoms of reflux should be referred after other etiologies have been excluded. For example, patients with chest pain should have coronary artery disease excluded prior to referral for esophageal evaluation. For the pulmonary problems of asthma and cough, the etiologies of allergens, medications, and infections must be considered. Many physicians, however, will try empiric treatment with proton pump inhibitors (PPIs) during the course of the investigation.

The identification of alarm symptoms requires that the patient be referred to a gastroenterologist without additional investigations. The gastroenterologist must exclude conditions more serious than GERD that could be causing the symptoms.

Often an issue in the care of these patients is the role of the upper GI barium study. In our practice, patients are often referred after having this test. Unfortunately, the barium study has limited predictive value for the diagnosis of esophagitis. Barium x-rays should not be ordered for the evaluation of heartburn. The only indication for the barium study is dysphagia. The barium study may show a mechanical obstruction (neoplasm or stricture) or a motility disorder (esophageal spasm, decreased peristalsis, or achalasia).

It is important for the primary physician to initiate medical therapy when symptoms strongly suggest GERD. For those with classic symptoms of reflux, the response to therapy is very important to confirm the diagnosis. Failure of medical therapy to improve the symptoms of heartburn and epigastric pain raises the possibility of other diagnoses.

The goal of empiric treatment is complete relief of symptoms. Antacids and over-the-counter H2 receptor antagonists (H₂RAs) are often started by the patient before seeing the doctor. Lifestyle modifications are frequent physician recommendations. The primary physician will often advise eating small meals, eliminating snacks, avoiding specific foods (fatty foods, chocolate, alcohol, peppermint, coffee), not eating for three hours before going to bed, and sleeping with the head of the bed elevated six inches. At present, there is no evidence that these lifestyle changes alter the symptoms of GERD. Only cessation of cigarette smoking has been shown to be beneficial in controlling symptoms.

There is disagreement over which method of inhibiting acid secretion is most cost-effective. Although H₂RAs are less expensive than PPIs, they are less effective, improving symptoms and healing esophagitis in only 50% of patients. In contrast, PPIs produce symptomatic relief in more than 75% of cases. We do not use the step-up approach of starting with an H2RA and switching to a PPI only if there is no improvement in symptoms. Instead, we recommend starting patients with classic GERD symptoms on a once-daily PPI for approximately four to six weeks. If there is no response, these patients should be referred to a gastroenterologist for further investigation.

The basis for choosing a PPI as the initial therapy is the assumption that the most cost-effective treatment is the one that reduces the total cost of care, not just the pharmacy cost. The higher success rate with PPI therapy will result in fewer patients being referred to a gastroenterologist and undergoing additional tests.

For the PPI medication to be effective, the drug should be given approximately 30 minutes before eating. Proton pump inhibitors are acid labile and can be destroyed by gastric acid released with food. The patient must eat after the medication is taken because only actively secreting proton pumps are inhibited by the PPI.

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SPECIALIST CARE OF PATIENTS WITH GERD

Gastroenterology referral is needed for patients who have alarm symptoms, atypical symptoms for which other causes have been excluded, classic symptoms refractory to medical therapy, or chronic symptoms of esophageal reflux. This last group needs evaluation to exclude Barrett's esophagus (see sidebar below).

The primary physician should expect the gastroenterologist to confirm that the symptoms are related to GERD, document the extent of esophageal damage, identify concurrent problems related to esophageal reflux, and provide recommendations regarding additional therapies.

Esophagogastroduodenoscopy is the initial investigation that the gastroenterologist will perform. This test evaluates the esophageal mucosa for signs of inflammation or ulceration and also examines the stomach and duodenum for other abnormalities that could produce the symptoms. Only 50% of patients with GERD will show endoscopic evidence of esophagitis. Patients with GERD symptoms and a normal endoscopy may have a condition referred to as nonerosive reflux disease (NERD). The symptoms of NERD are related to reflux of gastric contents but there is no associated esophageal mucosal damage. Reflux disease should not be excluded on the basis of a negative endoscopy because patients with NERD can have symptomatic improvement with acid inhibition therapy.

In addition to an assessment of esophageal damage, endoscopy can identify other consequences of GERD. Peptic strictures, Barrett's esophagus, and esophageal cancer are readily identified by endoscopy.

Evaluation of patients for Helicobacter pylori during the course of endoscopy is controversial. Some investigators suggest that H. pylori may protect against the development of GERD and its complications. In the presence of H. pylori infection, patients with GERD are likely to respond better to antisecretory therapy and less likely to experience relapses. Some case-control studies have suggested an increase in reflux symptoms or endoscopic findings of esophagitis in patients with peptic ulcer who have had successful treatment of H. pylori infection. Other studies failed to show this association. A 24-hour esophageal pH test is indicated for patients with symptoms of GERD and a normal endoscopy who have not responded to treatment and for those with esophagitis that persists despite PPI therapy. By documenting the pattern, frequency, and duration of esophageal acid exposure, the test allows the gastroenterologist to identify patients with excessive acid reflux and to observe the association between symptoms and the esophageal pH. If acid reflux is documented and temporally correlates with symptoms, the PPI dose can be doubled to achieve better acid suppression. When higher doses are required, it is better to switch to twice-daily dosing than to double the daily dose.

The gastroenterologist may change the PPI that is being used, although the literature indicates that the drugs produce equivalent therapeutic responses. Some incremental benefit may be seen with esomeprazole, based on improved pH control. An H₂RA is often prescribed to prevent nocturnal acid breakthrough, but there is little evidence that this significantly improves symptoms.

A number of other options have been proposed to treat GERD. Prokinetic agents have minimal benefit. Endoscopic therapies may be recommended by the gastroenterologist. Endoscopic fundoplication and radiotherapy have been reported to improve symptoms, although the long-term safety and success of these treatments remains to be demonstrated.

For patients who are refractory to medical treatment, surgery is an option. The best candidate for surgery, however, is the medical success—the patient who experiences improvement with medical therapy but does not want to take medication indefinitely. Prior to surgery, esophageal manometry should be performed to verify that esophageal peristalsis is normal. Performing a fundoplication in patients with esophageal dysmotility may result in symptomatic dysphagia. Additionally, a nuclear gastric emptying scan should be ordered to exclude concurrent gastroparesis, which can cause severe symptoms of gas bloating and abdominal pain after surgery.
 

MAINTENANCE CARE OF PATIENTS WITH GERD

What happens after the gastroenterologist confirms the diagnosis and treats the symptoms?

Esophageal reflux is a chronic condition that requires ongoing inhibition of acid secretion. Studies have shown that stopping treatment in asymptomatic patients with endoscopic evidence of healing frequently results in relapse. Over 80% of patients will suffer a recurrence within the 12 months following cessation of treatment. Therefore, the primary physician must be prepared to provide long-term treatment.

The literature suggests that PPIs are therapeutically superior to H₂RAs. Consequently, many patients receive a prolonged course of PPI therapy. Once healing has occurred, however, a different regimen can be considered. The goal of maintenance therapy is to titrate dosage to the severity of the symptoms. Options include switching from the PPI to an H₂RA, using a half-dose of the PPI, and "on demand" therapy with a PPI. A number of studies demonstrate the efficacy of reducing frequency or dosage of acid inhibitory medications after healing has been achieved.
 

UNDERSTANDING THE NATURE OF IRRITABLE BOWEL SYNDROME

The Rome II criteria define IBS by the presence for at least 12 weeks (not necessarily consecutive) during the preceding 12 months of abdominal pain or discomfort with two of the following three features: relieved by defecation; onset associated with a change in the frequency of defecation (diarrhea or constipation); or onset associated with a change in the form of stool (loose, watery, or pellet-like, for example). Structural and biochemical etiologies for the symptoms must be excluded. Depending on the predominant symptoms, IBS can be divided into four subcategories: abdominal pain, diarrhea, constipation, or alternating bowel pattern.

More than 75% of cases of IBS occur in individuals between the ages of 25 and 64. In North America, approximately 80% of cases of IBS are diagnosed in women. The prevalence of the disorder is considerably higher among whites than other racial groups.

At present, there are no biochemical or structural markers for the diagnosis of IBS. The diagnosis is based on symptom history. Note that a prolonged duration of symptoms is integral to the Rome II criteria. In practice, it is often easier to diagnose IBS in retrospect than when the patient is first assessed.

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PRIMARY CARE OF PATIENTS WITH IBS

The diagnosis of IBS can usually be safely made in general practice on the basis of the Rome II criteria, a normal physical examination, and absence of alarm symptoms (see table below). The diagnosis of IBS is more likely in a female patient less than 45 years old who describes a history of symptoms that started in adolescence or her early 20s. The presence of other nonorganic somatic symptoms such as lethargy, myalgia, and arthralgia suggests the diagnosis of IBS. The diagnostic dilemma arises when the patient is unable to provide a history that adequately details the nature and duration of symptoms.

The primary physician does not need to initiate an extensive evaluation. Based on a literature review and the recommendations of a consensus panel, Fass and colleagues recommend that the primary physician order a complete blood count, sedimentation rate, serum electrolytes, and thyroid function tests to exclude organic diseases. A flexible sigmoidoscopy should be done for the evaluation of patients with constipation or diarrhea. Stool analysis for ova and parasites and fecal leukocytes can be done if diarrhea is the predominant symptom. The goal of the primary physician evaluation is to exclude organic conditions that can have similar presenting symptoms.

The time that the primary physician spends with the patient explaining the disease and providing reassurance that the condition is not life-threatening is essential for the success of therapy. Subsequent use of other physicians can be reduced if the primary physician spends the time to identify the patient's concerns, to validate that the symptoms are real, and to reassure.

For those patients in whom the diagnosis of IBS is certain, the primary physician can manage their care. Many patients note an improvement in symptoms with dietary and lifestyle changes. The initial therapeutic trial can be guided by the patient's dominant symptom (see table below). For patients with constipation, increased dietary fiber intake (20-30 g) or the use of bulking supplements (psyllium, ispaghula, calcium polycarbophil) can be tried. Osmotic laxatives (lactulose, milk of magnesia) can also be useful. Diarrhea can be treated with a lactose-free diet and a trial of loperamide or diphenoxylate.

Low-dose tricyclic antidepressants such as desipramine, 50 to 150 mg, or amitriptyline, 25 to 100 mg, have been found effective in alleviating the abdominal pain of IBS. Anticholinergic side effects, however, may limit the use of these drugs. The selective serotonin reuptake inhibitors may also prove to be effective, but experience with them in IBS to date is limited.

The patient's symptoms should be reassessed three to six weeks after the initiation of empiric treatment. If the initial therapeutic trial fails or if new symptoms develop, the patient should be referred to a gastroenterologist.
 

SPECIALIST CARE OF PATIENTS WITH IBS

Patients presenting with alarm or atypical symptoms, recent onset of symptoms, or symptoms that first appeared after age 45 should be referred to a gastroenterologist. In communicating with the gastroenterologist, the primary physician should state clearly the problem or problems to be diagnosed and treated. These patients frequently have several complaints and the specialist needs to know the primary physician's priorities.

It is essential that colon cancer be excluded because the alarm symptoms can be early signs of this neoplasm. The medical literature indicates that colonoscopy is a more sensitive diagnostic test than air contrast barium enema or stool guaiac and flexible sigmoidoscopy for the diagnosis of colonic lesions. In our practice, patients who need to be evaluated for polyps and possible malignant lesions undergo colonoscopy.

Dialogue between the primary physician and the gastroenterologist is needed regarding the extent and nature of the investigation after any polyps have been addressed and cancer has been ruled out. Depending on the chief symptoms, the workup can be extensive, uncomfortable, and costly.

Patients with constipation should be evaluated for motility disorders. The gastroenterologist may request a colon transit study, defecography, anorectal manometry, and anorectal electromyography. Patients with diarrhea will require a small bowel x-ray. Depending on the characteristics of the diarrhea, the gastroenterologist may initiate an investigation for malabsorption or for causes of secretory diarrhea. Patients with abdominal pain should undergo small bowel x-rays. Other tests will be determined by the nature of the symptoms.

In summary, diagnosis and treatment of the patient with probable GERD or IBS require a close interaction and communication between the primary physician and the gastroenterologist. The consultation process is enhanced to the degree that it fosters sharing of clinical information, establishes goals in the initial communication from the primary physician, and provides detailed feedback to the primary physician.

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