DIAGNOSTIC CHALLENGES: Differentiating Nighttime GERD

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DIAGNOSTIC CHALLENGES: Differentiating Nighttime GERD

J Fam Pract. 2005 December;54(12):1073-1078

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References

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These results are consistent with 2 previous telephone surveys. In one survey, 13% of 1000 adults who experienced heartburn at least weekly had only nighttime episodes; 20% reported only daytime heartburn.¹⁵ Altogether, 79% of the heartburn sufferers reported experiencing heartburn at night. Of these, 75% reported that heartburn had a negative impact on sleep; 63% indicated that heartburn adversely affected their ability to sleep well; and 40% reported impaired functioning the next day. The prevalence of sleep disturbances increased directly with the incidence of nighttime heartburn.

The second telephone survey of persons with nighttime GERD had lower scores using the Short-Form 36 Health Survey (a measure of quality of life) than did persons with daytime GERD or controls (TABLE 1).⁴ In another study, the greatest differences between groups occurred in terms of physical and emotional role functioning, vitality, and general health.¹⁶ A comparison with other major disorders affirmed the substantial impairment in health-related quality of life caused by nighttime GERD (TABLE 2).⁴

In summary, although heartburn and regurgitation are common in daytime and nighttime GERD, patients with nighttime GERD are more likely to experience impaired sleep, fatigue, reduced work productivity, and decreased quality of life.

TABLE 1
Adjusted medical outcomes study Short-Form 36 Health Survey scores

Scale	Nocturnal GERD (n=945)	Non-nocturnal GERD (n=339)	Controls (n=268)
Physical functioning	63^†	68^†	69
Role limitations—physical	53*^†	64^†	67*
Bodily pain	54*^†	63^†	69*
General health	48*^†	53^†^‡	59*^‡
Vitality	41*^†	47^†^‡	54*^‡
Social functioning	70*^†	76^†	78*
Role limitations—emotional	69*^†	80^†	81*
Mental health	66*^†	71^†	74*
Physical component summary	39*^†	42^†	43*
Mental component summary	47^†	50^†	51
Analysis of covariance, adjusted for age, sex, and comorbidity.
*P<.001 nocturnal GERD vs controls; ^†P<.001 nocturnal vs non-nocturnal; ^‡P<.001 non-nocturnal GERD vs controls.
Farup C, et al. Arch Intern Med. 2001;161:45-52.⁴
Copyright © 2001 American Medical Association. Reproduced with permission.

TABLE 2
Mean medical outcomes study Short-Form 36 Health Survey scores

Scale	Nocturnal GERD (n=945)	Hypertension (n=2089)	Type 2 diabetes (n=541)	Congestive heart failure (n=216)	Clinical depression (n=502)	Angina (n=256)
Physical functioning	77	73	68*	48*	72*	63*
Role limitations—physical	69	62*	57*	34*	44*	44*
Bodily pain	62	72*	69*	63	59	62
General health	63	63	56*	47*	53*	52*
Vitality	49	58*	56*	44	40*	49
Social functioning	79	87*	82	71	57*	80
Role limitations—emotional	75	77	76	64*	39*	70
Mental health	71	78*	77*	75	46*	73
Physical component summary	45	44	42*	35*	45	39*
Mental component summary	48	52*	52*	50	35*	50
*P<.001 vs nocturnal GERD Norms for non-GERD disorders were obtained from the Short-Form 36 Health Survey: Manual and Interpretation Guide.
Farup C, et al. Arch Intern Med. 2001;161:45-52.⁴ Copyright © 2001 American Medical Association. Reproduced with permission.

Diagnosis: evaluation of symptoms

Physicians should inquire specifically about GERD symptoms to ensure diagnosis, as the signs of GERD are often subtle, nonspecific, or judged to be trivial by patients. Symptoms of GERD may include esophageal or nonesophageal complaints, or both. Importantly, heartburn or regurgitation may be absent in many patients: One group of investigators reported that neither heartburn nor regurgitation was experienced by approximately half of all patients who had nonclassical symptoms of GERD.³

Nonesophageal symptoms associated with GERD

Laryngitis, laryngospasm, chronic cough, hoarseness, excessive throat clearing, and globus pharyngeus are common nonesophageal symptoms in patients with GERD (TABLE 3).^17,18 In a recent investigation, 86% and 77% of patients with nighttime and daytime episodes of GERD, respectively, reported one or more nonesophageal symptom. In patients experiencing GERD at night, the most common symptoms were sinusitis (52%), dry cough/throat clearing (49%), and snoring (47%). Symptom severity scores were significantly higher in the nighttime vs daytime GERD groups (2.42 vs 1.80, respectively).⁵

In a cross-sectional international population survey of 2202 randomly selected persons and 459 additional individuals with asthma, Gislason et al estimated the possible association between reported symptoms of nighttime GERD, sleep-disordered breathing, respiratory symptoms, and asthma. The investigators reported a 2- to 3-fold increased prevalence of asthma and other respiratory symptoms (such as wheezing, chest tightness, breathlessness, and nighttime cough) in patients with nighttime reflux.¹⁹

TABLE 3
Nonesophageal conditions associated with GERD

Aspiration pneumonia Asthma Atelectasis Atypical chest pain Bronchiectasis Carcinoma of the larynx Chronic cough Decreased vocal pitch Exacerbation of reactive airway disease Globus pharyngeus Hemoptysis Hoarseness Laryngitis Laryngospasm Postnasal drip sensation Pulmonary fibrosis Sleep apnea Throat clearing (excessive)
Fass R, et al. Aliment Pharmacol Ther. 2004;20(suppl 9):26-38.¹⁷
McGuigan JE, et al. Aliment Pharmacol Ther. 2004;20(suppl 9):57-72.¹⁸

Patient history

The patient’s history is the primary focus of the diagnostic workup and the physician should explore patient risk factors for GERD. For patients with atypical symptoms of GERD, the history is especially important to determine the diagnosis.

The presence of at least one esophageal or non-esophageal sign and symptom should prompt consideration of GERD as the cause, and discussion with the patient may help classify GERD further. The symptoms of nighttime GERD range from mild to severe. Though they can be similar to the symptoms of daytime GERD, nocturnal symptoms may be exacerbated by lying down or may differ in their manifestation. Asking questions about a patient’s quality of sleep, with input from the patient’s sleep partner, if possible, is useful in assessing nighttime GERD (TABLE 4).

TABLE 4
Key questions in the assessment of nighttime GERD

Do you have trouble falling asleep? Are you restless? Do you wake up coughing? Do you snore? Do you awaken with an acid or bitter taste or food in your mouth? Do you experience daytime fatigue?
Note: Input should also be sought from the patient’s sleep partner.
Farup C, et al. Arch Intern Med. 2001;161:45-52.⁴