What imaging is recommended for worsening heartburn and acid reflux accompanied by gas pains?

Imaging for Worsening Heartburn, Acid Reflux, and Gas Pains

Upper endoscopy is not recommended as initial imaging for typical heartburn and acid reflux symptoms unless alarm symptoms are present (dysphagia, bleeding, anemia, weight loss, or recurrent vomiting). 1

Initial Approach to Imaging

When Imaging is NOT Indicated:

• For typical GERD symptoms (heartburn, regurgitation, gas pains) without alarm features
• Initial management should be a 4-8 week trial of once-daily proton pump inhibitor (PPI) therapy, which may be escalated to twice-daily if needed 1

When Upper Endoscopy IS Indicated:

1. Presence of alarm symptoms:

   • Dysphagia (difficulty swallowing)
   • Gastrointestinal bleeding
   • Anemia
   • Unexplained weight loss
   • Recurrent vomiting 1, 2

2. Treatment failure:

   • Persistent symptoms despite 4-8 weeks of twice-daily PPI therapy 1, 2

3. High-risk patients:

   • Men over 50 years with chronic GERD symptoms (>5 years) AND additional risk factors:
     • Nocturnal reflux symptoms
     • Hiatal hernia
     • Elevated BMI
     • Tobacco use
     • Intra-abdominal fat distribution 1

4. Follow-up for known conditions:

   • Severe erosive esophagitis (grade B or worse) after 8 weeks of PPI therapy to confirm healing and rule out Barrett's esophagus 1, 2
   • History of esophageal stricture with recurrent dysphagia 1
   • Surveillance in patients with Barrett's esophagus (every 3-5 years if no dysplasia) 1

CT Imaging Considerations

While CT is not the first-line imaging modality for GERD, it may be used when complications are suspected:

• CT may detect distal esophageal wall thickening (≥5 mm) in reflux esophagitis (sensitivity 56%, specificity 88%) 1
• CT can identify complications such as:
  • Gastric or duodenal wall thickening
  • Mucosal hyperenhancement or fat stranding
  • Fluid along gastroduodenal region
  • Focal outpouching from ulcerations
  • Perforation with free air 1

Clinical Pearls and Pitfalls

Pearls:

• Approximately 50-85% of patients with GERD have non-erosive reflux disease, meaning endoscopy will appear normal despite symptoms 1
• Young patients (≤50 years) with only extra-esophageal GERD symptoms and no alarm features rarely have clinically relevant lesions on endoscopy 3

Pitfalls:

1. Overuse of endoscopy:

   • Approximately 30% of endoscopic procedures have questionable indications 2
   • 81% of endoscopies in low-risk patients show no abnormalities 2

2. Symptom severity does not predict endoscopic findings:

   • Patients with non-erosive GERD often have more severe symptoms than those with erosive disease 4
   • Symptoms are only modestly predictive of findings at endoscopy (sensitivity 51-71%, specificity 49-68%) 5

3. Overlooking BMI as a factor:

   • Increased BMI is associated with persistent abnormal acid exposure despite PPI therapy 6
   • Consider this when evaluating patients with refractory symptoms

Conclusion

For patients with worsening heartburn, acid reflux, and gas pains, the decision to perform imaging should follow a stepwise approach. Initial management should focus on empiric PPI therapy, with upper endoscopy reserved for those with alarm symptoms, treatment failure, or high-risk features. CT imaging may be considered when complications are suspected but is not recommended as first-line evaluation for typical GERD symptoms.