What are the differences between gastroesophageal reflux disease (GERD), peptic ulcer disease, and gastritis in a 63-year-old female patient with a history of cholecystectomy and fatty liver disease?

Distinguishing GERD, Peptic Ulcer Disease, and Gastritis

GERD, peptic ulcer disease (PUD), and gastritis are distinct upper gastrointestinal conditions that frequently overlap in symptoms but differ fundamentally in their pathophysiology, location of disease, and diagnostic findings.

Core Pathophysiologic Differences

GERD is a condition where reflux of gastric contents into the esophagus causes troublesome symptoms (typically heartburn and regurgitation) and/or complications, with or without visible esophageal inflammation 1. The disease results from failure of the anti-reflux barrier, often mediated through transient lower esophageal sphincter relaxations 1.

Peptic ulcer disease involves focal mucosal breaks (ulcer craters) that extend through the epithelial lining into the submucosal layer, occurring in either the stomach (gastric ulcer) or duodenum (duodenal ulcer) 1, 2. PUD has an incidence of 0.1% to 0.3% and is primarily caused by Helicobacter pylori infection (42% of cases) and NSAID use (36% of cases) 2.

Gastritis refers to inflammation of the gastric mucosa without discrete ulcer formation, characterized by submucosal edema, mucosal hyperenhancement, and inflammatory infiltrate 1, 2. Unlike PUD, gastritis does not create focal outpouching or crater formation through the mucosal layers 1.

Clinical Presentation Distinctions

GERD Symptoms

• Heartburn (retrosternal burning sensation) is the most common and specific symptom of GERD 3
• Regurgitation of gastric contents 1
• Symptoms typically worsen after meals and when supine 1
• The positive predictive value of heartburn and regurgitation for endoscopy-positive GERD is only 0.37, while the negative predictive value is 0.90 4

PUD Symptoms

• Epigastric pain is the predominant symptom, often with specific timing patterns 1
• Nocturnal pain is characteristic, particularly for duodenal ulcers 2
• Complications include hemorrhage (most common at 73% of complicated cases, with 30-day mortality of 8.6%) and perforation (mortality up to 30% if delayed) 2, 5
• Occult blood in stool indicates gastrointestinal bleeding 2

Gastritis Symptoms

• Nonspecific epigastric discomfort, nausea, and vomiting 1
• Symptoms overlap extensively with both GERD and PUD, making clinical differentiation difficult 1
• May present with dyspeptic symptoms without the characteristic heartburn of GERD 1

Diagnostic Approach

When Symptoms Overlap

The symptoms of GERD, PUD, and gastritis are nonspecific and overlap considerably, requiring careful evaluation 1. Clinical history, risk factors, and symptom patterns are important for narrowing the differential diagnosis 1.

Endoscopic Findings

GERD endoscopy may show:

• Distal esophageal inflammation (erosive esophagitis) in only 33% of GERD patients 4
• Barrett's esophagus, esophageal stricture, or esophageal ulcer in complicated cases 1
• 67-85% of GERD patients under age 50 have endoscopy-negative disease 4

PUD endoscopy reveals:

• Focal ulcer craters with discrete margins 2
• Ulceroproliferative features, focal outpouching of mucosa 1, 5
• Endoscopy is the standard test of choice for diagnosing PUD 1, 2

Gastritis endoscopy shows:

• Erythema of gastric mucosa (64.43% of cases) 6
• Thickened gastric folds, mucosal edema 1, 6
• No discrete ulcer craters 1

CT Imaging Characteristics

While CT is not first-line for these conditions, when performed it can show:

• GERD: Distal esophageal wall thickening ≥5 mm (sensitivity 56%, specificity 88%), presence of air in the esophagus 1
• PUD/Gastritis: Gastric or duodenal wall thickening due to submucosal edema, mucosal hyperenhancement, fat stranding, focal interruption of mucosal enhancement 1, 7
• PUD complications: Extraluminal gas, fluid, or fat stranding indicating perforation 7, 5

Special Considerations for Your Patient

In a 63-year-old female with history of cholecystectomy and fatty liver disease:

• Cholecystectomy increases risk of both GERD (2.06-fold increased likelihood of endoscopy) and gastric pathology 8, 9
• Previous cholecystectomy is associated positively with esophagitis (p=0.002) and gastric ulcer, but negatively with duodenal ulcer (p=0.03) 8
• Bile reflux gastropathy occurs in 21.34% after therapeutic biliary interventions, with obesity and diabetes as additional risk factors 9
• The average time interval from cholecystectomy to discovery of bile reflux gastritis is 15.29 years 6

Critical Pitfalls to Avoid

• Never assume benign disease without histologic confirmation when ulceroproliferative features are present, as malignancy can mimic PUD 5
• Do not rely solely on symptoms to distinguish these conditions, as overlap is extensive and correlation between reflux symptoms and endoscopy-positive GERD is poor 1, 4
• Do not delay imaging or surgical consultation if peritoneal signs develop, as perforated ulcer mortality increases significantly with delayed diagnosis 2, 5
• Recognize that GERD is generally more resistant to antisecretory therapy than PUD, requiring higher or more frequent dosing 3