Could worsening gastroesophageal reflux disease (GERD) be related to a patient's symptoms of abdominal pain and diarrhea, in the context of a patient with a history of eczema?

Could Worsening GERD Be Related to Abdominal Pain and Diarrhea in a Patient with Eczema?

Yes, worsening GERD can be directly related to these symptoms, but you must consider eosinophilic esophagitis (EoE) as a critical alternative diagnosis given the patient's atopic history (eczema), especially if symptoms are unresponsive to acid suppression. 1

Primary Diagnostic Consideration: Eosinophilic Esophagitis

EoE should be your first consideration in this clinical scenario. The combination of atopic disease (eczema), GERD-like symptoms, and lower GI symptoms (abdominal pain and diarrhea) creates a high-risk profile for EoE rather than typical GERD. 1

Why EoE Must Be Ruled Out:

• Children with EoE commonly present with GERD-like symptoms (5-82% of cases), abdominal pain (5-68%), and diarrhea (1-24%). 1
• Adults with EoE also report GERD-like symptoms (7-100%), abdominal pain (3-25%), and diarrhea. 1
• The critical distinguishing feature: EoE symptoms are unresponsive or only partially responsive to acid blockade (PPIs). 1
• Patients with atopic conditions (eczema, environmental allergies, food allergies) have significantly higher rates of EoE. 1

Immediate Action Required:

If this patient has been on PPI therapy without adequate symptom resolution, proceed directly to upper endoscopy with esophageal biopsies (minimum 2-4 biopsies from proximal and distal esophagus). 1 The diagnosis of EoE requires ≥15 eosinophils per high-power field on biopsy, and histological findings can be present even when the endoscopy appears normal. 1

GERD as a Contributor to Lower GI Symptoms

Direct GERD-Related Mechanisms:

• GERD and IBS symptoms overlap in 71-79% of patients, with GERD patients commonly reporting lower abdominal symptoms including abdominal pain and altered bowel habits. 2, 3
• Epigastric pain occurs in approximately two-thirds of patients with GERD symptoms and may be generated by esophageal contact with refluxate. 1
• The overlap may represent either: (1) GERD affecting multiple levels of the GI tract through shared sensory-motor dysfunction, or (2) true overlap of two distinct disorders (GERD + IBS). 2, 3

Clinical Implications:

• GERD patients with concurrent IBS-like symptoms (abdominal pain, diarrhea) perceive their GERD symptoms as more severe and respond less effectively to anti-reflux treatment compared to those without IBS symptoms. 2
• This suggests that if symptoms worsen despite appropriate GERD therapy, you are likely dealing with either EoE or true GERD-IBS overlap rather than GERD alone. 2, 3

Post-Infectious Considerations

If the patient had recent gastroenteritis preceding symptom onset, consider post-infectious IBS as a contributor:

• Up to 27% of patients develop persistent bowel symptoms after bacterial gastroenteritis despite complete mucosal healing. 4
• Small intestinal bacterial overgrowth (SIBO) occurs in up to 30% of post-infectious cases and causes bloating, pain, and diarrhea. 4
• Bile acid diarrhea should be considered if diarrhea is prominent. 4

Algorithmic Approach to This Patient

Step 1: Assess PPI Response

• If symptoms persist despite 8 weeks of appropriate-dose PPI therapy (e.g., omeprazole 20-40 mg daily before meals), GERD is unlikely to be the sole diagnosis. 5
• PPI non-response strongly suggests EoE in the context of atopic disease. 1

Step 2: Endoscopic Evaluation

• Perform upper endoscopy with multiple esophageal biopsies (proximal and distal) to evaluate for EoE (≥15 eosinophils/HPF). 1
• Look for endoscopic features: rings, furrows, edema, exudates, strictures, or small-caliber esophagus—though these may be absent in early disease. 1
• Obtain biopsies even if endoscopy appears normal, as histological eosinophilia can be present without visible changes. 1

Step 3: Evaluate Lower GI Symptoms

• Check fecal calprotectin to assess for intestinal inflammation; values >50 μg/g warrant further investigation. 6
• Consider hydrogen breath testing for SIBO if bloating and diarrhea are prominent. 4
• Rule out alarm features (weight loss, nocturnal symptoms, blood in stool, fever) that would necessitate colonoscopy. 4, 6

Step 4: Treatment Based on Diagnosis

If EoE is confirmed:

• Initiate dietary elimination therapy or topical corticosteroids (swallowed fluticasone or budesonide). 1
• Continue PPI therapy as adjunctive treatment, as some EoE patients have concurrent GERD. 1

If GERD-IBS overlap is confirmed:

• Optimize PPI therapy (continue at effective dose). 5
• Add low FODMAP diet as first-line dietary intervention for IBS symptoms. 4
• Consider antispasmodics or low-dose tricyclic antidepressants for abdominal pain. 4
• If diarrhea predominates, trial rifaximin 550 mg three times daily for 14 days. 4

Critical Pitfalls to Avoid

• Do not assume worsening symptoms represent inadequate GERD control without first ruling out EoE, especially in patients with atopic disease. 1
• Do not continue escalating PPI doses indefinitely without endoscopic evaluation if symptoms persist beyond 8 weeks. 5
• Do not attribute all lower GI symptoms to IBS without objective assessment for inflammation (fecal calprotectin, endoscopy if indicated). 6
• Do not ignore the atopic history (eczema)—this significantly increases pre-test probability for EoE. 1
• Do not rely on symptom response to PPIs alone to confirm GERD, as PPI-responsive esophageal eosinophilia exists and represents a distinct entity. 1