How can I differentiate between GERD and other conditions that may present with similar symptoms, such as angina or peptic ulcer disease?

Differentiating gastroesophageal reflux disease (GORD) from angina and peptic ulcer disease involves careful clinical assessment focusing on symptom characteristics, associated features, and risk factors.

GORD typically presents with heartburn and acid regurgitation, often related to meals and lying down, and may improve with antacids or proton pump inhibitors (PPIs). Lifestyle factors such as obesity, smoking, and dietary triggers (coffee, chocolate, fatty or spicy foods) are common contributors, and symptoms often worsen at night or when bending forward NICE CKS,NICE CG184.

In contrast, angina usually manifests as chest pain described as pressure or tightness, often precipitated by exertion or emotional stress and relieved by rest or nitrates. The pain may radiate to the jaw, neck, or arms and is frequently associated with cardiovascular risk factors such as age, smoking, hypertension, or previous cardiac history. A detailed history assessing the typicality of chest pain (location, radiation, duration, provoking and relieving factors) and physical examination to identify cardiovascular disease signs are essential NICE CG95.

Peptic ulcer disease often presents with epigastric pain described as burning or gnawing, which may be relieved or worsened by food intake. It can be associated with Helicobacter pylori infection or NSAID use. Alarm features such as gastrointestinal bleeding, weight loss, or anaemia warrant urgent referral NICE CKS,NICE CKS.

When symptoms overlap, consider the following approaches: assess for alarm features (e.g., dysphagia, weight loss, haematemesis) that suggest serious pathology requiring urgent referral; review medication history for drugs that exacerbate reflux or cause dyspepsia; and evaluate response to initial treatment with PPIs or antacids NICE CKS,NICE CKS,NICE CG184.

If chest pain is suspected to be cardiac, use clinical judgement to decide on further investigations such as ECG or referral for cardiac evaluation, especially if typical angina features or risk factors are present NICE CG95. For persistent or unexplained GORD symptoms despite treatment, consider specialist investigations like endoscopy, pH monitoring, or manometry to exclude other causes including motility disorders or structural abnormalities NICE CKS,NICE CG184.

In summary, differentiation relies on detailed history taking emphasizing symptom quality, triggers, and associated features; targeted physical examination; assessment of risk factors; and appropriate use of initial empirical treatment and investigations. Collaboration with specialists is advised when diagnosis remains uncertain or alarm features are present NICE CKS,NICE CKS,NICE CG95,NICE CG184.