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 retrosternal burning discomfort or heartburn, often related to meals, lying down, or bending forward, and may be relieved by antacids or proton pump inhibitors (PPIs) NICE CKS,NICE CG184. In contrast, angina usually manifests as a pressure-like chest pain or tightness, often precipitated by exertion or emotional stress and relieved by rest or nitrates, with possible radiation to the jaw, neck, or arms NICE CG95. Peptic ulcer disease often causes epigastric pain described as gnawing or burning, which may improve or worsen with food intake, and can be associated with nausea or vomiting NICE CKS,NICE CG184.

Clinical history should include detailed characterization of pain location, quality, duration, precipitating and relieving factors, and associated symptoms such as breathlessness or diaphoresis, which suggest cardiac origin NICE CG95. Physical examination and assessment of cardiovascular risk factors are essential to exclude angina NICE CG95.

Alarm features such as gastrointestinal bleeding, weight loss, or dysphagia warrant urgent referral to exclude malignancy or complicated peptic ulcer disease NICE CKS,NICE CG184.

Initial management of suspected GORD includes lifestyle advice (weight loss, avoiding trigger foods, elevating the head of the bed) and a trial of full-dose PPI therapy for 4 weeks NICE CKS,NICE CG184. Lack of response or atypical features should prompt reconsideration of diagnosis and possible referral for specialist investigations such as endoscopy, pH monitoring, or cardiac evaluation NICE CKS,NICE CG95,NICE CG184.

In cases where chest pain persists despite treatment, consider alternative diagnoses including cardiac causes; non-invasive cardiac testing or specialist referral may be necessary NICE CG95. Similarly, peptic ulcer disease diagnosis may require endoscopy and Helicobacter pylori testing NICE CKS,NICE CG184.

Overall, differentiation relies on a thorough clinical assessment supported by targeted investigations guided by symptom patterns and risk factors, with awareness that some symptoms may overlap and require multidisciplinary evaluation NICE CKS,NICE CKS,NICE CG95,NICE CG184 Rosenthal & Cooper 1977.