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Gastroesophageal Reflux Disease (GERD)

BASICS

  • Inflammation and mucosal changes in esophagus from refluxed gastric contents
  • Common symptoms: heartburn, acid indigestion, regurgitation

EPIDEMIOLOGY

  • Incidence: 5 per 1000 person-years
  • Prevalence: ~15% in North America
  • No sex predilection
  • Increased risk with age (>50 years)
  • Pediatric: 50% of newborns have regurgitation, resolves by 1 year in 90%

ETIOLOGY AND PATHOPHYSIOLOGY

  • Reflux of acid damages squamous mucosa of esophagus
  • Causes include LES dysfunction, esophageal hypersensitivity, delayed gastric emptying, hiatal hernia
  • Genetic factors contribute 31-43% of predisposition

RISK FACTORS

  • Obesity (OR 1.7)
  • Tobacco use (OR 1.2)
  • Hiatal hernia
  • Pregnancy
  • Diet and alcohol use
  • Neuromuscular diseases (scleroderma)

GENERAL PREVENTION

  • Weight loss (strong evidence)
  • Tobacco cessation
  • Dietary modification: avoid spicy, acidic, fatty foods, alcohol, caffeine, chocolate, carbonated drinks
  • Elevate head of bed, avoid late meals, smaller portions, stay upright post-meal
  • Infants: car seat after feeding, thickened feeds, frequent burping

COMMONLY ASSOCIATED CONDITIONS

  • Nonerosive and erosive esophagitis
  • Barrett esophagus (~7%)
  • Esophageal adenocarcinoma
  • Peptic strictures
  • Extraesophageal reflux symptoms: chronic cough, asthma, laryngitis

DIAGNOSIS

History

  • Typical: heartburn, acid regurgitation, postprandial dysphagia
  • Extraesophageal: cough, hoarseness, wheezing, sore throat
  • Atypical: epigastric fullness, bloating, chest pain, lump in throat
  • Symptoms worse lying down or bending

Physical Exam

  • Often normal
  • Look for epigastric tenderness or dental erosions

Differential Diagnosis

  • Cardiac disease (angina)
  • Infectious or chemical esophagitis
  • Peptic ulcer disease
  • Achalasia and other motility disorders
  • Esophageal stricture, rings
  • Malignancy

DIAGNOSTIC TESTS & INTERPRETATION

  • Diagnosis criteria by SAGES: mucosal break on endoscopy, Barrett’s on biopsy, peptic stricture, positive pH testing
  • Initial tests: PPI trial for 8 weeks (78% sensitivity)
  • Endoscopy indicated for alarm symptoms or PPI failure
  • High-resolution manometry for refractory cases and surgical planning
  • Ambulatory pH monitoring (off PPI for 7 days) to quantify acid exposure
  • Barium swallow not for diagnosis but to assess dysphagia or anatomy

TREATMENT

General Measures

  • Lifestyle and dietary modification
  • Stepwise therapy: lifestyle + antacids/H2 blockers/PPIs → endoscopy → surgery

Medications

  • First-line:
  • H2 blockers (famotidine, nizatidine) - less effective than PPIs
  • PPIs (omeprazole, pantoprazole) – most effective for symptom relief and healing
  • PPI dosing 30-60 mins before meals
  • Caution with long-term PPI use: infections, fractures, deficiencies
  • Taper PPIs to avoid rebound acid hypersecretion

Second-line

  • Sucralfate
  • Prokinetics (metoclopramide) – limited efficacy, risk of adverse effects

Pregnancy

  • Lifestyle, antacids, sucralfate preferred
  • H2 blockers category B, PPIs mostly category B (omeprazole category C)

Pediatric

  • Antacids, liquid H2 blockers, PPIs available
  • Prokinetics limited role

ISSUES FOR REFERRAL

  • Treatment refractory cases
  • Severe esophagitis, dysplasia, Barrett esophagus

SURGERY/OTHER PROCEDURES

  • Laparoscopic fundoplication (partial preferred for fewer complications)
  • Bariatric surgery for obese patients
  • Endoscopic therapies: radiofrequency ablation, transoral incisionless fundoplication (TIF) – evidence mixed

ONGOING CARE

  • Monitor symptoms, repeat endoscopy if poor response or alarm symptoms
  • Maintenance PPI for complications

PATIENT EDUCATION

  • Lifestyle and dietary adherence essential
  • Awareness of alarm symptoms requiring prompt evaluation

PROGNOSIS

  • High relapse rate (2/3) after stopping PPIs in nonerosive cases
  • Long-term PPI may be required in erosive esophagitis
  • Surgery and medical therapy have similar symptom control outcomes

COMPLICATIONS

  • Peptic strictures (10-15%)
  • Barrett esophagus with risk of adenocarcinoma
  • GI bleeding

REFERENCES

  1. Maret-Ouda J, Markar SR, Lagergren J. Gastroesophageal reflux disease: a review. JAMA. 2020;324(24):2536-2547.
  2. Katz PO, Dunbar KB, Schnoll-Sussman FH, et al. ACG clinical guideline for the diagnosis and management of gastroesophageal reflux disease. Am J Gastroenterol. 2022;117(1):27-56.

CODES

  • ICD10: K21.9 Gastro-esophageal reflux disease without esophagitis
  • ICD10: K21.0 Gastro-esophageal reflux disease with esophagitis

CLINICAL PEARLS

  • Formal diagnosis requires endoscopy, biopsy, and pH monitoring.
  • Consider GERD in nonsmokers with chronic cough (>3 weeks).
  • PPIs provide rapid symptom relief and esophagitis healing.
  • Endoscopy recommended with alarm symptoms or refractory cases.