SUMMARY:

Gastroesophageal reflux disease (GERD) is a chronic condition characterized by the recurrent regurgitation of acidic stomach contents into the esophagus, and/or more proximally, due to a decrease in tone or inappropriate relaxation of the lower esophageal sphincter. GERD has been estimated to occur in 20% of the population of high-income countries. This condition may be diagnosed in association with classical symptoms or following recognition of GERD-related complications.

Symptoms

Esophageal Symptoms

Symptoms of GERD may be limited to the esophagus and GI tract (typical GERD) and/or may be extra-esophageal

• Heartburn/chest pain
• Acid regurgitation
• Nausea
• Dysphagia
• Belching
• Bloating
• Bleeding

Extra-esophageal Symptoms

Will occur with or rarely without typical GERD symptoms | Silent GERD is an unlikely diagnosis

• Extra-esophageal symptoms may include those of laryngopharyngeal reflux (LPR)
  • Hoarseness/chronic laryngitis
  • Chronic cough, including cough that awakens from sleep/wheezing
  • Recurrent throat irritation and/or throat clearing
  • Excessive pharyngeal mucus
  • Globus (sensation of a lump in the throat)
  • Chronic sinusitis
  • Eustachian tube dysfunction and otitis
  • Change in tone or pitch of speech
• Additional extra-esophageal symptoms may include
  • Halitosis
  • Dental caries
  • Erosion of dental enamel

Complications

• Esophageal ulcers or strictures
• Barrett’s esophagitis
• Esophageal carcinoma- adenocarcinoma may follow Barrett’s with dysplasia, lower esophageal location
• Aspiration

Risk Factors

• Obesity
• Female
• Pregnancy
  • Estrogen | Progesterone | Upward pressure of gravid uterus upon stomach
• Smoking
• Specific foods
  • Chocolate | Peppermint | Caffeine | Alcohol | Tomato | Citrus | Fatty foods
• Eating habits
  • Eating rapidly | Large portions, before sleep
• Hiatal hernia
• Medication
  • Antibiotics (tetracycline, clindamycin) | Bisphosphonates (fosamax, boniva, actonel, atelvia) | Anticholinergics (e.g., ditropan) | Iron supplements | Potassium supplements | Opioids | NSAIDs | Tricyclics | Calcium channel blockers | ACE inhibitors | Progesterone | Diazepam (Valium) | Temazepam (Restoril) | Quinidine

Note: Population studies suggest that there is an inverse relationship between H. pylori and GERD | Hypothesis is that H. pylori may associated with decreased acid production and eradication of the pathogen may exacerbate GERD due to increased risk of esophagitis

Differential Diagnosis

• Coronary Disease
  • Careful evaluation required | GERD may be exacerbated by physical activity (e.g., abdominal crunches or presses, high impact exercise, bending, lifting, running)
• Peptic ulcer disease
  • Nausea | Vomiting | Epigastric pain
• GI malignancy
  • Dysphagia | Vomiting | Weight loss
• Biliary disease
  • Abdominal pain | Jaundice
• Upper GI motility disorder
  • Dysphagia | Vomiting of undigested food
• Eosinophilic esophagitis
  • Dysphagia | Food impaction | Chest pain

Treatment

Lifestyle Modification

• Weight reduction
• Smoking cessation
• Alcohol avoidance
• Avoid food and beverage triggers and eating prior to bedtime
  • Aim for small portions, slower eating, thorough chewing
• Head elevation with wedge or 6 inch blocks, not with multiple bed pillows, as this places pressure on the abdomen and may worsen reflux

Medication: Proton Pump Inhibitors (PPIs)

• Lansoprazole (Prevacid) | Pantoprazole (Protonix) | Esomeprazole (Nexium) | Omeprazole (Prilosec)  | Rabeprazole (Aciphex)
• If incomplete response to once daily dosing
  • Consider twice daily dosing, change in timing or change in dose
  • Some may benefit from intermittent PPI treatment, as needed
• Treatment recommended for 4 to 8 weeks
  • 4 weeks if uncomplicated | 8 weeks for confirmed erosive esophagitis
  • Follow by taper or cessation of medication, then use of PPI as needed
• In general, avoid long-term treatment with PPIs
  • Potential for acute kidney injury or chronic kidney disease, C. difficile infection, osteoporosis, risk for gastric cancer
• In general, avoid long-term treatment with PPIs
  • Acid rebound may occur following acute cessation of long-term PPI treatment so consider taper
  • If long-term treatment is required, use lowest effective dose
  • Patients with Barrett’s esophagus or esophagitis need continuous daily PPI at lowest beneficial dose, as well as serial endoscopy
  • Check hepatic dosing
• Other medications
  • H2 receptor antagonists such as famotidine (Pepcid) are less effective than PPI’s
  • OTC antacids have limited efficacy, though may be used if symptomatic benefit

Note: Monitor patient response | If symptoms persist or there is weight loss after initial treatment refer to GI for further evaluation | Further evaluation may include manometric testing or endoscopy | Weight loss, dysphagia or bleeding may suggest malignancy

Evaluation and Treatment of Extra-esophageal GERD

• Investigate for non-GERD related etiologies
• American Gastroenterological Association recommends against acid suppression therapy for acute treatment in the absence of concurrent typical GERD symptoms
• pH monitoring is recommended, particularly in patients without typical GERD
• If no response to PPI, consider further diagnostics: ENT, pulmonary and/or allergy
  • Laryngoscopy-findings of erythema and edema, though non-specific to LPR and may be seen in over 80% of healthy controls and unreliable inter-observer validity to findings
  • multichannel intraluminal impedance and pH monitoring more accurate than routine ambulatory pH monitoring

Anti-reflux Surgery 

• When PPI and surgery offer similar efficacy, recommend PPI for safety
• Consider surgery if patient responds to PPI treatment but is intolerant or does not wish to continue PPI long term
• Consider surgery if no response to PPI
• Surgical procedures include
  • Laparoscopic fundoplication: Following endoscopy to rule out malignancy and manometry to rule out motility disorders (achalasia) | If GERD recurs after surgery –recommend endoscopy and pH monitoring
  • Stretta procedure: Radiofrequency ablation above and below the LES to thicken the LES
  • Trans-oral incisionless fundoplication: Involves circumferentially suturing the gastroesophageal area with non-absorbable material, applied via endoscopy | Long-term efficacy uncertain
  • LINX procedure (magnetic sphincter augmentation): Involves endoscopically placing titanium beads with magnetized centers around the lower esophagus to increase tone | Limited long-term safety data, though response, in terms of post-op PPI requirements and GERD-related symptoms, appears similar to laparoscopic fundoplication

 Primary Sources – Learn More

Gastroesophageal Reflux Disease: A Review 

American Gastroenterological Association Medical Position Statement on the management of gastroesophageal reflux disease

Relationship between Helicobacter pylori infection and GERD