Definition

 Gastroesophageal reflux: regurgitation of stomach contents into

the esophagus (can also occur in healthy individuals, e.g., after consuming
greasy foods or wine)
 Gastroesophageal reflux disease (GERD)
o A condition in which reflux causes troublesome symptoms (typically
including heartburn or regurgitation) and/or esophageal
injury/complications
Etiology
GERD develops when reflux-promoting factors, such as corrosiveness of the gastric
juice, overcome protective mechanisms, such as the gastroesophageal junction and
esophageal acid clearance.

Mechanisms
o Imbalance between intragastric and lower esophageal sphincter (LES)
pressures [5]
 Reflux occurs when the intragastric pressure is higher than
that created by the LES.
 LES tone can be decreased by substances such
as caffeine and nitroglycerin, as well as by conditions that
cause denervation of the muscle layer, such
as scleroderma (see “Risk factors/associations” below).
 Intragastric pressure is increased in pregnancy, delayed
gastric emptying, and obesity, among other conditions.
o Anatomic abnormalities of gastroesophageal junction (e.g., hiatal
hernia, tumors)
 Impaired esophageal acid clearance [6]
o Normally, acid reflux is neutralized by salivary bicarbonate and
evacuated back to stomach via esophageal peristalsis.
o Clearance can be disrupted by reduced salivation (e.g., due to smoking)
and/or decreased peristalsis (e.g., due to inflammation).

Risk factors for GERD

 Smoking, caffeine and alcohol consumption [6][7][8]

 Stress [2]

 Obesity [9]
  Pregnancy [6]

 Angle of His enlargement (> 60°) [10]

 Iatrogenic (e.g., after gastrectomy)

 Inadequate esophageal protective factors (i.e., saliva, peristalsis) [6]
Symptoms
 Retrosternal burning pain , Regurgitation
 Dysphagia, odynophagia, Water brash: a symptom of excessive salivation
triggered by refluxing of stomach acid
 chest pain
 Belching, bloating
 Dyspepsia, epigastric pain
 Nausea
 Halitosis
 Hoarseness

Aggravating factors
 Lying down shortly after meals
 Certain foods/beverages
Diagnostics
 All patients
o Perform a clinical evaluation, focusing on red flags in GERD and
evaluating dyspepsia if present (see “Approach to dyspepsia”).
o Rule out life-threatening differential diagnoses of GERD and chest
pain (e.g., acute coronary syndrome)
 Red flags in GERD: Refer to gastroenterology for EGD before initiating treatment.
 Extraesophageal symptoms: Rule out other diagnoses prior to initiating treatment
for GERD.
 Refractory symptoms: Optimize PPI therapy.
o If symptoms are relieved: Continue PPI.
o If symptoms persist: Refer to gastroenterology.
Resolution of chest pain with antacids is not diagnostic for GERD and does not rule out
life-threatening causes of chest pain. [18]

EGD
 Supportive findings (typically in the lowest third of the esophagus) [22]

o Erythema, edema, friability

 o Erosions, mucosal breaks, ulcerations
o Peptic strictures and rings
o Salmon pink mucosa (suggestive of Barrett esophagus)
o Proximal migration of the gastroesophageal junction (Z line), e.g.,
in Barrett esophagus or hiatal hernia [23]

Esophageal pH monitoring [15][22]

Esophageal pH monitoring can be used to objectively identify abnormal reflux of gastric
content into the esophagus; however, it is not a routine diagnostic test. [15]

 Procedure
o Measurement of esophageal pH over 24–48 hours using
a telemetry capsule or a transnasal catheter
o Documentation of relevant events by the patient
 Supportive finding: Drops in esophageal pH to 4 or less that correlate with
symptoms of acid reflux and precipitating activities. [25]

Not routinely indicated, as they play a limited role in the diagnosis of GERD; useful if
endoscopy is inconclusive.Esophageal barium swallow

o Consider if the main symptom is dysphagia or if there is suspicion of

structural abnormalities (e.g., esophageal rings or webs) or motility
disorders (e.g., achalasia, distal esophageal spasm)
See “Diagnostics” in “Dysphagia”.
o
 Esophageal manometry: Consider if achalasia or esophageal hypermotility
disorders are suspected.
Treatment
The initial management of GERD consists of implementing lifestyle changes and
initiating acid suppression therapy, preferably with PPIs. Surgical therapy is not routinely
indicated and should only be considered in select cases, e.g., patients who develop
complications despite receiving optimal medical therapy.

Pharmacological therapy [15][20]

 PPIs: standard dose of PPI for 8 weeks
 H2 receptor antagonists: Consider as alternate maintenance therapy
 Maintenance therapy: lowest effective dose of acid suppression medication
A negative response to a PPI trial does not exclude GERD.

Lifestyle changes
There is conflicting evidence as to which lifestyle modifications confer a significant
benefit. The following recommendations are commonly mentioned in the literature but
should be approached on a case-by-case basis, as they may offer relief only for some
patients.

 Dietary recommendations
o Small portions
o Avoid eating at least 2–3 hours before bedtime.
o Avoid foods and beverages that appear to trigger symptoms. [35]

 Physical recommendations
o Weight loss in patients with obesity
o Elevate the head of the bed (10–20 cm) for patients with nighttime
symptoms.
 Reduce or avoid triggering substances
o Tobacco, alcohol, and/or caffeine if the patient
experiences correlation with symptoms
o Medications that may worsen symptoms (e.g., CCBs, diazepam) [7]

Surgical therapy
Indications
 Discontinuation of medical therapy (e.g., due to nonadherence or side effects)
 Symptoms refractory to medical therapy
 Complications despite optimal medical therapy, e.g., severe esophagitis, strictures,
recurrent aspiration
 Large hiatal hernia
Fundoplication
 Definition: an antireflux procedure in which the gastric fundus is wrapped
around the lower esophagus and secured with stitches to form a cuff; results in
a narrowing of the distal esophagus and the gastroesophageal junction (GEJ),
preventing reflux