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  • Clinician

Gastroesophageal reflux disease

Summary

Gastroesophageal reflux disease (GERD) is a chronic condition in which stomach contents flow back into the esophagus, causing irritation to the mucosa. Reflux is primarily caused by an inappropriate, transient relaxation of the lower esophageal sphincter (LES). Risk factors include obesity, stress, certain eating habits (e.g., heavy meals or lying down shortly after eating), and changes in the anatomy of the esophagogastric junction (e.g., hiatal hernia). Typical symptoms are retrosternal burning pain (heartburn) and regurgitation, but the presentation is variable and may also include symptoms like chest pain and dysphagia. Most patients with suspected GERD should receive empirical treatment with proton pump inhibitors (PPIs). Diagnostic studies, e.g., esophagogastroduodenoscopy (EGD) and/or 24-hour pH test, may be indicated to confirm the diagnosis or to rule out other causes of symptoms. Management involves lifestyle modifications, medication, and, in some cases, surgery. Treating esophagitis is especially important because chronic mucosal damage can cause Barrett esophagus, a premalignant condition that can progress to adenocarcinoma.

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): A condition in which reflux causes troublesome symptoms (typically including heartburn or regurgitation) and/or esophageal injury/complications. The most common endoscopic finding associated with esophageal mucosal injury is reflux esophagitis. [1]
    • NERD (non-erosive reflux disease): characteristic symptoms of gastroesophageal reflux disease in the absence of esophageal injury, such as reflux esophagitis, on endoscopy (50–70% of GERD patients) [2]
    • ERD (erosive reflux disease): gastroesophageal reflux with evidence of esophageal injury, such as reflux esophagitis, on endoscopy (30–50% of GERD patients) [2]

References:[1][2]

Epidemiology

  • Prevalence: ∼ 15–30% in the US (increases with age) [3]
  • Sex: = [3]

References:[3][4]

Epidemiological data refers to the US, unless otherwise specified.

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

  • Gastroesophageal junction dysfunction can occur due to the following factors:
  • Impaired esophageal acid clearance [7]
    • Normally, acid reflux is neutralized by salivary bicarbonate and evacuated back to stomach via esophageal peristalsis.
    • Clearance can be disrupted by reduced salivation (e.g., due to smoking) and/or decreased peristalsis (e.g., due to inflammation).

Risk factors/associations

References:[10][11]

Clinical features

  • Typical symptoms
  • Atypical symptoms
  • Extraesophageal symptoms
    • Chronic nonproductive cough and nighttime cough
    • Hoarseness
    • Dental erosions
  • Aggravating factors
    • Lying down shortly after meals
    • Certain foods/beverages

References:[3][10][4][12]

Pathology

The histopathological findings include the following (may vary depending on the severity of mucosal damage): [13]

Differential diagnoses

Differential diagnoses of gastroesophageal reflux disease [15]

Gastrointestinal tract Esophageal causes
Gastric causes
Biliopancreatic disorders
Functional disorders
Others
Non-GI diagnoses

Other forms of esophagitis

The differential diagnoses listed here are not exhaustive.

Diagnostics

Approach [10][17]

  • Typical symptoms: Presume GERD diagnosis and start an empiric PPI trial.
    • Good response: often used to confirm GERD diagnosis
    • Symptoms persist: EGD is indicated.
  • Atypical symptoms or alarm features: consider endoscopic evaluation (see “Indications for EGD”).
  • Extraesophageal symptoms: Rule out other diagnoses first.

If the presenting symptom is chest pain, other diagnoses should be ruled out first. (See “Diagnostics” in “Chest pain” for a comprehensive workup.)

A negative response to a PPI trial does not exclude GERD.

EGD [10][18][19][17]

> 50% of patients with GERD present with nonerosive reflux and normal endoscopic findings. [22]

Esophageal pH monitoring [10][20]

Esophageal pH monitoring is the gold standard and can be used to objectively identify abnormal reflux of gastric content into the esophagus. It is not a routine diagnostic test. [10]

  • Indications
    • Refractory GERD symptoms despite PPI therapy
    • Confirmation of suspected NERD
    • Evaluation before surgical or endoscopic antireflux procedure
  • Procedure
    • Measurement of esophageal pH over 24–48 hours using a telemetry capsule or a transnasal catheter
    • 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. [23]

Further diagnostic studies [10][20]

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

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 [10][19]

See “Antacids and acid suppression medications” for agents, detailed dosages, and pharmacological considerations.

  • PPIs: : standard dose of PPI for 8 weeks
    • Indications
      • Empiric PPI trial in patients with typical symptoms
      • After EGD: ERD or presumed NERD
    • Continuous management (based on the clinical response after 8 weeks) [25]
      • Good response and no complications: Discontinue PPI.
      • Good response in patients with complications : Continue PPI at maintenance dose.
      • Partial response: Increase dose (to twice daily therapy), adjust timing, or switch to a different PPI.
      • Recurrence of symptoms after discontinuation of PPI or during weaning: Consider confirming the diagnosis (e.g., with ambulatory esophageal pH monitoring) prior to continuing maintenance therapy.
      • No response: further diagnostic evaluation
    • There is controversy surrounding the risks of long-term PPI therapy [26][27][28][29]
  • H2 receptor antagonists: Consider as alternate maintenance therapy for NERD, or in addition to PPIs to control nighttime symptoms
  • Maintenance therapy: lowest effective dose of acid suppression medication
  • Adjunctive therapy: Consider adding in patients with partial response to PPIs; Not recommended without confirmatory diagnostic studies
    • Prokinetic medication for patients with gastroparesis: e.g., metoclopramide
    • Baclofen (off-label) for refractory symptoms

Lifestyle changes [10][19][30][31][32]

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
    • Small portions
    • Avoid eating at least 3 hours before bedtime.
    • Avoid foods/beverages that appear to trigger symptoms. [33]
  • Physical recommendations
    • Weight loss in patients with obesity
    • Elevate the head of the bed (10–20 cm) for patients with nighttime symptoms.
  • Reduce or avoid triggering substances

Surgical therapy [10][34][19]

Antireflux surgery may be considered for select patients after careful evaluation. Predictors of successful outcomes include: [35][36]

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

Fundoplication

Complications

Barrett esophagus [37][38][19]

Additional complications

We list the most important complications. The selection is not exhaustive.

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last updated 11/19/2020
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