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  • Clinician

Gastroesophageal reflux disease


Gastroesophageal reflux disease (GERD) is a chronic condition in which retrograde flow of stomach contents into the esophagus causes irritation to the epithelial lining. Reflux episodes are primarily caused by inappropriate, transient relaxation of the lower esophageal sphincter (LES). Risk factors include smoking, alcohol consumption, stress, obesity, and anatomical abnormalities of the esophagogastric junction (e.g., hiatal hernia). The chief complaint is retrosternal burning pain (heartburn), but a variety of other symptoms, such as dysphagia and a feeling of increased pressure, are also common. Suspected GERD should already receive empirical treatment, but further diagnostic steps, such as an upper endoscopy and/or 24-hour pH test, may be indicated to confirm the diagnosis. Management involves lifestyle modifications, medications, and possibly surgery. Proton pump inhibitors (PPIs) are the treatment of choice, although other agents – such as histamine H2-receptor antagonists (H2RAs) – may also be helpful. In addition to relieving symptoms, treating esophagitis is especially important, as chronic mucosal damage can lead to a premalignant condition known as Barrett's esophagus, further progressing to adenocarcinoma of the esophagus.


  • 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][3][4]



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


Epidemiological data refers to the US, unless otherwise specified.



Clinical features

  • Chief complaint: retrosternal burning pain (heartburn) that worsens while lying down (e.g., at night) and after eating [3]
  • Pressure sensation in the chest
  • Belching, regurgitation [4]
  • Dysphagia [4]
  • Chronic non-productive cough and nocturnal cough [11]
  • Nausea and vomiting [4]
  • Halitosis
  • Triggers:
    • Bending down, supine position
    • Habits: smoking and/or alcohol consumption
    • Psychological factors: especially stress



The histopathological findings vary depending on the severity of mucosal damage: [4]


Differential diagnoses

Other forms of esophagitis

Conditions not involving esophagitis

The differential diagnoses listed here are not exhaustive.


  • Empirical therapy: If GERD is clinically suspected and there are no indications for endoscopy, empiric therapy – ranging from lifestyle modifications to a short trial with PPIs – should be initiated. A GERD diagnosis is assumed in patients who respond to this therapeutic regimen. [7]
  • Upper endoscopy (esophagogastroduodenoscopy (EGD))
  • Esophageal pH monitoring
    • Measured over 24 hours via nasogastric tube with a pH probe [4]
    • Sudden drops to a pH ≤ 4 are consistent with episodes of acid reflux into the esophagus [4]
    • Indications
      • To confirm suspected NERD [4]
      • Before endoscopic or surgical treatment options are initiated in patients with NERD [7]
    • GERD is diagnosed when drops in esophageal pH correlate with symptoms of acid reflux and precipitating activities noted in the patient's event diary.
  • Esophageal manometry [4]
    • A pressure-sensitive nasogastric tube measures the muscle contractions in several sections of the esophagus while the patient swallows [15]
    • Indications:
      • Ensure correct placement of pH probes [16]
      • Evaluate peristaltic function prior to anti-reflux surgery [7][4]
      • Exclude motor disorders that may mimic the symptoms of GERD [4]



Lifestyle modifications

  • Dietary
    • Small portions; avoid eating (< 3 hours) before bedtime [3][7]
    • Avoid foods with high fat content [14]
  • Physical
    • Normalize body weight [7]
    • Elevate the head of the bed for patients with nighttime symptoms [7]
  • Avoid toxins: nicotine, alcohol, coffee [14][7] , and certain drugs (e.g., calcium channel blockers, diazepam) [6]

Medical therapy

  • Treatment of choice: Standard-dose of PPI for at least 8 weeks (once-daily therapy)
    • No response: further diagnostic evaluation
    • Partial response: increase the dose (to twice daily therapy) or switch to a different PPI
    • Good response: discontinue PPI after 8 weeks
  • Maintenance therapy: if symptoms recur after discontinuation of PPIs and in the case of complications (see “Complications” below)
    • After 8 weeks of initial treatment, reduce PPI to lowest effective dose or switch to H2RAs (only in patients without complications!)

Surgical therapy


Acute management checklist

  • Start a PPI (e.g., omeprazole ).
  • Consider alternative/adjunctive therapies.
  • Lifestyle changes (e.g., weight reduction, avoiding spicy foods and caffeine, upright position after eating)
  • Discontinue NSAIDs, if possible.
  • Consider test and treat for H. pylori infection (outpatient).



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

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last updated 09/21/2020
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