Gastroesophageal Reflux Disease (GERD) is a chronic condition that arises when reflux of gastric contents into the esophagus leads to troublesome symptoms and/or complications, such as esophagitis, strictures, or Barrett’s esophagus.
Etiology and Risk Factors
GERD occurs due to a failure of the anti-reflux barrier at the gastroesophageal junction. Contributing factors include:
- Lower esophageal sphincter (LES) dysfunction: Transient LES relaxation or hypotensive LES tone.
- Hiatal hernia: Weakens diaphragmatic support of LES.
- Delayed gastric emptying: Increases intragastric pressure.
- Obesity: Increases intra-abdominal pressure.
- Dietary and lifestyle triggers: Fatty meals, caffeine, alcohol, chocolate, peppermint, and smoking.
- Medications: Calcium channel blockers, nitrates, anticholinergics, progesterone, and benzodiazepines.
Pathophysiology
The esophagus is normally protected by:
- LES tone – maintains a barrier to prevent reflux.
- Diaphragmatic support – crural fibers of the diaphragm reinforce LES.
- Esophageal peristalsis – clears refluxate.
- Salivary and bicarbonate secretion – neutralizes acid.
- The angle of His – helps prevent backflow.
Failure in any of these mechanisms allows gastric acid, bile salts, and pepsin to damage the esophageal mucosa.
Clinical Features
Typical (Esophageal) Symptoms:
- Heartburn (retrosternal burning)
- Regurgitation (acidic or bitter fluid into the mouth)
- Dysphagia (from stricture or motility disorder)
Atypical (Extraesophageal) Symptoms:
- Chronic cough, hoarseness, asthma-like symptoms
- Laryngitis, sore throat, non-cardiac chest pain
- Dental erosion and otitis media (due to reflux reaching upper airways)
🔍 50% of patients with GERD-related asthma do not experience heartburn.
Complications
- Erosive esophagitis – inflammation and ulceration
- Strictures – fibrotic narrowing due to chronic inflammation
- Barrett’s esophagus – metaplasia of the distal esophageal epithelium (risk of adenocarcinoma)
- Seen in ~10% of chronic GERD cases
- Esophageal adenocarcinoma
Esophagitis Classification (LA Grade):
- Grade A: ≤5 mm mucosal breaks
- Grade B: >5 mm, non-confluent
- Grade C: Confluent, <75% of circumference
- Grade D: >75% of circumference
Diagnosis
Clinical Diagnosis:
- Often based on symptoms; empiric PPI trial may confirm.
Diagnostic Testing:
- Endoscopy: Recommended for alarm symptoms (dysphagia, weight loss, bleeding).
- 24-hour pH monitoring: Gold standard for confirming GERD (sensitivity ~96%, specificity ~95%).
- Esophageal manometry: Assesses LES function and esophageal motility.
- Barium swallow: Can identify strictures or hiatal hernias.
Management
Lifestyle Modifications:
- Weight loss
- Elevate head of bed
- Avoid meals before bedtime
- Eliminate dietary triggers
Pharmacologic Therapy:
- Antacids: Short-term relief (e.g., aluminum/magnesium hydroxide)
- H2-Receptor Antagonists: Decrease acid secretion (e.g., ranitidine, famotidine)
- Proton Pump Inhibitors (PPIs): First-line for moderate to severe GERD (e.g., omeprazole, esomeprazole)
🔔 PPIs promote mucosal healing and symptom control.
Surgical Management:
- Fundoplication: Laparoscopic wrapping of the gastric fundus around the LES.
- Considered in patients with refractory symptoms, large hiatal hernia, or medication intolerance.
Prognosis
-
Most patients respond to medical therapy.
-
Barrett’s esophagus requires regular surveillance endoscopy due to risk of malignant transformation.
Key Points:
- GERD is the most common cause of non-cardiac chest pain.
- Always consider Barrett’s esophagus in chronic GERD.
- Lifestyle modifications + PPIs are the first-line approach.
- Alarm features (e.g., weight loss, dysphagia, GI bleeding) warrant endoscopy.
- Long-standing GERD increases risk of adenocarcinoma, especially in white males.
