Gastroesophageal Reflux Disease (GERD)

By usmlevideoss

Introduction

Gastroesophageal reflux disease (GERD) is a chronic condition characterized by the retrograde flow of stomach contents into the esophagus, causing symptoms like heartburn and regurgitation. Persistent acid exposure can lead to complications, including esophagitis, Barrett’s esophagus, and esophageal adenocarcinoma.

  • Most common digestive disease.
  • Types:
    • Erosive esophagitis: Visible breaks in the distal esophageal mucosa on endoscopy.
    • Non-erosive reflux disease (NERD): Endoscopically negative reflux disease.

Etiology

  1. Lower Esophageal Sphincter (LES) Dysfunction:
    • Transient LES relaxation (most common).
    • Hypotonic LES.
  2. Increased Intra-abdominal Pressure:
    • Obesity.
    • Pregnancy.
    • Coughing or straining.
  3. Delayed Gastric Emptying:
    • Gastroparesis.
    • Pyloric obstruction.
  4. Hiatal Hernia: Weakens LES by altering its structure.
  5. Other Risk Factors:
    • Smoking, alcohol consumption.
    • Certain medications (e.g., calcium channel blockers, anticholinergics).

Epidemiology

  • Prevalence: ~20% of adults in Western countries report weekly symptoms.
  • Gender: No significant difference.
  • Age: Commonly begins in adulthood; incidence increases with age.
  • Risk Factors: Obesity, pregnancy, high-fat or caffeine diets.

Pathophysiology

  1. LES Dysfunction:
  • Transient relaxation or hypotonia allows reflux of stomach contents into the esophagus.
  1. Esophageal Mucosal Damage:
    • Acid, bile, and pepsin cause irritation and inflammation.
  2. Complications:
    • Esophagitis, strictures, Barrett’s esophagus (intestinal metaplasia), and malignancy.

Clinical Manifestations

  1. Typical Symptoms:
    • Heartburn: Retrosternal burning sensation, worsens after meals or lying down.
    • Regurgitation: Sour or bitter taste due to refluxed stomach contents.
  2. Atypical Symptoms:
    • Chronic cough, laryngitis, hoarseness.
    • Asthma exacerbations, non-cardiac chest pain.
  3. Alarm Symptoms:
    • Dysphagia, odynophagia, weight loss.
    • Hematemesis or melena (indicating complications).

Diagnosis

  1. Clinical Diagnosis:
    • Based on typical symptoms without alarm features.
  2. Diagnostic Tests:
    • Endoscopy: For alarm symptoms or refractory GERD to detect esophagitis, strictures, or Barrett’s esophagus.
    • pH Monitoring: Gold standard for confirming acid reflux.
    • Esophageal Manometry: Assesses LES pressure and motility.
    • Barium Swallow: Detects anatomic abnormalities (e.g., hiatal hernia).

Treatment

  1. Lifestyle Modifications:
    • Weight loss.
    • Avoid triggers (spicy foods, caffeine, alcohol).
    • Eat smaller meals and avoid lying down within 2–3 hours after eating.
    • Elevate the head of the bed.
    • Avoid foods that relax LES (chocolate, alcohol, coffee, peppermint).
  2. Medical Therapy:
    • Proton Pump Inhibitors (PPIs): First-line for moderate-to-severe symptoms or erosive esophagitis (e.g., omeprazole, pantoprazole).
    • H2 Receptor Antagonists (H2RAs): For mild symptoms (e.g., ranitidine, famotidine).
    • Antacids: For immediate symptom relief.
  3. Surgical Therapy:
    • Nissen Fundoplication: For refractory GERD or intolerance to PPIs.

Note: Routine screening for H. pylori infection and empiric eradication are not recommended in GERD patients.

Prognosis

  • Good prognosis with lifestyle changes and medical therapy.
  • Untreated GERD can lead to complications:
    • Barrett’s esophagus (1–5% risk of adenocarcinoma).
    • Esophageal strictures.
    • Chronic laryngitis or respiratory complications.

SUPERPoint

GERD is caused by LES dysfunction, leading to acid reflux and symptoms like heartburn and regurgitation. Diagnosis is clinical but may require endoscopy or pH monitoring in atypical or severe cases. PPIs are the mainstay of treatment, and lifestyle changes improve outcomes.

SUPERFormula

Patient reports heartburn + Regurgitation + LES dysfunction + Increased intra-abdominal pressure + Acid irritation of the esophagus + Obesity or Hiatal hernia + Responds to PPIs and lifestyle changes = Gastroesophageal Reflux Disease (GERD).