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Updated: Dec 11 2021

Gastroesophageal Reflux Disease (GERD)

  • Snapshot
    • A 45-year-old man with hypertension and obesity presents with complaints of heartburn and regurgitation with a sour taste that is aggravated by drinking coffee and eating spicy foods. He also endorses intermittent night time coughing when he eats a late dinner with occasional sore throat and hoarseness. He has tried an antacid with slight improvement but his symptoms are still bothersome.
  • Introduction
    • Clinical definition
      • reflux of gastric contents into the esophagus
    • Associated conditions
      • hiatal hernia
      • gastric outlet obstruction
      • scleroderma
  • Epidemiology
    • Demographics
      • common
      • increases with age
    • Risk factors
      • alcohol
      • smoking
      • coffee
      • pregnancy
      • obesity
    • Pathogenesis
      • ↓ lower esophageal sphincter (LES) tone allowing gastric contents to reflux into the esophagus
      • ↓ esophageal motility leading to ↓ clearance of retrograde gastric contents
      • ↓ gastric emptying
  • Presentation
    • Symptoms
      • classic
        • postprandial retrosternal pain, may radiate to neck or chest
        • regurgitation or sour taste
      • other
        • hypersalivation
        • dysphagia or globus sensation
        • odynophagia
        • cough
        • hoarseness
        • early satiety
        • weight loss
    • Physical exam
      • dental enamel erosion
      • wheezing
      • benign abdominal exam
  • imaging
    • Esophagogastroduodenoscopy (EGD) with biopsy
      • visualize erosive disease, complications, and other anatomical abnormalities
      • first test of choice for atypical presentations
  • Studies
    • Diagnostic testing
      • diagnostic approach
        • classic presentation does not require work up below
        • may require ruling out cardiac etiology
      • studies
        • manometry
          • evaluate LES and motility
          • indicated if empirical therapy fails or atypical work up
        • 24-hour intraesophageal pH monitoring
          • gold standard diagnostic test but not always indicated
          • indicated for atypical history or inconclusive EGD
  • Differential
    • Angina pectoralis
      • distinguishing factor
        • not associated with eating
    • Chemical esophagitis
      • distinguishing factor
        • no reflux
    • Peptic ulcer disease
      • distinguishing factor
        • localized epigastric or central abdominal pain that does not radiate
  • Treatment
    • Management approach
      • empiric treatment with lifestyle modification and acid suppression therapy for classic presentation
      • step-up therapy for mild or intermittent symptoms
        • histamine H2 receptor antagonist → proton pump inhibitor
      • step-down therapy for severe or erosive symptoms for faster relief
        • proton pump inhibitor → histamine H2 receptor antagonist
    • All patients
      • lifestyle modification
        • avoid triggering foods (fatty, caffeine, acidic, and alcohol)
        • stop smoking
        • sleep in an elevated position
      • antacids
    • Mild to intermittent symptoms
      • histamine H2 receptor antagonist
        • cimetidine, famotidine, or ranitidine
    • Moderate to severe symptoms
      • proton pump inhibitor
        • omeprazole or lansoprazole
        • side effects include pneumonia, Clostridium difficile, hypergastrinemia, fractures, and hypomagnesemia
    • Surgical
      • fundoplication
        • for failed medical management or complications
  • Complications
    • Barrett esophagus
    • Esophageal cancer
    • Esophageal ulcer with bleeding or perforation
    • Peptic stricture
    • Pulmonary aspiration
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