Gastroesophageal Reflux Disease (GERD)

Key Features

Essentials of Diagnosis

• Heartburn exacerbated by meals, bending, or recumbency

• Typical uncomplicated cases do not require diagnostic studies

• Endoscopy demonstrates abnormalities in one-third of patients

General Considerations

• In a 2020 survey or US adults, 31% reported GERD symptoms within the prior week

• Most patients have mild disease

• However, esophageal mucosal damage (reflux esophagitis) develops in up to one-third patients

• Serious complications develop in a few patients

• Pathogenesis includes

  • Relaxation or incompetence of lower esophageal sphincter

  • Hiatal hernia

  • Abnormal acid clearance (esophageal peristalsis), eg, systemic sclerosis (scleroderma)

  • Impaired salivation (exacerbates GERD), eg, Sjögren syndrome, anticholinergics, oral radiation therapy

  • Delayed gastric emptying (exacerbates GERD), eg, gastroparesis

Clinical Findings

Symptoms and Signs

• Heartburn, most often 30–60 minutes after meals and upon reclining, with relief from antacids

• Regurgitation—spontaneous reflux of sour or bitter gastric contents into the mouth

• Dysphagia common due to erosive esophagitis, abnormal esophageal peristalsis, or stricture

• Other symptoms include dyspepsia, dysphagia, belching, and hoarseness

• Atypical manifestations

  • Asthma

  • Chronic cough

  • Chronic laryngitis

  • Sore throat

  • Noncardiac chest pain

  • Sleep disturbances

• Gradual development of solid food dysphagia progressive over months to years suggests stricture formation

• Physical examination normal

Differential Diagnosis

• Angina pectoris

• Eosinophilic esophagitis

• Peptic ulcer disease, gastritis, functional disorders

• Infectious esophagitis: Candida, herpes simplex virus, cytomegalovirus

• Pill-induced esophagitis

• Esophageal motility disorders, eg, achalasia, esophageal spasm, systemic sclerosis

• Zollinger-Ellison syndrome (gastrinoma) may cause severe esophagitis due to acid hypersecretion

Diagnosis

Laboratory Tests

• Laboratory test results are normal

Imaging Studies

• Upper endoscopy reveals visible mucosal abnormalities (known as reflux esophagitis) in up to one-third

• Endoscopy is indicated

  • In patients who have not responded to empiric medical management

  • In patients with symptoms suggesting complicated disease (dysphagia, odynophagia, weight loss, or iron deficiency anemia)

  • In patients who have long-standing (> 5 years) symptoms to look for Barrett esophagus

  • To differentiate peptic stricture from other benign or malignant causes of dysphagia

• Barium esophagography

  • Should not be used to diagnose GERD

  • May be performed before endoscopy is used to detect stricture in patients with severe dysphagia

Diagnostic Procedures

• Clinical diagnosis has sensitivity and specificity of about 65%

• In patients with typical GERD symptoms without complications, empiric medical management is recommended without diagnostic procedures

• Esophageal pH monitoring measures the amount of esophageal acid reflux, whereas combined pH-impedance testing measures both acidic and nonacidic reflux

  • Unnecessary in most patients who have typical symptoms and satisfactory response to empirical anti-secretory therapy

  • Most accurate studies for documenting gastroesophageal reflux

  • Indications include

    • Unsatisfactory response to empiric therapy

    • Atypical or extraesophageal symptoms

    • Consideration of antireflux surgery