Gastroesophageal Reflux

Aka: Gastroesophageal Reflux, Esophageal Reflux, Reflux Esophagitis, Heartburn, Acid Reflux, Acid Regurgitation, Water Brash, Pyrosis, GERD, Causes of Decreased Lower Esophageal Sphincter Pressure

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II. Epidemiology

  1. Incidence: 36% in U.S.
  2. Most take OTC Medications and do not seek medical help
  3. GERD patients wait 1-3 years before seeing a doctor

III. Risk Factors: Reduced Lower Esophageal Sphincter (LES) pressure

  1. Smooth Muscle relaxants
    1. Aminophylline
    2. Anticholinergics
    3. Benzodiazepines
    4. Calcium Channel Blockers
    5. Nitrates
    6. Calcium Channel Blockers
    7. Caffeine
    8. Inhaled Albuterol
    9. Opioids
    10. Tricyclic Antidepressants
    11. Crowell (2001) Chest 120:1184-9 [PubMed]
  2. Tobacco Abuse
  3. Pregnancy
    1. Progesterone-mediated relaxation of the lower esophageal sphincter
  4. Scleroderma
  5. Diabetes Mellitus (esp. longer standing disease)
    1. Esophageal Dysmotility, decreased lower esophageal sphincter tone, prolonged transit time

IV. Complications

  1. Barrett's Esophagus (10-20% Incidence)
  2. Asthma
  3. Persistent Chest Pain
  4. Chronic Cough
  5. Dental Erosions (dental enamel loss)
  6. Hoarseness
  7. Laryngeal Cancer
  8. Persistent Pharyngitis
  9. Vocal Cord Polyps
  10. Subglottic Stenosis
  11. Interstitial fibrosis

V. Symptoms: Classic

  1. Heartburn (Initial GERD symptom)
    1. Location: Epigastric and retrosternal Chest Pain
    2. Characteristic: Caustic or stinging
    3. No radiation to the back
  2. Acid Regurgitation (Water Brash or Pyrosis)
    1. Suggests progressing GERD
    2. Provoked by lying supine or leaning forward
    3. Regurgitation of digested food or clear burning fluid
    4. Undigested food suggests alternative diagnosis
      1. Achalasia
      2. Esophageal Diverticulum
  3. Difficult Swallowing (Dysphagia)
    1. See Dysphagia from Esophageal Cause
    2. Mechanical obstruction of solid foods
      1. Suggests peptic stricture
    3. Liquid obstruction suggests alternative diagnosis
      1. Neuromuscular disorder
      2. Neoplasm
      3. Esophageal Diverticulum

VI. Symptoms: Atypical

  1. Abdominal Pain (29%)
  2. Chronic Cough (27%)
    1. GERD is responsible for a non-smoker with 3 weeks of Chronic Cough in 40% of cases
    2. Consider empiric Proton Pump Inhibitor
    3. Palombini (1999) Chest 116(2): 279-84 [PubMed]
  3. Hoarseness (21%)
  4. Belching (15%)
  5. Bloating (15%)
  6. Aspiration (14%)
  7. Wheezing (7%)
  8. Globus Hystericus (4%)
  9. Recurrent Pharyngitis
  10. Halitosis

VII. Signs: Orofacial effects of chronic Acid Reflux

  1. Dental Erosions (yellow discoloration)
  2. Masticatory Mucosa inflammation
  3. Chronic Sinusitis

VIII. Red Flags: Symptoms Indicating Evaluation (e.g. Endoscopy)

  1. Dysphagia
    1. Immediately assess for Barrett's Esophagus
  2. Odynophagia
    1. Assess for Esophageal Ulcer
  3. Weight Loss (Suggests Dysphagia or Odynophagia)
  4. Early satiety or Vomiting
  5. Aspiration
  6. Wheezing or cough
  7. Gastrointestinal Bleeding
  8. Unexplained Iron Deficiency Anemia
    1. Suggests esophageal ulcer
  9. High risk patients
    1. Males age >=50 years old with longstanding GERD symptoms (>=5 years)
    2. History of severe Erosive Gastritis
    3. Tobacco Abuse with weekly GERD symptoms in the last year (OR 51.4)
    4. Obesity (BMI >30 kg/m^2) with weekly GERD symptoms in the last year (OR 34.4)
    5. Elderly with reflux (use high level of suspicion)
      1. Even serious pathology may present as mild GERD
      2. Johnson (2004) Gastroenterology 126:660-4 [PubMed]

IX. Differential Diagnosis

  1. Myocardial Ischemia (Angina)
  2. Peptic Ulcer Disease
  3. Dyspepsia
  4. Cholelithiasis
  5. Esophageal Achalasia
  6. Esophageal Spasm

X. Pathophysiology

  1. Transient relaxation of lower esophageal sphincter

XI. Diagnosis: Typical cases

  1. See GerdQ Questionnaire
  2. Symptoms and signs are sufficient for diagnosis for uncomplicated cases
  3. Empiric management is the recommended strategy for uncomplicated cases

XII. Diagnosis: Complicated or refractory cases

  1. Upper endoscopy
    1. Indicated for red flag symptoms (see above)
    2. Test Sensitivity and Specificity are low for GERD diagnosis
    3. Standard for evaluating GERD complications (e.g. Barrett Esophagus)
  2. pH probe (24 hour pH monitoring)
    1. Indicated prior to Anti-Reflux Surgery (Nissen Fundoplication)
    2. Test Sensitivity: 70 to 96%
    3. Test Specificity: 70 to 96%

XIII. Management: General Measures

  1. Drink 8 glasses (8 ounces) non-caffeinated fluid daily
  2. Decrease provocative foods
    1. Decrease or eliminate Caffeine
    2. Decrease or eliminate Alcohol
    3. Avoid spicy foods
    4. Avoid milk products toward end of day
    5. Avoid Chocolate
    6. Avoid fatty foods
  3. Tobacco Cessation
  4. No eating food 2-3 hours before bedtime
  5. Elevate head of bed to 30 degrees
    1. Place 6-8 inch blocks under legs at head of bed
    2. Place Styrofoam wedge under mattress
  6. Symptomatic therapy for mild intermittent symptoms
    1. OTC Antacid medications (e.g. Maalox, Tums, Rolaids)
      1. More effective than Placebo for GERD symptoms
      2. Chatfield (1999) Curr Med Res Opin 15:152-9 [PubMed]
    2. Antacid chewing gum (Surpass by Wrigley)

XIV. Management: Medications

  1. Institute general measures above
  2. Proton Pump Inhibitor (PPI)
    1. Onset to full activity requires 7 days (consider concurrent H2 Blocker for first week)
    2. All Proton Pump Inhibitors equivalent in GERD
      1. Klok (2003) Aliment Pharmacol Ther 17:1237-45 [PubMed]
    3. Initial treatment for 6 to 12 weeks
      1. Dose 30-60 minutes prior to meal
      2. Use high dose (twice daily or double dose daily) for severe or refractory symptoms
    4. Taper to lower dose for 4 to 8 weeks
    5. Trial off Proton Pump Inhibitor after 8-12 weeks
      1. Limit to 8 weeks in treatment naive patients with classic GERD and no alarm symptoms
      2. Exception: Continue PPI (lowest effective dose) longterm if Barrett's Esophagus or severe erosive Esophagitis
      3. Longterm Proton Pump Inhibitors are associated with adverse effects (Clostridium difficile, Osteoporosis)
      4. Use H2 Blocker for acid rebound symptoms on tapering and stopping PPI
  3. Consider H2 Blocker maintenance therapy
    1. Consider concurrent with first week of Proton Pump Inhibitor use (until complete pump blockade)
    2. Use prn for breakthrough symptoms (esp. after tapering or discontinuing PPI)
    3. H2 Blockers are inferior to PPI for control of GERD symptoms
      1. Starting with Proton Pump Inhibitor (instead of stepping up from H2 Blocker) is more cost effective
      2. Sigterman (2013) Cochrane Database Syst Rev 5:CD002095 [PubMed]
      3. Habu (2005) J Gastroenterol 40(11): 1029-35 [PubMed]
  4. Medications not found to be beneficial
    1. Sucralfate (Carafate) offers minimal benefit in GERD

XV. Management: Refractory (persists despite Proton Pump Inhibitor or recurs when stopped)

  1. See Red Flags as above
  2. Restart Proton Pump Inhibitor (e.g. Omeprazole)
  3. Consider Endoscopy (EGD)
    1. Evaluate for Barrett's Esophagus
  4. Consider evaluation for Anti-Reflux Surgery (Nissen Fundoplication)
    1. Upper Endoscopy (evaluate for Barrett's Esophagus)
    2. Upper Gastrointestinal Series (defines anatomy)
    3. Manometry
    4. 24-Hour pH Monitoring
  5. Consider other Esophageal Dysmotility
    1. Esophageal Achalasia
    2. Esophageal Spasm

XVI. Management: Follow-up

  1. Normal upper endoscopy (EGD)
    1. No repeat EGD for 10 years unless symptoms progress
    2. Schnell (2001) Gastroenterology 120:1607-19 [PubMed]

XVII. References

  1. (2022) Presc Lett 29(2): 9-10
  2. Feldman (1998) Sleisenger GI, Saunders, p. 509-17
  3. Townsend (2001) Sabiston Surgery, Saunders, p. 755-66
  4. Anderson (2015) Am Fam Physician 91(10): 692-7 [PubMed]
  5. Devault (1999) Am J Gastroenterol 94:1434-42 [PubMed]
  6. Heidelbaugh (2003) Am Fam Physician 68:1311-22 [PubMed]
  7. Heidelbaugh (2008) Am Fam Physician 78(4): 483-8 [PubMed]
  8. Horgan (1997) Surg Clin North Am 77(5):1063-82 [PubMed]
  9. Peters (1998) Ann Surg 228(1):40-50 [PubMed]

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