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

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. Male over 45 years old with longstanding GERD symptoms
    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]

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
    1. All Proton Pump Inhibitors equivalent in GERD
      1. Klok (2003) Aliment Pharmacol Ther 17:1237-45 [PubMed]
    2. Initial treatment for 6 to 12 weeks
      1. Dose 30-60 minutes prior to meal
      2. Use high dose (twice daily) for severe or refractory symptoms
    3. Taper to lower dose for 4 to 8 weeks
    4. Trial off Proton Pump Inhibitor
  3. Consider H2 Blocker maintenance therapy
    1. Consider concurrent with first week of Proton Pump Inhibitor use (until complete pump blockade)
    2. 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. Restart Proton Pump Inhibitor (e.g. Omeprazole)
  2. Consider Endoscopy (EGD)
    1. Evaluate for Barrett's Esophagus
  3. 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
  4. 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]

Images: Related links to external sites (from Bing)

Related Studies

Ontology: Gastroesophageal reflux disease (C0017168)

Definition (MSH) Retrograde flow of gastric juice (GASTRIC ACID) and/or duodenal contents (BILE ACIDS; PANCREATIC JUICE) into the distal ESOPHAGUS, commonly due to incompetence of the LOWER ESOPHAGEAL SPHINCTER.
Definition (MEDLINEPLUS)

Your esophagus is the tube that carries food from your mouth to your stomach. Gastroesophageal reflux disease (GERD) happens when a muscle at the end of your esophagus does not close properly. This allows stomach contents to leak back, or reflux, into the esophagus and irritate it.

You may feel a burning in the chest or throat called heartburn. Sometimes, you can taste stomach fluid in the back of the mouth. If you have these symptoms more than twice a week, you may have GERD. You can also have GERD without having heartburn. Your symptoms could include a dry cough, asthma symptoms, or trouble swallowing.

Anyone, including infants and children, can have GERD. If not treated, it can lead to more serious health problems. In some cases, you might need medicines or surgery. However, many people can improve their symptoms by

  • Avoiding alcohol and spicy, fatty or acidic foods that trigger heartburn
  • Eating smaller meals
  • Not eating close to bedtime
  • Losing weight if needed
  • Wearing loose-fitting clothes

NIH: National Institute of Diabetes and Digestive and Kidney Diseases

Definition (MSHCZE) Žaludeční reflux, při němž dochází k pronikání kyselého žaludečního obsahu zpět do jícnu, který je poškozován a může v něm vzniknout zánět, popř. i krvácející vřed (viz Barrettův jícen). Příznakem je pálení žáhy (pyróza). Jde o poměrně častý stav, který je podmíněn nedostatečností dolního jícnového svěrače. Výrazně jej zhoršují alkohol, kouření, černá káva, moučná kynutá jídla, poloha vleže, usilovné zvýšení nitrobřišního tlaku např. silné tlačení na stolici při zácpě. V léčbě je proto nutné upravit dietu, dále se podávají antacida, léčiva snižující tvorbu žaludeční šťávy, prokinetika. Těžké stavy je nutné řešit operačně. (cit. Velký lékařský slovník online, 2013 http://lekarske.slovniky.cz/ )
Definition (NCI_NCI-GLOSS) The backward flow of stomach acid contents into the esophagus (the tube that connects the mouth to the stomach).
Definition (NCI_CTCAE) A disorder characterized by reflux of the gastric and/or duodenal contents into the distal esophagus. It is chronic in nature and usually caused by incompetence of the lower esophageal sphincter, and may result in injury to the esophageal mucosal. Symptoms include heartburn and acid indigestion.
Definition (NCI) A chronic disorder characterized by reflux of the gastric and/or duodenal contents into the distal esophagus. It is usually caused by incompetence of the lower esophageal sphincter. Symptoms include heartburn and acid indigestion. It may cause injury to the esophageal mucosa.
Concepts Disease or Syndrome (T047)
MSH D005764
ICD9 530.81
ICD10 K21 , K21.9
SnomedCT 235595009, 102620007, 54856001, 266498005, 196624002, 155673008, 196600005, 698065002
LNC LP100601-6
English Esophageal Reflux, Gastro Esophageal Reflux, Gastro-Esophageal Reflux, Gastroesophageal Reflux, Reflux, Gastro-Esophageal, Gastroesophageal reflux, Gastroesophageal reflux disease, GOR - Gastro-oeso reflux, GORD - Gastro-oeso reflux dis, Gastro-esophageal reflux dis, Gastro-oesophageal reflux dis, Gastrooesophageal reflux disease, GASTROESOPHAGEAL REFLUX DISEASE, GASTROESOPHAGEAL REFLUX, GASTROESOPHAGEAL REFLUX, PEDIATRIC, GASTROESOPHAGEAL REFLUX DIS, Gastresophageal reflux, esophageal reflux (diagnosis), esophageal reflux, Esophageal reflux NOS, Gastroesophageal Reflux [Disease/Finding], reflux esophageal, diseases esophageal reflux, gastro esophageal reflux, gerd, reflux gastroesophageal, esophageal reflux disease, gastresophageal reflux disease, gastro-esophageal reflux disease, gastroesophageal reflux disease, Reflux;oesophageal, disease gastro-esophageal reflux, gastro oesophageal reflux, reflux disease esophageal, acid reflux, gastrooesophageal reflux, reflux acid, gastro-esophageal reflux, gastro-oesophageal reflux, gastroesophageal reflux disease (GERD), gastrooesophageal reflux disease, ge reflux, Acid Reflux, Gastric, Gastric Acid Reflux, Reflux, Gastric Acid, Gastric Acid Reflux Disease, GER, Acid Reflux, Gastresophageal reflux disease, Gastroesophageal reflux (finding), Gastrooesophageal reflux, Acid reflux (finding), Acid reflux, reflux, gastroesophageal reflux, gastric reflux, GERD, Gastro oesophageal Reflux, Gastro-oesophageal Reflux, Gastroesophageal Reflux Disease, Reflux, Gastro-oesophageal, Gastro-esophageal reflux, Esophageal reflux, Oesophageal reflux, Gastro-esophageal reflux disease, Gastro-oesophageal reflux disease, GORD - Gastro-esophageal reflux disease, GORD - Gastro-oesophageal reflux disease, GOR - Gastro-esophageal reflux, GOR - Gastro-oesophageal reflux, Gastro-oesophageal reflux, Gastroesophageal reflux disease (disorder), gastroesophageal; reflux, reflux; gastroesophageal, Gastroesophageal reflux disease [Ambiguous], Reflux, Gastroesophageal, GERD - Gastro-esophageal reflux disease, Reflux;esophageal, oesophageal reflux
Portuguese REFLUXO GASTROESOFAGICO, Doença do refluxo gastresofágico, Refluxo esofágico, Refluxo gastresofágico, Doença de refluxo gastroesofágico, Afecção de refluxo gastroesofágico, Refluxo Esofágico, Refluxo Gastroesofágico
Spanish REFLUJO GASTROESOFAGICO, Reflujo esofágico, Reflujo gastroesofágico, esofagitis por reflujo, reflujo gastroesofágico, reflujo gastroesofágico (hallazgo), ERGE, enfermedad por reflujo gastroesofágico (concepto no activo), reflujo ácido (hallazgo), reflujo ácido, RGE, enfermedad por reflujo gastroesofágico (trastorno), enfermedad por reflujo gastroesofágico, reflujo esofágico, Enfermedad por reflujo gastroesofágico, Reflujo Esofágico, Reflujo Gastroesofágico
Italian Malattia da reflusso gastroesofageo, Reflusso esofageo, GERD, Reflusso gastro-esofageo, Reflusso gastroesofageo
Dutch gastro-oesofageale reflux, oesofageale reflux, gastro-oesofagaal; reflux, reflux; gastro-oesofagaal, gastro-oesofageale refluxziekte, Aandoeningen door gastro-oesofagale reflux, Gastro-oesofageale reflux, Oesofageale reflux, Reflux, gastro-oesofageale
French Reflux gastro-oesophagien RGO, Maladie de reflux gastro-oesophagien, RGO (Reflux Gastro-Oesophagien), REFLUX GASTRO-OESOPHAGIEN, Reflux gastro-oesophagien, Reflux gastrooesophagien, Reflux oesophagien
German gastroesophagealer Reflux, Oesophagusreflux, GERD, Gastro-oesophageale Refluxkrankheit, GASTROOESOPHAGEALER REFLUX, Gastrooesophageale Refluxkrankheit, gastrooesophageale Refluxerkrankung, Gastroösophagealer Reflux, Ösophagealer Reflux, Reflux, gastroösophagealer
Japanese 胃食道逆流性疾患, ショクドウギャクリュウ, イショクドウギャクリュウセイシッカン, 食道逆流, 胃食道逆流症, 食道逆流現象, 胃・食道逆流現象, 食道逆流症, 胃食道逆流, イショクドウギャクリュウ
Swedish Gastroesofageal reflux
Czech gastroezofageální reflux, Gastroezofageální reflux, Refluxní choroba jícnu, Jícnový reflux, Choroga gastroezofágového refluxu, refluxní syndrom, refluxní ezofagitida, kardioezofageální iritace, refluxní nemoc jícnu
Finnish Gastroesofageaalinen refluksi
Korean 위-식도 역류질환
Polish Refluks żołądkowo-przełykowy, Odpływ żołądkowo-przełykowy, GERD, Choroba refluksu żołądkowo-przełykowego, Zarzucanie żołądkowo-przełykowe
Hungarian Gastrooesophagealis reflux betegség, Gastrooesophagealis reflux, Oesophagealis reflux, GORB
Norwegian GØRS, Gastroøsofageal reflukssykdom, Refluks, gastroøsofageal, Sure oppstøt

Ontology: Heartburn (C0018834)

Definition (MSHCZE) Pálení žáhy. Důsledek gastroezofageálního refluxu do jícnu a někdy až do úst. Rychlou úlevu přinesou antacida. (cit. Velký lékařský slovník online, 2012 http://lekarske.slovniky.cz/ )
Definition (MEDLINEPLUS)

Heartburn is a painful burning feeling in your chest or throat. It happens when stomach acid backs up into your esophagus, the tube that carries food from your mouth to your stomach.

If you have heartburn more than twice a week, you may have GERD. But you can have GERD without having heartburn.

Pregnancy, certain foods, alcohol, and some medications can bring on heartburn. Treating heartburn is important because over time reflux can damage the esophagus.

Over-the-counter medicines may help. If the heartburn continues, you may need prescription medicines or surgery.

If you have other symptoms such as crushing chest pain, it could be a heart attack. Get help immediately.

Definition (NCI) Abdominal discomfort with retrosternal pain usually associated with gastroesophageal reflux..(NICHD)
Definition (MSH) Substernal pain or burning sensation, usually associated with regurgitation of gastric juice into the esophagus.
Concepts Sign or Symptom (T184)
MSH D006356
ICD9 787.1
ICD10 R12
SnomedCT 207117006, 207120003, 207118001, 158425009, 139300004, 158428006, 271831008, 158426005, 16331000
English Pyroses, Pyrosis, PYROSIS, Heartburn NOS, [D]Heartburn (context-dependent category), [D]Heartburn NOS (context-dependent category), [D]Pyrosis (context-dependent category), [D]Heartburn, [D]Heartburn NOS, [D]Pyrosis, Heart burn, heartburn, heartburn (symptom), Heartburn [Disease/Finding], brash, [D]Heartburn (situation), [D]Pyrosis (situation), [D]Heartburn NOS (situation), HEARTBURN, Burning reflux, Heartburn symptom, Heartburn (finding), pyrosis, Heartburn
French PYROSIS, BRULURE EPIGASTRIQUE, Brûlures gastriques, Brûlures épigastriques, Aigreurs d'estomac, Pyrosis, Brûlures d'estomac
Spanish PIROSIS, Ardor de estómago, [D]ardor epigástrico (categoría dependiente del contexto), [D]pirosis (categoría dependiente del contexto), [D]ardor epigástrico, SAI (categoría dependiente del contexto), ARDOR EPIGASTRICO, ardor retroesternal, [D]ardor epigástrico, [D]ardor epigástrico (situación), [D]pirosis (situación), [D]pirosis, [D]ardor epigástrico, SAI, [D]ardor epigástrico, SAI (situación), acedía, acidez, ardor en el estómago, pirosis (hallazgo), pirosis, Pirosis
German SODBRENNEN, PYROSIS, Pyrosis, Sodbrennen
Portuguese PIROSE, Azia, Pirose
Dutch pyrosis, maagzuur, Zuurbranden [pyrosis], Zuurbranden, Brandend maagzuur, Pyrose, Pyrosis
Swedish Halsbränna
Japanese ムネヤケ, 胸やけ, そうそう, そう囃, 呑酸, 胸焼け, 呑酸そう囃
Czech pyróza, Pyróza, Pálení žáhy, pálení žáhy
Finnish Närästys
Korean 속쓰림
Polish Zgaga
Hungarian Gyomorégés, Pyrosis
Norwegian Halsbrann, sure oppstøt
Italian Pirosi

Ontology: Gastro-esophageal reflux disease with esophagitis (C0677659)

Concepts Disease or Syndrome (T047)
ICD10 K21.0
SnomedCT 266433003, 196600005, 155673008, 266498005
English GORD with esophagitis, GORD with oesophagitis, Gastro-esophageal reflux disease with esophagitis, Oesophag.reflux+esophagitis, Oesophag.reflux+oesophagitis, Gastroesophageal reflux disease with esophagitis, reflux esophagitis, esophagitis refluxing, reflux oesophagitis, esophageal reflux with esophagitis (diagnosis), Gastro-oesophageal reflux with oesophagitis, Gastro-esophageal reflux with esophagitis, Reflux esophagitis, Gastro-oesophageal reflux disease with oesophagitis, Reflux oesophagitis, Esophageal reflux with esophagitis, Oesophageal reflux with oesophagitis, Gastroesophageal reflux disease with esophagitis (disorder), gastroesophageal; reflux with esophagitis, reflux; gastroesophageal, with esophagitis
German Gastrooesophageale Refluxkrankheit mit Oesophagitis
Korean 식도염을 동반한 위-식도역류질환
Dutch gastro-oesofagaal; reflux met oesofagitis, reflux; gastro-oesofagaal, met oesofagitis, Gastro-oesofagale reflux met oesofagitis
Spanish enfermedad por reflujo gastroesofágico con esofagitis (trastorno), enfermedad por reflujo gastroesofágico con esofagitis, esofagitis por reflujo