Gastroesophageal Reflux Disease

Gastroesophageal reflux disease (GERD), also known as gastro-oesophageal reflux disease (GORD) in British English, is a chronic condition where stomach contents persistently and regularly flow back into the oesophagus. This results in symptoms and complications, including dental erosion, dysphagia, heartburn, odynophagia, regurgitation, non-cardiac chest pain, chronic cough, hoarseness, reflux-induced laryngitis, and asthma.

Complications can include esophagitis, esophageal strictures, and Barrett's oesophagus. Risk factors for GERD include obesity, pregnancy, smoking, hiatal hernia, and certain medications.

Signs and Symptoms

Adults

The most common symptoms of GERD in adults are an acidic taste in the mouth, regurgitation, and heartburn. Less common symptoms include sore throat, increased salivation (water brash), nausea, chest pain, coughing, and globus sensation.

GERD can also lead to complications such as reflux esophagitis, esophageal strictures, Barrett's oesophagus, and esophageal adenocarcinoma.

Children and Babies

In children, GERD may cause repeated vomiting, effortless spitting up, coughing, respiratory problems, inconsolable crying, refusing food, failure to gain adequate weight, bad breath, and burping. Infants often outgrow reflux by their first birthday.

Mouth

Acid reflux into the mouth can cause enamel breakdown, especially on the inner surfaces of the teeth, leading to smooth, silky-glazed surfaces without perikymata. Other symptoms include dry mouth, burning sensation, bad breath, and redness of the palate.

Barrett's Oesophagus

GERD may progress to Barrett's oesophagus, where the esophageal lining changes to resemble the intestine, increasing the risk of esophageal cancer. Due to this risk, regular endoscopic surveillance is recommended for those with chronic GERD.

Causes

GERD occurs due to poor closure of the lower esophageal sphincter, allowing acid to reflux from the stomach into the oesophagus. Contributing factors include hiatal hernia, obesity, and certain medications.

Diagnosis

Diagnosis is typically made based on symptoms and may involve gastroscopy, upper GI series, esophageal pH monitoring, or esophageal manometry. The gold standard for diagnosing GERD is esophageal pH monitoring, which objectively measures acid reflux.

Treatment

Lifestyle Changes

Initial management includes lifestyle changes such as avoiding lying down after meals, elevating the head of the bed, losing weight, and stopping smoking. Dietary modifications include avoiding foods that trigger symptoms like chocolate, alcohol, caffeine, and spicy foods.

Medications

Medications for GERD include antacids, H2 receptor blockers, proton pump inhibitors (PPIs), and prokinetics. PPIs, such as omeprazole, are the most effective, followed by H2 receptor blockers like ranitidine.

Antacids can provide immediate relief but are less effective for long-term management.

Surgery

Surgery may be considered for severe cases unresponsive to medical treatment. The Nissen fundoplication procedure wraps the upper part of the stomach around the lower esophageal sphincter to strengthen it and prevent reflux.

The LINX device, a ring of magnetic beads, is another option approved by the FDA for severe GERD cases.

Special Populations

Pregnancy

GERD is common during pregnancy and is usually managed with dietary and lifestyle modifications. Calcium-based antacids are recommended if these measures are ineffective.

Babies

Management in infants includes smaller, more frequent feedings, holding the baby upright after feeding, and using milk protein-free formula if necessary. Medications like ranitidine may be used, though PPIs are not recommended due to a lack of evidence for safety and efficacy in this population.

Epidemiology

GERD affects about 10-20% of Western populations, with higher prevalence in older adults. In the United States, 20% of people experience symptoms weekly, and 7% daily.

The condition is equally prevalent in men and women.

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Self-assessment MCQs (single best answer)

Which of the following is a common risk factor for GERD?

What is the gold standard for diagnosing GERD?

Which lifestyle modification is recommended for managing GERD symptoms?

Which medication class is most effective in treating GERD?

What is Barrett's oesophagus?

Which symptom is NOT typically associated with GERD?

Which surgical procedure is commonly used to treat severe GERD?

Which of the following foods should be avoided to help manage GERD symptoms?

Which symptom of GERD is more likely to be observed in infants rather than adults?