Gastroesophageal reflux disease

Chronic condition where gastric contents flow back into the esophagus, resulting in troublesome symptoms (e.g., heartburn, regurgitation) and/or complications (e.g., erosive esophagitis, Barrett esophagus).

• Extremely common (affecting ~10–20% of adults in Western countries) and frequently tested. GERD's complications (like Barrett esophagus with progression to adenocarcinoma) and its management (e.g., appropriate use of PPIs, lifestyle changes, surgical options) are high-yield for boards.

• Classic presentation: burning epigastric or retrosternal pain (heartburn) after meals, often worse lying down or at night, with sour-tasting regurgitation and relief by antacids. Acid reflux can also cause chronic cough, hoarseness (laryngitis), or dental enamel erosion without obvious heartburn (extraesophageal GERD).
• Red flags in adults: dysphagia (trouble swallowing), odynophagia (painful swallowing), weight loss, or GI bleeding (alarm features suggesting complications or an alternate diagnosis).
• Infants: frequent spitting up is usually benign GER (gastroesophageal reflux) if the baby is growing well. Warning signs include poor weight gain, feeding aversion, or episodic back arching (Sandifer syndrome) after feeds, which suggest pathologic GERD. Older children and adolescents can present like adults (recurrent heartburn, regurgitation or chest discomfort).

1. Empiric trial: In adults <50 with typical symptoms and no alarms, diagnose GERD by an 8-week trial of a PPI (proton pump inhibitor); symptom resolution is considered diagnostic. Avoid unnecessary initial endoscopy in these straightforward cases.
2. Endoscopy (EGD): Indicated for alarm features (dysphagia, odynophagia, bleeding, anemia, weight loss, vomiting) or if symptoms persist despite therapy. Also recommended in chronic GERD patients with multiple Barrett esophagus risk factors (age ≥50, male, white, obesity, smoking, long-standing reflux).
3. If EGD is normal but GERD is still suspected (atypical or refractory cases), consider 24-hour pH monitoring (often combined with impedance) to confirm pathologic acid reflux. Esophageal manometry can evaluate motility if dysphagia or to prep for anti-reflux surgery, but it doesn't diagnose GERD.
4. Differentiating GERD from others: cardiac workup for chest pain when in doubt (GERD does not cause exertional pain). For refractory heartburn, think about eosinophilic esophagitis (especially in young males with atopy – look for esophageal rings on EGD) or achalasia if prominent regurgitation of undigested food.

1. Lifestyle first: eat smaller meals, avoid trigger foods (spicy, caffeine, alcohol), weight loss if overweight, avoid lying down for 2–3 hours after eating, elevate head of bed.
2. Medications: For mild/intermittent symptoms, use antacids or H2 blockers (e.g., ranitidine). For frequent or severe symptoms or erosive disease, PPIs (e.g., omeprazole) are first-line (most potent acid suppression). Ensure appropriate PPI use (once daily before meals; long-term use only if needed due to potential side effects).
3. Refractory cases or complications: consider surgical management with Nissen fundoplication (wrap the gastric fundus around the LES to prevent reflux) or newer endoscopic techniques. Surgery is often considered in young patients who respond to PPIs but require lifelong therapy, or if a large hiatal hernia is present.
4. Pediatric notes: Many infants outgrow GER by 12–18 months. If treatment is needed (e.g., poor growth or esophagitis), thicken feeds, keep infant upright after feeding, and consider a trial of acid suppression for 4–8 weeks in older infants/children. Avoid unnecessary PPI use for isolated extraesophageal symptoms (e.g., infant cough or fussiness without overt reflux).

• Think Sandifer syndrome in infants: intermittent torticollis/arching after feeding due to reflux discomfort (often mistaken for seizures).
• GERD can exacerbate asthma or chronic cough—microaspiration of acid irritates airways. Consider reflux as a trigger in asthmatics with worsening night-time cough.
• Persistent GERD leads to metaplastic changes (Barrett esophagus) in ~10% of chronic cases, increasing esophageal adenocarcinoma risk. Surveillance EGD is advised if Barrett esophagus is present.

• Any dysphagia, odynophagia, vomiting, or bleeding (melena) → evaluate with prompt endoscopy to rule out ulceration, stricture, or cancer.
• GERD with chest pain radiating to arm/jaw or occurring with exertion is not typical GERD → evaluate for cardiac ischemia.
• In infants, bilious vomiting, forceful projectile vomiting, or onset of vomiting after 6 months old are NOT typical for simple GER and warrant further workup for other causes (e.g., pyloric stenosis, malrotation).

1. Symptoms of heartburn/regurgitation → clinical diagnosis of GERD likely. If no alarm features, start lifestyle modifications and empiric PPI trial.
2. If patient improves on PPI → continue for 8 weeks, then attempt weaning to lowest effective dose or PRN. If symptoms recur after stopping, consider long-term therapy. If no improvement on PPI → proceed to diagnostic testing.
3. Perform endoscopy if alarm signs or PPI failure. If EGD shows erosive esophagitis (LA grade C/D) or Barrett esophagus, this confirms GERD; treat and follow guidelines for surveillance (Barrett esophagus).
4. If endoscopy is normal but reflux is still suspected, do 24h pH monitoring off therapy to confirm abnormal acid exposure. Concurrent impedance can detect non-acid reflux if symptoms persist despite acid control.
5. Once GERD is confirmed, manage with appropriate long-term strategy: lifestyle measures for all, medication (step-up or step-down therapy depending on severity), and surgical referral if needed for refractory disease or patient preference.

• Overweight adult with long-standing heartburn and regurgitation, using antacids frequently, gets relief when sitting up → classic GERD presentation. Best next step is trial of a PPI and lifestyle changes (weight loss, diet).
• Patient with chronic GERD now has progressive dysphagia to solids, and an endoscopy reveals a stricture in the distal esophagus → peptic esophageal stricture (from acid scarring).
• Chronic GERD patient with new onset odynophagia, weight loss, and Barrett esophagus on history → concern for esophageal adenocarcinoma (requires biopsy).