Gastroesophageal reflux disease

Last updated: July 28, 2022

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Gastroesophageal reflux disease (GERD) is a chronic condition in which stomach contents flow back into the esophagus, causing irritation to the mucosa. Reflux is primarily caused by an inappropriate, transient relaxation of the lower esophageal sphincter (LES). Risk factors include obesity, stress, certain eating habits (e.g., heavy meals or lying down shortly after eating), and changes in the anatomy of the esophagogastric junction (e.g., hiatal hernia). Typical symptoms are retrosternal burning pain (heartburn) and regurgitation, but the presentation is variable and may also include symptoms like chest pain and dysphagia. Most patients with suspected GERD should receive empirical treatment with proton pump inhibitors (PPIs). Diagnostic studies, e.g., esophagogastroduodenoscopy (EGD) and/or 24-hour pH test, may be indicated to confirm the diagnosis or to rule out other causes of symptoms. Management involves lifestyle modifications, medication, and, in some cases, surgery. Treating esophagitis is especially important because chronic mucosal damage can cause Barrett esophagus, a premalignant condition that can progress to adenocarcinoma.

  • Gastroesophageal reflux: regurgitation of stomach contents into the esophagus (can also occur in healthy individuals, e.g., after consuming greasy foods or wine)
  • Gastroesophageal reflux disease (GERD)
    • A condition in which reflux causes troublesome symptoms (typically including heartburn or regurgitation) and/or esophageal injury/complications
    • The most common endoscopic finding associated with esophageal mucosal injury is reflux esophagitis. [1]
      • NERD (non-erosive reflux disease): characteristic symptoms of gastroesophageal reflux disease in the absence of esophageal injury, such as reflux esophagitis, on endoscopy (50–70% of GERD patients) [2]
      • ERD (erosive reflux disease): gastroesophageal reflux with evidence of esophageal injury, such as reflux esophagitis, on endoscopy (30–50% of GERD patients) [2]

Epidemiological data refers to the US, unless otherwise specified.

GERD develops when reflux-promoting factors, such as corrosiveness of the gastric juice, overcome protective mechanisms, such as the gastroesophageal junction and esophageal acid clearance.

Mechanisms

  • Gastroesophageal junction dysfunction can occur because of the following factors:
    • Increased frequency of transient lower esophageal sphincter relaxations (TLESRs) [4]
      • TLESRs allow venting of accumulated gases to prevent distention of the stomach.
      • In individuals with GERD [5]
        • About two-thirds of TLESRs are also accompanied by reflux of gastric content.
        • The frequency of TLESRs increases.
    • Imbalance between intragastric and lower esophageal sphincter (LES) pressures [5]
      • Reflux occurs when the intragastric pressure is higher than that created by the LES.
      • LES tone can be decreased by substances such as caffeine and nitroglycerin, as well as by conditions that cause denervation of the muscle layer, such as scleroderma (see “Risk factors/associations” below).
      • Intragastric pressure is increased in pregnancy, delayed gastric emptying, and obesity, among other conditions.
    • Anatomic abnormalities of gastroesophageal junction (e.g., hiatal hernia, tumors)
  • Impaired esophageal acid clearance [6]

Risk factors for GERD

The histopathological findings include the following (may vary depending on the severity of mucosal damage): [11]

Typical symptoms

Atypical symptoms

Extraesophageal symptoms [15]

Aggravating factors

  • Lying down shortly after meals
  • Certain foods/beverages

Red flags in GERD [15]

Consider investigating epigastric pain or burning lasting > 1 month (see “Approach to dyspepsia”). [15][16]

Rule out acute coronary syndrome in patients with atherosclerotic risk factors before making a clinical diagnosis of GERD.

The differential diagnoses listed here are not exhaustive.

There is no gold standard test for the diagnosis of GERD. The diagnosis is based on clinical presentation, endoscopic evaluation, reflux assessment, and therapeutic response. [15]

Approach [13][15]

Resolution of chest pain with antacids is not diagnostic for GERD and does not rule out life-threatening causes of chest pain. [18]

GERD is common during pregnancy and usually subsides after delivery; diagnostic workup is rarely necessary.

EGD [15][19][20][21]

> 50% of patients with GERD present with nonerosive reflux and normal endoscopic findings. [24]

Despite the limited value of esophageal biopsies in diagnosing GERD, they are necessary for establishing a diagnosis of eosinophilic esophagitis. [15]

Esophageal pH monitoring [15][22]

Esophageal pH monitoring can be used to objectively identify abnormal reflux of gastric content into the esophagus; however, it is not a routine diagnostic test. [15]

  • Indications
    • Refractory GERD symptoms despite PPI therapy
    • Confirmation of suspected NERD
    • Evaluation before surgical or endoscopic antireflux procedure
  • Procedure
    • Measurement of esophageal pH over 24–48 hours using a telemetry capsule or a transnasal catheter
    • Documentation of relevant events by the patient
  • Supportive finding: Drops in esophageal pH to 4 or less that correlate with symptoms of acid reflux and precipitating activities. [25]

Further diagnostic studies [15][22]

Not routinely indicated, as they play a limited role in the diagnosis of GERD; useful if endoscopy is inconclusive.

The initial management of GERD consists of implementing lifestyle changes and initiating acid suppression therapy, preferably with PPIs. Surgical therapy is not routinely indicated and should only be considered in select cases, e.g., patients who develop complications despite receiving optimal medical therapy.

Pharmacological therapy [15][20]

See “Antacids and acid suppression medications” for agents, detailed dosages, and pharmacological considerations.

  • PPIs: : standard dose of PPI for 8 weeks
    • Indications
      • Empiric PPI trial in patients with typical symptoms
      • After EGD: ERD or presumed NERD
    • Continuous management (based on the clinical response after 8 weeks) [27]
      • Good response and no complications: Discontinue PPI.
      • Good response in patients with complications : Continue PPI at maintenance dose. [15]
      • Partial response: Increase dose (to twice-daily therapy), adjust timing, or switch to a different PPI.
      • Recurrence of symptoms after discontinuation of PPI or during weaning: Consider confirming the diagnosis (e.g., with ambulatory esophageal pH monitoring) prior to continuing maintenance therapy.
      • No response: further diagnostic evaluation
    • There is controversy surrounding the risks of long-term PPI therapy [28][29][30][31]
  • H2 receptor antagonists: Consider as alternate maintenance therapy for NERD, or in addition to PPIs to control nighttime symptoms
  • Maintenance therapy: lowest effective dose of acid suppression medication
  • Adjunctive therapy: Consider adding in patients with partial response to PPIs; Not recommended without confirmatory diagnostic studies

A negative response to a PPI trial does not exclude GERD.

Lifestyle changes [15][20][32][33][34]

There is conflicting evidence as to which lifestyle modifications confer a significant benefit. The following recommendations are commonly mentioned in the literature but should be approached on a case-by-case basis, as they may offer relief only for some patients.

  • Dietary recommendations
    • Small portions
    • Avoid eating at least 2–3 hours before bedtime.
    • Avoid foods and beverages that appear to trigger symptoms. [35]
  • Physical recommendations
    • Weight loss in patients with obesity
    • Elevate the head of the bed (10–20 cm) for patients with nighttime symptoms.
  • Reduce or avoid triggering substances

Surgical therapy [9][15][20][36]

Antireflux surgery may be considered for select patients after careful evaluation. Predictors of successful outcomes include: [37][38]

Indications

  • Discontinuation of medical therapy (e.g., due to nonadherence or side effects)
  • Symptoms refractory to medical therapy
  • Complications despite optimal medical therapy, e.g., severe esophagitis, strictures, recurrent aspiration
  • Large hiatal hernia

Fundoplication

Barrett esophagus [20][39][40]

Endoscopic examination of the esophagus is indicated to screen for Barrett esophagus in men with chronic (> 5 years) and/or frequent (occurring at least weekly) GERD symptoms and ≥ 2 of the following risk factors: age > 50 years, white ethnicity, obesity, current or past history of smoking, family history of Barrett esophagus or esophageal adenocarcinoma.

Additional complications

We list the most important complications. The selection is not exhaustive.

Gastroesophageal reflux disease in infants

  • Etiology: persistent lower esophageal sphincter insufficiency
  • Clinical features
    • Poor appetite, refusal to feed, weight loss
    • Failure to thrive
    • Crying and irritability
    • Abdominal distention, pain/discomfort
    • Regurgitation, persistent vomiting
    • Extraesophageal symptoms: wheezing, stridor, hoarseness, chronic cough
  • Diagnostics: based on clinical findings
  • Differential diagnoses: See GER in infants.
  • Treatment [43]
    • Conservative measures: lifestyle and dietary changes should be re-evaluated every 2–4 weeks
      • Positioning therapy: maintain the infant in an upright position for 20–30 minutes after feeding
      • If there is suspicion of cow's milk and/or soy protein intolerance:
        • Remove cow's milk or soy protein from the infant's diet
        • In breastfed infants, remove soy protein, cow's milk proteins, and beef from the mother's diet.
        • In formula-fed infants, substitute for a hypoallergenic formula
      • Using food thickeners
      • Avoid exposure to tobacco smoke [44]
    • Pharmacological treatment
    • Surgical treatment (complete or partial Nissen fundoplication): indicated in infants with complications from severe GERD who did not respond to conservative and pharmacological treatment

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  1. Vakil N, Van Zanten SV, Kahrilas PJ et al. The Montreal definition and classification of Gastro-esophageal Reflux Disease (GERD) – a global evidence-based consensus. Zeitschrift für Gastroenterologie. 2007; 45 (11): p.1125-1140.
  2. Hershcovici T, Fass R. Nonerosive Reflux Disease (NERD) - An Update. J Neurogastroenterol Motil. 2010; 16 (1): p.8-21. doi: 10.5056/jnm.2010.16.1.8 . | Open in Read by QxMD
  3. Yamasaki T, Hemond C, Eisa M, Ganocy S, Fass R. The Changing Epidemiology of Gastroesophageal Reflux Disease: Are Patients Getting Younger?. Journal of neurogastroenterology and motility. 2018; 24 (4): p.559-569. doi: 10.5056/jnm18140 . | Open in Read by QxMD
  4. Schneider JH, Küper MA, Königsrainer A, Brücher BLDM. Transient Lower Esophageal Sphincter Relaxation and Esophageal Motor Response. J Surg Res. 2010; 159 (2): p.714-719. doi: 10.1016/j.jss.2009.02.021 . | Open in Read by QxMD
  5. Diamant N.. Pathophysiology of gastroesophageal reflux disease. GI Motility online. 2006 . doi: 10.1038/gimo21 . | Open in Read by QxMD
  6. De giorgi F, Palmiero M, Esposito I et al. Pathophysiology of gastro-oesophageal reflux disease. Acta Otorhinolaryngol Ital. 2006; 26 (5): p.241-246.
  7. Börger HW, Schafmayer A, Arnold R et al. [The influence of coffee and caffeine on gastrin and acid secretion in man (author's transl)]. Dtsch Med Wochenschr. 1976; 101 (12): p.455-457.
  8. Chen S, Wang J, Li Y. Is alcohol consumption associated with gastroesophageal reflux disease?. Journal of Zhejiang University SCIENCE B. 2010; 11 (6): p.423-428. doi: 10.1631/jzus.b1000013 . | Open in Read by QxMD
  9. Katz PO, Gerson LB, Vela MF. Guidelines for the diagnosis and management of gastroesophageal reflux disease. Am J Gastroenterol. 2013; 108 (3): p.308-328. doi: 10.1038/ajg.2012.444 . | Open in Read by QxMD
  10. Puri P. Newborn Surgery. Hodder & Stoughton Ltd ; 2011
  11. Walls R, Hockberger R, Gausche-Hill M. Rosen's Emergency Medicine. Elsevier Health Sciences ; 2018
  12. Altman KW, Prufer N, Vaezi MF. A review of clinical practice guidelines for reflux disease: Toward creating a clinical protocol for the otolaryngologist. Laryngoscope. 2011; 121 (4): p.717-723. doi: 10.1002/lary.21429 . | Open in Read by QxMD
  13. Katz PO, Dunbar KB, Schnoll-Sussman FH, Greer KB, Yadlapati R, Spechler SJ. ACG Clinical Guideline for the Diagnosis and Management of Gastroesophageal Reflux Disease. Am J Gastroenterol. 2021; 117 (1): p.27-56. doi: 10.14309/ajg.0000000000001538 . | Open in Read by QxMD
  14. Moayyedi PM, Lacy BE, Andrews CN, Enns RA, Howden CW, Vakil N. ACG and CAG Clinical Guideline: Management of Dyspepsia. Am J Gastroenterol. 2017; 112 (7): p.988-1013. doi: 10.1038/ajg.2017.154 . | Open in Read by QxMD
  15. Tintinalli JE, Stapczynski JS, Ma OJ, Yealy D, Meckler GD, Cline DM. Tintinalli's Emergency Medicine: A Comprehensive Study Guide, 9th edition. McGraw Hill Professional ; 2019
  16. DeVault KR, Castell DO. Updated Guidelines for the Diagnosis and Treatment of Gastroesophageal Reflux Disease. Am J Gastroenterol. 2005; 100 : p.190-200. doi: 10.1111/j.1572-0241.2005.41217.x . | Open in Read by QxMD
  17. Management of Gastroesophageal Reflux Disease. https://www.aafp.org/afp/2003/1001/p1311.pdf. Updated: January 1, 2003. Accessed: January 17, 2020.
  18. Muthusamy VR, Lightdale JR, Acosta RD, et al. The role of endoscopy in the management of GERD. Gastrointest Endosc. 2015; 81 (6): p.1305-1310. doi: 10.1016/j.gie.2015.02.021 . | Open in Read by QxMD
  19. Fisichella PM, Schlottmann F, Patti MG. Evaluation of gastroesophageal reflux disease. Updates in Surgery. 2018; 70 (3): p.309-313. doi: 10.1007/s13304-018-0563-z . | Open in Read by QxMD
  20. Kahrilas PJ, Kim HC, Pandolfino JE. Approaches to the diagnosis and grading of hiatal hernia. Best Practice & Research Clinical Gastroenterology. 2008; 22 (4): p.601-616. doi: 10.1016/j.bpg.2007.12.007 . | Open in Read by QxMD
  21. Vakil N, van Zanten SV, Kahrilas P, Dent J, Jones R. The Montreal Definition and Classification of Gastroesophageal Reflux Disease: A Global Evidence-Based Consensus. Am J Gastroenterol. 2006; 101 (8): p.1900-1920. doi: 10.1111/j.1572-0241.2006.00630.x . | Open in Read by QxMD
  22. Tutuian, Castell. Gastroesophageal reflux monitoring: pH and impedance. GI motility online. 2006 . doi: 10.1038/gimo31 . | Open in Read by QxMD
  23. Klingler PJ, Hinder RA, Wetscher GJ, et al. Accurate placement of the esophageal pH electrode for 24-hour pH monitoring using a combined pH/manometry probe. Am J Gastroenterol. 2000; 95 (4): p.906-909. doi: 10.1111/j.1572-0241.2000.01927.x . | Open in Read by QxMD
  24. Tripathi M, Streutker CJ, Marginean EC. Relevance of histology in the diagnosis of reflux esophagitis. Ann N Y Acad Sci. 2018; 1434 (1): p.94-101. doi: 10.1111/nyas.13742 . | Open in Read by QxMD
  25. Peters Y, Al-Kaabi A, Shaheen NJ, et al. Barrett oesophagus.. Nature reviews. Disease primers. 2019; 5 (1): p.35. doi: 10.1038/s41572-019-0086-z . | Open in Read by QxMD
  26. Castell DO. Medication-induced esophagitis. In: Post TW, ed. UpToDate. Waltham, MA: UpToDate. http://www.uptodate.com/contents/medication-induced-esophagitis.Last updated: November 8, 2016. Accessed: January 9, 2017.
  27. Freedberg DE, Kim LS, Yang Y-X. The Risks and Benefits of Long-term Use of Proton Pump Inhibitors: Expert Review and Best Practice Advice From the American Gastroenterological Association. Gastroenterology. 2017; 152 (4): p.706-715. doi: 10.1053/j.gastro.2017.01.031 . | Open in Read by QxMD
  28. Moayyedi P, Eikelboom JW, Bosch J, et al. Safety of Proton Pump Inhibitors Based on a Large, Multi-Year, Randomized Trial of Patients Receiving Rivaroxaban or Aspirin. Gastroenterology. 2019; 157 (3): p.682-691.e2. doi: 10.1053/j.gastro.2019.05.056 . | Open in Read by QxMD
  29. Ma C, Shaheen AA, Congly SE, Andrews CN, Moayyedi P, Forbes N. Interpreting Reported Risks Associated With Use of Proton Pump Inhibitors: Residual Confounding in a 10-Year Analysis of National Ambulatory Data. Gastroenterology. 2020; 158 (3): p.780-782.e3. doi: 10.1053/j.gastro.2019.10.023 . | Open in Read by QxMD
  30. Corley DA. Safety and Complications of Long-Term Proton Pump Inhibitor Therapy: Getting Closer to the Truth. Gastroenterology. 2019; 157 (3): p.604-607. doi: 10.1053/j.gastro.2019.07.039 . | Open in Read by QxMD
  31. Savarino V, Marabotto E, Furnari M, Zingone F, Zentilin P, Savarino E. Latest insights into the hot question of proton pump inhibitor safety – a narrative review. Digestive and Liver Disease. 2020; 52 (8): p.842-852. doi: 10.1016/j.dld.2020.04.020 . | Open in Read by QxMD
  32. Joelle Ayoub, Nicole D. White. GERD Management. American Journal of Lifestyle Medicine. 2017; 11 (1): p.24-28. doi: 10.1177/1559827616671505 . | Open in Read by QxMD
  33. Kaltenbach T, Crockett S, Gerson LB. Are Lifestyle Measures Effective in Patients With Gastroesophageal Reflux Disease?. Arch Intern Med. 2006; 166 (9): p.965. doi: 10.1001/archinte.166.9.965 . | Open in Read by QxMD
  34. Commisso A, Lim F. Lifestyle Modifications in Adults and Older Adults With Chronic Gastroesophageal Reflux Disease (GERD). Crit Care Nurs Q. 2019; 42 (1): p.64-74. doi: 10.1097/cnq.0000000000000239 . | Open in Read by QxMD
  35. Becker DJ, Sinclair J, Castell DO, Wu WC. A comparison of high and low fat meals on postprandial esophageal acid exposure. Am J Gastroenterol. 1989; 84 (7): p.782-786.
  36. Richter JE. Gastroesophageal Reflux Disease Treatment: Side Effects and Complications of Fundoplication. Clin Gastroenterol Hepatol. 2013; 11 (5): p.465-471. doi: 10.1016/j.cgh.2012.12.006 . | Open in Read by QxMD
  37. John Cameron, Andrew Cameron. Current Surgical Therapy 13th Edition. Elsevier ; 2019
  38. Guidelines for Surgical Treatment of Gastroesophageal Reflux Disease (GERD). https://www.sages.org/publications/guidelines/guidelines-for-surgical-treatment-of-gastroesophageal-reflux-disease-gerd/. Updated: February 1, 2010. Accessed: January 9, 2017.
  39. Siewert R, Lepsien G, Weiser HF, Schattenmann G, Peiper HJ. [The telescope phenomenon. A complication possibility following fundoplication].. Chirurg. 1977; 48 (10): p.640-5.
  40. Shaheen NJ, Falk GW, Iyer PG, Gerson LB. ACG Clinical Guideline: Diagnosis and Management of Barrett’s Esophagus. Am J Gastroenterol. 2015; 111 (1): p.30-50. doi: 10.1038/ajg.2015.322 . | Open in Read by QxMD
  41. Runge TM, Abrams JA, Shaheen NJ. Epidemiology of Barrett’s Esophagus and Esophageal Adenocarcinoma. Gastroenterol Clin North Am. 2015; 44 (2): p.203-231. doi: 10.1016/j.gtc.2015.02.001 . | Open in Read by QxMD
  42. Naini BV, Souza RF, Odze RD. Barrett’s Esophagus. Am J Surg Pathol. 2016; 40 (5): p.e45-e66. doi: 10.1097/pas.0000000000000598 . | Open in Read by QxMD
  43. Richter JE. Peptic strictures of the esophagus. Gastroenterol Clin North Am. 1999; 28 (4): p.875-891. doi: 10.1016/s0889-8553(05)70095-9 . | Open in Read by QxMD
  44. Baird DC, Harker DJ, Karmes AS. Diagnosis and Treatment of Gastroesophageal Reflux in Infants and Children.. Am Fam Physician. 2015; 92 (8): p.705-14.
  45. Edmond D. Shenassa, Mary-Jean Brown. Maternal Smoking and Infantile Gastrointestinal Dysregulation: The Case of Colic. Pediatrics. 2004; 114 (4): p.e497-e505. doi: 10.1542/peds.2004-1036 . | Open in Read by QxMD
  46. Smith CH, Israel DM, Schreiber R, Goldman RD. Proton pump inhibitors for irritable infants.. Can Fam Physician. 2013; 59 (2): p.153-6.
  47. Clerico A, Giannoni A, Vittorini S, Emdin M. The paradox of low BNP levels in obesity. Heart Fail Rev. 2011; 17 (1): p.81-96. doi: 10.1007/s10741-011-9249-z . | Open in Read by QxMD
  48. Gastroesophageal Reflux Disease. https://www.ncbi.nlm.nih.gov/books/NBK441938/. Updated: May 5, 2019. Accessed: January 17, 2020.
  49. Genta RM, Spechler SJ, Kielhorn AF. The Los Angeles and Savary-Miller systems for grading esophagitis: utilization and correlation with histology. Diseases of the Esophagus. 2011; 24 (1): p.10-17. doi: 10.1111/j.1442-2050.2010.01092.x . | Open in Read by QxMD
  50. Odze RD, Goldblum JR. Surgical Pathology of the GI Tract, Liver, Biliary Tract, and Pancreas. Elsevier Health Sciences ; 2009
  51. Roark R, Sydor M, Chatila AT, et al. Management of gastroesophageal reflux disease. Disease-a-Month. 2020; 66 (1): p.100849. doi: 10.1016/j.disamonth.2019.02.002 . | Open in Read by QxMD

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