GERD is an esophageal disorder of the lower esophageal sphincter allowing gastric contents to reflux into the esophagus, presenting as burning epigastric pain. It is diagnosed clinically and treated with lifestyle modification, antacid, and surgical repair.
Pathophysiology
- Lower esophageal sphincter incompetence
- Generalised loss of intrinsic sphincter tone
- Recurrent inappropriate transient relaxation
- Gastric distension causes lower esphageal sphincter to relax
Contextual Factors
- Older age
- Weight gain
- Smoking
- Trigger foods
- Fatty foods
- Caffeinated or carbonated drinks
- Alcohol
- Drugs
- Anticholinergics
- Antihistamines
- Tricyclic antidepressants
- Calcium channel blockers
- Progesterone
- Nitrates
Clinical Manifestation
- Epigastric pain
- Heart burn
- Gastric content regurgitation leading to:
- Cough
- Hoarseness
- Wheezing
Complications
- Esophagitis
- Esophageal ulcer
- Esophageal stricture
- Barrett esophagus
- Esophageal adenocarcinoma
Diagnosis
- Clinical
- Endoscopy if not responding to medications
- pH testing
Endoscopic Esophagitis Grading
| Grade | Features |
|---|---|
| A | 1+ mucosal break <= 5mm that do not cross 2 mucosal folds |
| B | 1+ mucosal break > 5mm that do not cross 2 mucosal folds |
| C* | 1+ mucosal break < 75% of esophageal circumference that cross >= 2 mucosal folds |
| D* | 1+ mucosal break >= 75% of esophageal circumference |
* Indicative of GERD
Treatment
- Medications that decrease acid production
- Proton pump inhibitors
- H2 blockers
- Lifestyle modifications
- Head of bed elevation
- Eating more than 3 hours before bedtime
- Avoiding trigger foods: caffeine, alcohol, fat, acid
- Smoking cessation
- Medication avoidance that relax lower esophageal sphincter tone
- Surgery for patients with grade C or D esophagitis, large hiatal herniation, hemorrhage, stricture, ulcers, or poor response to medications