Gastroesophageal Reflux Disease (GERD)

Snapshot

• A 65 year-old male presents complaining of heartburn, belching, and epigastic pain. His symptoms are aggravated by drinking coffee and eating fatty foods. His heartburn improves when he takes calcium carbonate.

Introduction

• Symptomatic reflux of gastric contents into the esophagus
• Transient lower esophageal spincter relaxation is the most common cause   
• Other causes include
  • pregnancy
    • ↓ motility secondary to progesterone
  • ↑ gastric acidity
  • gastric outlet obstruction
  • ↓ esophageal motility
  • hiatal hernia
  • obesity
• Associated with:
  • tobacco
  • alcohol
• scleroderma

Presentation

• Symptoms
  • heartburn 30-90 minutes after a meal
    • worse with reclining
    • improves with antacids
  • regurgitation
  • dysphagia
  • may mimic asthma/MI
• can cause dyspepsia (epigastric discomfort that is worse with food)

Evaluation

• Diagnosis based on history
• Upper endoscopy 
  • should be performed if patient has longstanding symptoms
  • look for Barrett’s esophagus and adenocarcinoma 
• 24-hour intraesophageal pH monitoring
  • gold standard 
• Manometry
• reveals decreased LES pressure

Treatment

• 1st line – lifestyle changes
  • don’t lie down after eating
  • avoid spicy foods
  • eat small servings
• 2nd line
  • H2 receptor antagonists (cimetidine, ranitidine) or
  • a promotility agent in patients with pathologic LES relaxation/hypotension
    • no longer as commonly used due to moderate efficacy and side effect profiles
• 3rd line
  • proton pump inhibitors (omeprazole, lansoprazole) 
    • PPI’s are often used as the best initial therapy and are both diagnostic and therapeutic
    • mechanism is irreversible inhibition of hydrogen-potassium ATPase 
• 4th line
  • surgical fundiplication or hiatal hernia repair
    • wrapping of stomach around GE junction