GERD 101 - Gastroesophageal Reflux Disease

Definition

• Current Surgical Therapy 14e
• Murray & Nadel's Textbook of Respiratory Medicine

Pathophysiology

The Anti-Reflux Barrier - 5 Components

1. Lower Esophageal Sphincter (LES) - a 3-4 cm smooth muscle segment creating a sustained high-pressure zone. Most GERD patients have a defective LES. Additionally, excessive transient LES relaxations (TLESRs) are a major contributing mechanism.
2. Diaphragmatic crus - provides extrinsic compression on the LES, pinching the lower esophagus during increased abdominal pressure.
3. Angle of His - the acute angle between the esophagus and gastric fundus acts as a barrier to refluxate rise.
4. Gubaroff valve - a thickening of esophageal mucosa at the EGJ acting as a cushion keeping the area closed.
5. Intraabdominal esophageal segment - positive abdominal pressure collapses this segment, contributing to the valve effect.

• Sabiston Textbook of Surgery

What Breaks the Barrier?

• Sabiston Textbook of Surgery, Harrison's Principles of Internal Medicine 22E

Obesity and GERD

• Yamada's Textbook of Gastroenterology, 7e

Symptoms

Typical Symptoms

• Heartburn (pyrosis) - burning sensation rising from the stomach/lower chest toward the neck and throat; usually postprandial; worsened by spicy food, citrus, fats, chocolate, alcohol, supine position, bending over. GERD is usually diagnosed symptomatically when heartburn occurs ≥2 days/week, though less frequent symptoms don't exclude the diagnosis.
• Regurgitation - perception of refluxed gastric contents flowing into the mouth or pharynx. Patients with daily regurgitation often have low LES pressure, associated gastroparesis, and esophagitis.
• Acid brash

Atypical (Extraesophageal) Symptoms

• Chronic cough
• Wheezing / asthma
• Dysphonia / voice changes
• Sore throat
• Globus sensation
• Noncardiac chest pain
• Dental erosions
• Laryngitis

Alarm Symptoms - Require Further Workup

• Dysphagia / odynophagia
• Unintended weight loss
• Anorexia / early satiety
• GI bleeding

• Sleisenger & Fordtran's GI and Liver Disease, Current Surgical Therapy 14e

Diagnosis

Step-Up Approach

• 24-hour dual-probe catheter (transnasal)
• 48-hour wireless capsule (endoscopic placement)
• Thresholds: DeMeester score >14.72 or total distal esophageal acid exposure time >5-6% indicates pathologic reflux

• Assess esophageal motility (guides fundoplication choice)
• Rule out achalasia (which can mimic GERD)
• Chicago Classification v4.0: if ineffective esophageal motility is present, prefer partial (Toupet 270°) over complete (Nissen 360°) fundoplication to reduce postoperative dysphagia

• Current Surgical Therapy 14e, Sabiston Textbook of Surgery

Complications

• Yamada's, Mulholland & Greenfield's Surgery

Treatment

Step 1 - Lifestyle Modifications

• Weight loss (strongest evidence; proven in RCTs)
• Head-of-bed elevation (for nocturnal symptoms)
• Avoid large meals; avoid lying down within 2-3 hours of eating
• Avoid triggers: fatty foods, chocolate, coffee, alcohol, citrus, spicy food
• Quit smoking

Step 2 - Medical Therapy

• Onset slower than antacids, duration 6-10 hours
• Can be used prophylactically before meals
• Healing rate in erosive esophagitis: <50% - inadequate for significant disease
• Useful for infrequent heartburn (<3x/week)

• First-line for frequent heartburn, erosive esophagitis, and Barrett's
• Superior acid suppression; once-daily dosing controls symptoms and heals erosive esophagitis in >80%
• Should be taken 30-60 min before meals for optimal efficacy
• Approximately 50% of Barrett's patients on full-dose PPIs still have abnormal acid exposure on pH monitoring - highlighting limits of medical therapy
• Long-term use concerns: hypomagnesemia, C. difficile risk, bone density (controversial), B12 deficiency
• Katzung's Basic and Clinical Pharmacology 16e, Yamada's Textbook of Gastroenterology

Step 3 - Surgical/Interventional Therapy

• Failure or intolerance of medical therapy
• Patient preference (to avoid lifelong PPIs)
• Objective confirmation of GERD on pH testing

• Standard of care for patients with normal esophageal motility
• Wraps the gastric fundus around the LES to recreate the valve mechanism
• Highly effective; most durable antireflux procedure

• Preferred when ineffective esophageal motility is present (Chicago Classification v4.0)
• Reduces risk of postoperative dysphagia

• Current Surgical Therapy 14e, Sabiston Textbook of Surgery

Special Populations

• Pregnancy: Reduced LES pressure from progesterone (in the setting of elevated estrogen) is the primary mechanism; symptoms are nearly universal in the third trimester; lifestyle measures first; antacids and H2RAs are generally safe.
• Elderly: May lack classic symptoms; can present with severe GERD or complications (ulceration, bleeding) as their first presentation; dysphagia and regurgitation are more common presenting features than heartburn.
• Obesity: Weight loss is a primary therapeutic target; bariatric surgery (particularly Roux-en-Y gastric bypass) resolves GERD in >85% of patients.

Summary Algorithm

Typical symptoms (heartburn/regurgitation ≥2x/week)
         ↓
No alarm symptoms → Empiric PPI trial (4-8 weeks)
         ↓
Responds → GERD confirmed → Lowest effective dose; lifestyle meds
         ↓
Fails OR alarm symptoms → Upper endoscopy + ambulatory pH testing
         ↓
Objective GERD confirmed → Optimize PPI; consider surgery if refractory
         ↓
Barrett's found → Surveillance endoscopy per protocol

• Sabiston Textbook of Surgery (Antireflux Mechanism chapter)
• Current Surgical Therapy 14e (GERD chapter)
• Sleisenger & Fordtran's Gastrointestinal and Liver Disease
• Yamada's Textbook of Gastroenterology, 7e
• Katzung's Basic and Clinical Pharmacology, 16e
• Harrison's Principles of Internal Medicine, 22e (2025)
• Mulholland & Greenfield's Surgery, 7e