Gastroesophageal Reflux Disease (GERD)

Definition

Pathophysiology

The Antireflux Barrier

1. Lower Esophageal Sphincter (LES) — 3–4 cm of smooth muscle creating a sustained high-pressure zone. A defective LES (hypotensive or short intraabdominal length) is the most common finding. Transient LES Relaxations (TLESRs) — inappropriate, prolonged relaxations unrelated to swallowing — are also a major mechanism of reflux.
2. Diaphragmatic Crura — external pinching of the esophagus at the EGJ during increased abdominal pressure.
3. Angle of His — the acute angle between esophagus and gastric fundus; acts as a barrier against refluxate.
4. Gubaroff Valve — mucosal fold at the EGJ acting as a cushion keeping the area closed.
5. Intraabdominal Esophagus — compressed by positive abdominal pressure, contributing to the valve mechanism.

Conditions Causing EGJ Incompetence

Symptoms

Typical (Esophageal) Symptoms

• Heartburn (pyrosis) — burning sensation starting inferiorly, radiating retrosternally toward the neck; most common within 1 hour after meals, aggravated by lying down, bending, straining
• Regurgitation — effortless return of bitter/acidic fluid or food into the mouth; more common at night or on bending; indicates more severe disease
• Waterbrash — sudden flooding of the mouth with clear salty saliva (vagally mediated salivary gland reflex, not regurgitated material)
• Dysphagia — may signal underlying motility disorder, peptic stricture, or obstructing lesion; always warrants investigation
• Chest pain / odynophagia

Symptoms of heartburn and regurgitation confer ~70% sensitivity and specificity for a diagnosis of GERD. — Harrison's Principles of Internal Medicine, 22nd Ed.

Atypical / Extraesophageal Symptoms

• Chronic cough
• Laryngitis / hoarseness
• Asthma / wheezing
• Globus sensation / throat clearing
• Dental erosions
• Non-cardiac chest pain

Alarm Features (require urgent endoscopy)

• Dysphagia / odynophagia
• Unintentional weight loss
• GI bleeding / iron-deficiency anemia
• Age >45–50 with new onset symptoms
• Refractory symptoms despite PPI

Diagnosis

Empirical PPI Trial

Upper Endoscopy (EGD)

• Standard for documenting esophagitis grade, complications, and excluding other diagnoses
• Only 20–60% of patients with abnormal pH testing have visible esophagitis — so a normal EGD does not exclude GERD
• Sensitivity ~50%, Specificity 90–95%
• Graded by Los Angeles (LA) Classification: A (small breaks <5 mm), B (breaks >5 mm), C (>75% circumference), D (circumferential)

Ambulatory pH Monitoring (24-hour or 48-hour wireless Bravo capsule)

• Gold standard for confirming pathological acid exposure
• Measures DeMeester score and % time pH <4
• Catheter-based or wireless (Bravo)
• Essential if endoscopy is normal but symptoms persist, or before antireflux surgery

Combined pH-Impedance Monitoring

• Detects non-acid and weakly acid reflux events in addition to acid reflux
• Best for patients on PPIs with persistent symptoms

Esophageal Manometry (High-Resolution Manometry)

• Does not diagnose GERD directly, but identifies:
  • Hypotensive/short LES
  • Esophageal motility disorders (achalasia, IEM) that may contraindicate full fundoplication
  • EGJ type (separation of LES and diaphragm pressures = hiatal hernia)
• Mandatory before antireflux surgery

Barium Swallow

• Identifies hiatal hernia, strictures, mucosal rings
• Not diagnostic for GERD, but useful for anatomical assessment pre-surgery

Complications

Treatment

Step 1: Lifestyle Modifications

• Weight loss (most effective intervention, especially for central obesity)
• Elevation of head of bed (6–8 inches)
• Avoid late-night meals (no food 3 hours before bed)
• Dietary triggers: reduce fatty foods, chocolate, citrus, tomato-based foods, onions, coffee, alcohol, carbonated beverages
• Smoking cessation
• Avoid tight-fitting clothing

Step 2: Medical Therapy

• Rapid but short-lived symptom relief
• Not effective for esophagitis healing

• Useful for breakthrough symptoms
• Limited by tachyphylaxis with repeated dosing
• Less potent than PPIs

• Most potent antisecretory agents; highest rates of symptom control and esophagitis healing
• Dose: Start once daily (30–60 min before breakfast); escalate to twice daily for partial response
• Duration: 4–8 week initial trial; many patients require long-term therapy
• All PPIs (omeprazole, lansoprazole, pantoprazole, rabeprazole, esomeprazole) are equally effective at equivalent doses
• Adverse effects of long-term PPI use: ↑ risk of C. difficile infection, community-acquired pneumonia, chronic kidney disease worsening; possible ↑ risk of osteoporosis, hypomagnesemia (uncertain evidence)

Step 3: Surgical Management

• Refractory to maximal medical management
• PPI intolerance / patient preference to avoid long-term medications
• Significant regurgitation not controlled by PPIs (PPIs reduce acid but not volume reflux)
• Complications (e.g., aspiration, Barrett's progression)

1. EGD — exclude malignancy, confirm esophagitis, assess for Barrett's
2. Ambulatory pH monitoring — confirm pathological acid exposure
3. Esophageal manometry — exclude achalasia; assess motility
4. Upper GI barium series — define anatomy, identify hiatal hernia

• Dysphagia — up to 50% in first few months, usually self-limited; persistent >3 months requires barium swallow
• Gas bloat syndrome — inability to belch; more common after Nissen than partial wrap
• Wrap herniation — fundoplication herniates into mediastinum; may require revision
• Perioperative mortality ~0.1%

Endoscopic Therapies

• LINX device — magnetic sphincter augmentation; small ring of magnetic beads placed around LES laparoscopically; reversible; good for patients without hiatal hernia
• Transoral Incisionless Fundoplication (TIF) — endoscopic reconstruction of the valve; less invasive but less durable
• Stretta procedure — radiofrequency ablation of LES; controversial efficacy

GERD and Barrett's Esophagus — Surveillance

• Confirmed Barrett's without dysplasia: upper endoscopy every 3–5 years
• Low-grade dysplasia: every 6–12 months or ablation
• High-grade dysplasia: endoscopic ablation (radiofrequency ablation / RFA is preferred) or esophagectomy
• EET (Endoscopic Eradication Therapy) with RFA is the standard of care for dysplastic Barrett's

Summary Table

• Sabiston Textbook of Surgery, 21st Ed., pp. 1699–1720
• Sleisenger and Fordtran's Gastrointestinal and Liver Disease, pp. 194–197, 1413–1427
• Harrison's Principles of Internal Medicine, 22nd Ed. (2025)
• Goldman-Cecil Medicine, p. 2035
• Clinical Gastrointestinal Endoscopy, 3rd Ed.