Gastroesophageal reflux disease (GERD)

GERD is a chronic disorder where stomach contents flow back into the esophagus, irritating the mucosa. It can be classified into:

• NERD (Non-erosive Reflux Disease): Characteristic symptoms without evidence of injury (50-70% of GERD patients).
• ERD (Erosive Reflux Disease): With evidence of esophageal injury (30-50% of GERD patients).

GERD develops due to factors like:

• Gastroesophageal Junction Dysfunction:
  • Increased transient lower esophageal sphincter relaxations (TLESRs) ➜ Most common cause
  • An imbalance between intragastric and LES pressures,
  • Anatomical abnormalities (e.g., hiatal hernia).
• Impaired Esophageal Acid Clearance: Reduced salivation or peristalsis.

• Smoking
• Stress
• Obesity
• Pregnancy
• Angle of His enlargement
• Iatrogenic causes
• Inadequate protective factors
• Gastrointestinal malformations and tumors
• Scleroderma
• Asthma

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

• Superficial coagulative necrosis in the nonkeratinized squamous epithelium
• Thickening of the basal cell layer
• Elongation of the papillae in the lamina propria and dilation of the vascular channels at the tip of the papillae (leading to hyperemia)
• Inflammatory cells (granulocytes, lymphocytes, macrophages)
• Transformation of squamous into columnar epithelium leads to Barrett metaplasia

• Typical Symptoms:
  • Heartburn (most common),
  • Regurgitation,
  • Dysphagia.
• Atypical Symptoms: Noncardiac chest pain, belching, bloating, dental erosion, etc.
• Red Flags: Dysphagia, anemia, unintentional weight loss, vomiting, signs of GI bleeding.

The diagnosis is based on a combination of clinical presentation, endoscopic evaluation, reflux assessment, and therapeutic response.

• Approach: Includes clinical evaluation, rule out life-threatening diagnoses, empiric PPI trial, EGD, esophageal pH monitoring.
• EGD (Esophagogastroduodenoscopy):
  • Indicated in red flags, no symptomatic improvement after PPI trial.
  • Not necessary for a typical GERD presentation
• 24 Esophageal pH Monitoring:
  • Used to identify abnormal reflux (Best and most sensitive).
  • 24-hour pH monitoring is considered the gold standard for GERD diagnosis.
• Esophageal barium swallow
  • Contrast medium is swallowed and serial
  • May show strictures, tumors, hiatal hernias, and severe esophagitis
• Esophageal manometry.
  • To rule out esophageal motility disorders

• Lifestyle Changes: Include modifications in diet and eating habits.
  • Avoid eating < 3 hours before bedtime.
  • Weight loss (if obese)
  • Elevate the head of the bed (if with nocturnal symptoms).
  • Avoid triggers (e.g., alcohol, coffee , spices).
  • Smoking cessation
• Pharmacological Therapy:
  • PPIs (Proton Pump Inhibitors): Standard treatment for 8 weeks.
    • Once-daily therapy, 30–60 minutes before a meal
    • Most effective therapy 
    • Most common maintenance therapy
    • Heal esophagitis, if present
    • Examples: omeprazole, pantoprazole
  • H2 receptor antagonists:
    • Consider as alternate maintenance therapy for NERD, or in addition to PPIs to control nighttime symptoms
    • Decreases acid secretion by blocking H2 receptors in gastric parietal cells
    • Examples: famotidine,cimetidine
• Surgical Therapy (Nissen's fundoplication): Indicated in select cases with complications despite medical therapy.
  • 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

• Reflux esophagitis: most common complication of GERD
• Erosive esophagitis
  • 30% of patients with untreated GERD
• Iron deficiency anemia: mucosal erosions and ulcerations → chronic bleeding → anemia
• Esophageal stricture
  • Results from healing of erosive esophagitis
  • Causes dysphagia to solids/food impaction
• Esophageal rings: e.g., Schatzki rings
• Barrett esophagus
  • Definition: intestinal metaplasia of the esophageal mucosa induced by chronic reflux.
    • Histopathological examination of the mucosa shows a columnar epithelium instead of the normal squamous epithelium.
  • Precursor to esophageal adenocarcinoma
  • Diagnosed by endoscopy with biopsy
• Reflux laryngitis: hoarseness (due to laryngopharyngeal reflux)