Gastroesophageal reflux disease

Gastroesophageal reflux disease (GERD) (or gastro-oesophageal reflux disease in British English, but that's abbreviated GORD) is a common disease where gastric contents reflux into the oesophagus, causing symptoms like heartburn, regurgitation, and possible severe complications. It’s caused by excessive relaxation of the lower oesophageal sphincter, and is therefore sort of the opposite disorder of achalasia.

Etiology

Risk factors include those which decrease the tone of the LES and/or increase the pressure inside the stomach:

• Smoking
• Coffee consumption
• Alcohol consumption
• Obesity
• Pregnancy
• Scleroderma
• Sliding hiatal hernia

Classification

We distinguish GERD into one of three types:

• Non-erosive reflux disease (NERD)
• Erosive reflux disease (ERD), also called erosive oesophagitis
• Complicated erosive reflux disease

In NERD, which accounts for 60% of cases, the gastroesophageal mucosa is visibly normal. In ERD, erosions are present on the mucosa. Complicated ERD is characterised by the presence of complications like ulcers, stenosis, or Barrett oesophagus.

Clinical features

The typical symptoms of GERD are heartburn and regurgitation. Atypical symptoms may occur if the regurgitation reaches the larynx, bronchi, or teeth, causing symptoms like hoarseness and coughing.

In complicated GERD the patient may have strictures or oesophagitis, which may cause dysphagia or odynophagia, or frank pain.

Diagnosis and evaluation

In most cases, patients don’t need to undergo procedures for the precise diagnosis. If a patient with typical symptoms presents without being at risk of complications, the patient can undergo a so-called PPI test. The patient is prescribed a PPI for 4 weeks, and if the symptoms improve, then the diagnosis of GERD is likely.

In cases where the diagnosis is uncertain, proper diagnostic modalities are necessary. There are many options:

• Upper endoscopy (first choice)
• Oesophageal manometry
• 24-hour oesophageal pH measurement
• Impedance measurement
• Bilitec

Treatment

Treatment involves lifestyle changes such as smoking cessation, weight loss, not eating before bedtime, elevating the head in the bed.

In most cases, medical therapy is necessary. The standard treatment is PPIs. Alternatives include H2 receptor antagonists, antacids, and surface agents like sucralfate.

For surgical treatment, refer to the corresponding surgery topic.

Complications

• Erosive reflux disease
• Barrett oesophagus, oesophageal carcinoma