GERD

A condition characterized by retrosternal, and sometimes epigastric pain, as a result of reflux of the acidic contents of the stomach into the oesophagus

Aetiology

Risk factors

  • Hiatus hernia
  • Some foods e.g. fat, caffeine, sour & spicy, chocolate
  • Smoking
  • Obesity - increases intra-abdominal pressure
  • Alcohol
  • H. pylori
  • ‘Stress’

Pathophysiology

Incompetent lower oesophageal sphincter

  • LOS usually contracted at all times (when not swallowing)
  • Problems occur when LOS relaxes when it shouldn’t or LOS tone doesn’t increase when patient lying flat
  • This can be caused by CNS depressants (alcohol), pregnancy, hypothyroidism and systemic sclerosis

Poor oesophageal clearance

  • Increases the amount of time the oesophageal mucosa will stay in contact with the stomach acid for
  • This effect can be exaggerated by a hiatus hernia, because gastric contents can be trapped within the hernial sac

Barrier function/ visceral sensitivity

  • The stratified squamous epithelium of the oesophagus normally forms a tight protective barrier - defects in the barrier mean the oesophagus is more prone to damage by gastric contents
  • A hypersensitive oesophagus has a lower threshold for symptom perception and reporting

Histological changes

  • ‘Regenerative and hyperplastic’ epithelium - basal zone hyperplasia, elongation of the lamina propria papillae

Clinical presentation

Typical (Esophageal) Symptoms
  • Heartburn (retrosternal burning)
  • Regurgitation (sour or bitter taste)
  • Dysphagia (suggests complication)
Atypical / Extra-Esophageal Symptoms
  • Chronic cough
  • Hoarseness
  • Laryngitis
  • Asthma exacerbation
  • Chest pain (non-cardiac)

Alarm Symptoms (Red Flags)

  • Dysphagia
  • Odynophagia
  • Unintentional weight loss
  • Gastrointestinal bleeding
  • Anemia
  • Persistent vomiting

Classification

Based on Endoscopic Findings
Type
Description
Non-erosive reflux disease (NERD)
Symptoms without mucosal injury
Erosive esophagitis
Visible mucosal breaks
Complicated GERD
Stricture, Barrett’s esophagus
Los Angeles Classification of Esophagitis
Grade
Description
A
Mucosal break ≤5 mm
B
>5 mm, not bridging folds
C
Continuous between ≥2 folds
D
Circumferential injury

Investigations

Clinical Diagnosis

  • Typical symptoms → empirical PPI trial
  • No routine testing required initially

GERD-Q Score

Symptom Assessed
Predictor Type
0 days
1 day
2–3 days
4–7 days
Heartburn (burning behind breastbone)
Positive
0
1
2
3
Regurgitation (acid/food coming up)
Positive
0
1
2
3
Sleep disturbance due to reflux
Positive
0
1
2
3
Use of OTC antacids
Positive
0
1
2
3
Epigastric pain
Negative
3
2
1
0
Nausea
Negative
3
2
1
0
Scoring Summary
  • Total score range: 0–18
  • Score ≥8: Diagnostic of GERD (high likelihood)

Upper GI Endoscopy

Indications:
  • Alarm symptoms
  • Refractory GERD
  • Suspected complications
Findings:
  • Erosive esophagitis
  • Stricture
  • Barrett’s esophagus

Ambulatory 24-Hour pH Monitoring

  • Gold standard for reflux detection
  • Indicated when:
    • Endoscopy is normal
    • Symptoms persist despite therapy

Esophageal Manometry

  • Assesses LES pressure and motility
  • Pre-operative evaluation

Management

Lifestyle Modification

  • Weight reduction
  • Elevation of head end of bed
  • Avoid late meals
  • Avoid trigger foods (fatty food, caffeine, chocolate)
  • Smoking and alcohol cessation

Medication

✨ Proton Pump Inhibitor (PPI) → First Line
  • PPIs irreversibly inhibit the H⁺/K⁺-ATPase (proton pump) of gastric parietal cells
  • Most effective when taken 30–60 minutes before meals
  • Goal of therapy:
    • Symptom control
    • Healing of esophagitis
    • Prevention of relapse and complications
  • Use the lowest effective dose for the shortest necessary duration
Uncomplicated GERD / NERD
Duration: 4-8 weeks
PPI
Standard Dose
Frequency
Pantoprazole
40 mg
Once daily
Esomeprazole
40 mg
Once daily
Lansoprazole
30 mg
Once daily
Rabeprazole
20 mg
Once daily
Omeprazole
20 mg
Once daily
Erosive Esophagitis (LA Grade A–C)
  • Once-daily PPI
  • Duration: 8 weeks
Severe or Complicated GERD
(LA Grade D, strictures, Barrett’s esophagus)
  • High-dose PPI
  • Twice daily (before breakfast and dinner)
  • Long-term or maintenance therapy required

Complications

  • 10% of GERD patients
  • Refers to the metaplasia of lower oesophageal stratified squamous epithelium to gastric columnar epithelium
  • Protective response to chronic acid exposure - faster regeneration
  • Unstable mucosa increases risk of dysplasia, which increases risk of adenocarcinoma