Gastroesophageal Reflux Disease (GERD)

Gastroesophageal Reflux Disease (also known as GERD) is a condition whereby the eating pipe or esophagus is irritated due to reflux or backflow of the stomach contents. GERD is clinically diagnosed and can be managed through lifestyle modifications and medications.

The esophagus comprises of an opening on its lower end (also known as the lower esophageal sphincter). This opens in response to food contents entering the stomach.  However, if this sphincter weakens or undergoes abnormal relaxation, it gives way to the stomach acid to backflow up towards the esophageal lining and irritates it.

GERD’s contributing factors include obesity and pregnancy, while aggravating factors include large or late-night meals, fatty meals, alcoholic and caffeinated beverages, and smoking.  GERD can also occur on a background of certain conditions like gastroparesis, hiatal hernia, and scleroderma (a connective tissue disease).
In terms of prevalence, GERD is found in 10-20% of the people in the West, while the prevalence is less than 5% in Asia.

The signs and symptoms of GERD include:

• Heartburn usually occurs after meals and is aggravated by lying flat
• Sour taste in the mouth
• Chest pain can often be a mimic of myocardial infarction or heart attack
• Difficulty swallowing (usually a late finding)
• Pain on swallowing, although this is rare
• Voice changes such as hoarseness
• Chronic cough

GERD is diagnosed clinically through history and physical exam.
Patients are usually started on a trial of medications, either by neutralizing the stomach acid, blocking the stomach acid production, or decreasing the stomach acid production. Diagnostic tests can be used in certain cases. These tests include:

• A 24-hour pH monitoring test is performed if the diagnosis of GERD is unclear.
• Esophagogastroduodenoscopy (or EGD) with biopsy can be done for patients with symptoms that persist despite initial treatment for GERD or chronic GERD to rule out conditions like Barrett’s esophagus or adenocarcinoma. This is a test of choice if certain symptoms are present (also known as alarm symptoms), such as unintentional weight loss, bloody stool, difficulty swallowing, or pain on swallowing.
• Other tests include barium swallow or esophageal manometry.

The differential diagnosis for GERD includes pill esophagitis, infectious esophagitis, eosinophilic esophagitis, achalasia, gastritis, peptic ulcer disease, and esophageal cancer.

GERD can be managed through lifestyle modifications and medications. Lifestyle modifications include:

• Weight management
• Taking small frequent meals
• Avoiding late-night meals
• Dietary modifications including avoiding alcohol and coffee
• Limit use of tomatoes, citrus-based juices
• Elevating the head of the bed if the patient experiences nighttime symptoms.

Medications for GERD are based on the severity of the condition. In mild GERD with intermittent symptoms, antacids can be used. For frequent episodes or chronic GERD, medications which block acid production, also known as PPIs or acid-reducing medications, also called H2-receptor blockers (cimetidine, ranitidine), can be used.

Procedures like Nissen fundoplication can be performed if symptoms persist. However, patients are usually started on a trial on PPIs first.