Gastroesophageal Reflux Disease

Gastroesophageal reflux disease (GERD) is a common complaint in a general gastroenterology clinic and a widespread threat to quality of life in patients of all ages and comorbidities. It consists of the effortless regurgitation or flow of acidic gastric contents into the esophagus or oropharyngeal cavity, often experienced as a burning sensation in the chest, that occurs with sufficient frequency and severity as to impair day-to-day activities.

A.

The first and most important step in obtaining a history from a patient reporting reflux symptoms is the exclusion of life-threatening disorders. This risk stratification is most commonly done by assessing for the presence of alarm symptoms, such as unintended weight loss, impaired esophageal transit on swallowing, or evidence of gastrointestinal (GI) blood loss, for example. If any of these signs or symptoms is present, the patient warrants an urgent upper endoscopy. This is often accompanied by additional laboratory and imaging studies.
B.

When alarm symptoms are absent but acid reflux is considered, the signs and symptoms can be categorized as typical or atypical. Atypical reflux symptoms include chronic cough, recurrent sinusitis, and chest pressure or pain, for example. If the patient endorses such symptoms, it is important to advise urgent cardiopulmonary evaluation and treat accordingly, if, for example, coronary artery disease is discovered. If the patient’s cardiopulmonary evaluation is unrevealing, they may proceed to a trial of proton pump inhibitors (PPIs), alongside those patients with typical GERD symptoms.
C.

An 8-week PPI trial is generally advised due to the slow, but lasting, process of decreasing acid production by irreversibly inhibiting the hydrogen-potassium ATPase pump of the gastric parietal cells. If the symptoms substantially improve, an extended course or a temporary increase in dose is considered, alongside lifestyle measures (e.g., decreasing portion sizes, maintaining 3 hours between eating and reclining, quitting tobacco product use, and elevating head of bed). Once the symptoms resolve, a slow weaning process is often recommended in order to avoid rebound acid production. While exact practices can differ widely, it often involves halving the dose of the PPI approximately every 2 weeks, as symptoms permit. The patients may do well with no medications or with a combination of lifestyle modification and as-needed short-acting agents like famotidine or calcium carbonate, for example. On the other hand, if there is no substantial improvement despite the PPI trial, an upper endoscopic exam, with or without confirmatory pH testing, can be considered.
D.

An esophagogastroduodenoscopy (EGD) examines the upper GI tract and offers the ability to get biopsies and photo-document the mucosal lining from the esophagus to the third portion of duodenum. In an evaluation of a patient exhibiting symptoms of GERD, it can help exclude typical signs of acid reflux such as moderate to severe reflux esophagitis (Los Angeles grade C or D), Barrett esophagus changes, or peptic esophageal strictures. If these are seen, one can consider continued focus on acid reduction, lifestyle measures, and ancillary medications such as alginates, antihistamines, and neuromodulators. If signs of reflux features are not seen, confirmatory pH testing after discontinuation of acid-reducing medications can be considered and is especially useful in defining the role of acid reflux in patients with atypical symptoms.
E.

During pH testing, a wireless pH sensing capsule is attached to the lower esophageal mucosa via suction and provides a report of acid reflux events, while the patient documents symptom events (e.g., heartburn, cough, and chest pain). If the timing of the two events correlates, one can conclude that reflux may be contributing to symptoms and refocus on GERD treatment measures.
F.

If the acid reflux and symptom events do not correlate or if acidic gastroesophageal reflux is not seen on pH testing, one can consider the possibility of alternative diagnoses. These can include motility disorders (e.g., achalasia, scleroderma, and gastroparesis), bile reflux, functional heartburn, and others. Additional testing and treatment trials are then discussed and can include esophageal and gastric motility studies and use of agents such as tricyclic antidepressants. Of note, a pH study without interruption of medical therapy can also be useful in cases of documented and confirmed GERD with incomplete symptom control in order to determine the utility of ongoing acid reflux suppression. If symptom correlation is low, one may focus on treatment of possible overlapping syndromes like functional dyspepsia.
G.

Patients with confirmed acid reflux disease whose symptoms remain inadequately controlled with medical management (i.e., lifestyle measures, PPIs, ancillary medications like prokinetics, antihistamines, or alginates) can consider surgical or endoscopic options. These include procedures that augment the gastroesophageal junction pressure, such as endoscopic transoral incisionless fundoplication (TIF), laparoscopically placed magnetic ring system, or surgical partial or circumferential fundoplication. Each option must take into consideration the patient’s comorbidities and anatomical factors, such as the presence of hiatal hernia or esophageal dysmotility.