GERD (Gastroesophageal Reflux Disease): Symptoms, Diagnosis & Management

GERD is chronic reflux of gastric contents causing troublesome symptoms or complications. It affects ~20% of Western adults.

Typical Symptoms

• Heartburn (retrosternal burning, postprandial, worse supine)
• Regurgitation (effortless return of gastric contents)

Atypical / Extraesophageal Symptoms

• Chronic cough, laryngitis, asthma exacerbation
• Non-cardiac chest pain
• Dental erosions, globus sensation

Diagnosis

• Empiric PPI trial (8 weeks) – diagnostic if typical symptoms respond.
• Endoscopy (EGD): Alarm symptoms (dysphagia, weight loss, anemia, age >60 new onset), or refractory to PPI. Grades esophagitis (LA classification), detects Barrett's.
• Ambulatory pH/impedance monitoring: Off PPI – confirms pathologic reflux; correlates symptoms with episodes.
• Esophageal manometry: Pre-surgical evaluation; rules out achalasia.

Management

Lifestyle (First-Line)

• Weight loss (if BMI >25); head-of-bed elevation 6–8 inches.
• Avoid triggers: caffeine, alcohol, chocolate, mint, fatty/spicy foods, late meals (<3 hrs before bed).
• Smoking cessation.

Medications

• PPIs (omeprazole, esomeprazole, etc.) – acid suppression; 30–60 min before meal.
• H2RAs (famotidine) – nocturnal breakthrough, on-demand.
• Alginate (Gaviscon) – raft barrier; postprandial/bedtime.
• Prokinetics (limited evidence).

Surgical/Endoscopic

• Laparoscopic Nissen fundoplication (gold standard for refractory, proven reflux).
• Magnetic sphincter augmentation (LINX).
• TIF (transoral incisionless fundoplication) – select patients.

Complications

• Erosive esophagitis, strictures, Barrett's esophagus (↑ adenocarcinoma risk), dental erosion, aspiration pneumonia.

Long-term PPI use requires monitoring for B12, magnesium, bone health, C. diff risk. Step-down to lowest effective dose.