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Updated: Feb 10 2022

Gastroesophageal Reflux Disease (GERD)

  • Snapshot
    • A 65 year-old male presents complaining of heartburn, belching, and epigastic pain. His symptoms are aggravated by drinking coffee and eating fatty foods. His heartburn improves when he takes calcium carbonate.
  • Introduction
    • Symptomatic reflux of gastric contents into the esophagus
    • Transient lower esophageal spincter relaxation is the most common cause
    • Other causes include
      • pregnancy
        • ↓ motility secondary to progesterone
      • ↑ gastric acidity
      • gastric outlet obstruction
      • ↓ esophageal motility
      • hiatal hernia
      • obesity
    • Associated with:
      • tobacco
      • alcohol
      • scleroderma
  • Presentation
    • Symptoms
      • heartburn 30-90 minutes after a meal
        • worse with reclining
        • improves with antacids
      • regurgitation
      • dysphagia
      • may mimic asthma/MI
      • can cause dyspepsia (epigastric discomfort that is worse with food)
  • Evaluation
    • Diagnosis based on history
    • Upper endoscopy
      • should be performed if patient has longstanding symptoms
      • look for Barrett's esophagus and adenocarcinoma
    • 24-hour intraesophageal pH monitoring
      • gold standard
    • Manometry
      • reveals decreased LES pressure
  • Treatment
    • 1st line - lifestyle changes
      • don't lie down after eating
      • avoid spicy foods
      • eat small servings
    • 2nd line
      • H2 receptor antagonists (cimetidine, ranitidine) or
      • a promotility agent in patients with pathologic LES relaxation/hypotension
        • no longer as commonly used due to moderate efficacy and side effect profiles
    • 3rd line
      • proton pump inhibitors (omeprazole, lansoprazole)
        • PPI's are often used as the best initial therapy and are both diagnostic and therapeutic
        • mechanism is irreversible inhibition of hydrogen-potassium ATPase
    • 4th line
      • surgical fundiplication or hiatal hernia repair
        • wrapping of stomach around GE junction
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