GERD is incredibly common, with an estimated prevalence of 10-20% in the Western hemisphere.  It’s important to note that GERD has many overlap symptoms with cardiac chest pain, thus cardiovascular causes should be ruled out first before the diagnosis of GERD.

 

GERD

  • Clinically
    • Insomnia/poor sleep quality, diminished work output
    • Typical heartburn, liquid regurgitation with resultant metallic or acidic quality
    • Alarm symptoms:  dysphagia (r/o malignancy, ring, web), weight loss, bloody vomitus, and black tarry stools).
      • Upper endoscopy is generally a preferred modality in these cases
    • Pregnancy-induced GERD is common
    • Risk factors:  obesity, “trigger” foods (caffeine, spices, oranges/grape fruit, alcohol, foods high in fat)
    • GERD can lead to:
      • erosive esophagitis, Barrett metaplasia, cancer, and stricture.
  • Diagnosis of GERD
    • Clinical history, response to PPI, and pH testing.
    • If NO alarm symptoms, then response to empiric PPI will confirm dx.
    • If no response to empiric PPI, perform EGD.
    • If + alarm symptoms, first step is to perform EGD.
    • Ambulatory pH testing; Impedance pH exam can see acid and non-acid reflux.
  • Treatment
    • Lifestyle changes including diet/exercise.
    • Raise head of bed (pillows, incline) and stop nocturnal eating.
    • If a food leads to heartburn, eliminate it.
    • Best regimen:  PPI qdaily for 8 weeks
      • 30-60 minutes prior to first meal
      • OK for use in pregnancy
    • Alternative:  H2 blocker
    • Laparoscopic fundoplication or bariatric surgery only indicated when:
      • patient preference, side effects to meds, refractory GERD, and large hiatal hernia.
      • Will need pH-impedance testing, manometry to objectively identify GERD
      • May still need PPI 5-10 years down the road, despite therapeutic surgery.

Bibliography

  • ACP MKSAP 17:  Gastroenterology and Hepatology, pgs. 7-9
  • Image source:  https://en.wikipedia.org/wiki/Gastroesophageal_reflux_disease

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