PANCE Blueprint GI and Nutrition (9%)

Gastroesophageal reflux disease (GERD)

Patient will present as → a 38-year-old male with a 6-month history of heartburn and regurgitation, particularly after meals, drinking coffee, and lying down. He also complains of a chronic cough, especially at night. He is overweight and has a diet high in fatty foods. On examination, he is obese, and his abdominal examination is unremarkable. A trial of a proton pump inhibitor (PPI) is initiated, and he is counseled on lifestyle modifications, including weight loss, elevation of the head of the bed, and dietary changes to avoid trigger foods. He is advised to return if symptoms persist or worsen, in which case further diagnostic evaluation, such as an upper endoscopy, may be considered.

Chronic gastroesophageal reflux disease can put patients at risk for which disease?
Barrett esophagus

Incompetence of the lower esophageal sphincter allows reflux of gastric contents into the esophagus, causing burning pain

  • Prolonged reflux may lead to esophagitis, stricture, and rarely metaplasia or cancer
  • Gastroesophageal reflux disease (GERD) is common, occurring in 10 to 20% of adults. It also occurs frequently in infants, typically beginning at birth
  • Factors contributing to reflux include weight gain, fatty foods, caffeinated or carbonated beverages, alcohol, tobacco smoking, and drugs

Drugs that lower LES pressure include anticholinergics, antihistamines, tricyclic antidepressants, Ca channel blockers, progesterone, and nitrates

  • The PH Probe study is the gold standard for diagnosis
  • The upper GI study is a study of anatomy, not for reflux
  • A chronic cough can be an easily overlooked symptom of GERD
  • Chronic GERD may predispose to Barrett's esophagus and cancer
"Once Barrett's esophagus has been identified, screening every 3 to 5 years by upper endoscopy is recommended to look for dysplasia or adenocarcinoma. There is an 11-fold increase in esophageal adenocarcinoma in a patient with Barrett's esophagus."

Patients with foul odor of breath and increasing symptoms think Zenker's Diverticulum, which is an outpouching of the hypopharynx resulting in regurgitation of solid foods – needs surgical repair.

Patients with typical symptoms of GERD may be given a trial of PPI therapy

  • Patients who do not improve or have long-standing symptoms or symptoms of complications should be studied
  • Endoscopy with cytologic washings and biopsy of abnormal areas is the test of choice
  • Endoscopic biopsy is the only test that consistently detects the columnar mucosal changes of Barrett's esophagus. Patients with unremarkable endoscopy findings who have typical symptoms despite treatment with proton pump inhibitors should undergo 24-hour pH testing.
  • The PH Probe study is the gold standard for diagnosis
  • Any patient with symptoms of GERD accompanied by dysphagia, recurrent vomiting, weight loss, hematemesis, anemia, melena, or age > 50 should undergo endoscopy as these are considered high risk for the presence of an upper gastrointestinal malignancy

Management of uncomplicated GERD consists of elevating the head of the bed about 15 cm (6 in) and avoiding eating within 2 to 3 h of bedtime, strong stimulants of acid secretion (eg, coffee, alcohol), certain drugs (eg, anticholinergics), specific foods (eg, fats, chocolate), and smoking.

  • Weight loss is recommended for overweight patients and those who have gained weight recently
  • Drug therapy is stepwise:
    • Start with a low-dose histamine 2 receptor antagonist QD, then increase to BID if needed
    • Switch to a proton pump inhibitor if symptoms persist. Start low dose and increase to standard dose if needed
    • Once symptoms are controlled, treatment should be continued for at least eight weeks
Medication Low dose (oral) Standard dose (oral)
Histamine 2 receptor antagonists
Famotidine 10 mg BID 20 mg BID
Nizatidine 75 mg BID 150 mg BID
Cimetidine 200 mg BID 400 mg BID
Proton pump inhibitors (PPIs)
Omeprazole 10 mg QD 20 mg QD
Lansoprazole 15 mg QD 30 mg QD
Esomeprazole 10 mg QD 20 mg QD
Pantoprazole 20 mg QD 40 mg QD
Dexlansoprazole Not available 30 mg QD
Rabeprazole 10 mg QD 20 mg QD

osmosis Osmosis
Gastroesophageal Reflux Disease (GERD) Assessment


GERD is the reflux of gastric contents into the esophagus, which is characterized by inflammatory symptoms resulting from the irritating effects of gastric or duodenal contents on the esophageal mucosa. Patients who are obese are at increased risk for the disease due to increased intra-abdominal pressure, which allows the reflux (backward flow) of stomach contents into the esophagus.

Play Video + Quiz

Question 1
A 26 year old mildly obese woman presents with 2-month history of heartburn, 2 weeks history of regurgitation. She drinks alcohol and smokes occasionally. Which of the following would you not advise her to do?
Eating smaller meals at a time
Eating smaller meals at a time reduces symptoms of GERD.
Elimination of acidic foods
Elimination of acidic foods reduces symptoms of GERD.
Weight loss; stop smoking and alcohol ingestion
Weight loss; stop smoking and alcohol ingestion reduces symptoms of GERD.
Lying down within 3 hours after meal
Question 1 Explanation: 
Lying down within 3 hours after meal is not advisable for patient with GERD as it worsen reflux. Patient should wait 3 hours after a meal before lying down.
Question 2
Which of the following drug class is most effective in relieving symptoms of GERD?
Proton pump inhibitors (PPI)
The dopamine antagonist prokinetic agents
The dopamine antagonist prokinetic agents are not as effective as PPIs.
H2-receptor antagonists
H2-receptor antagonists are not as effective as PPIs.
Alginate-containing antacids
Alginate-containing antacids are not as effective as PPIs.
Question 2 Explanation: 
Proton pump inhibitors (e.g. Omeprazole) are the most effective in symptom relief and more commonly used.
Question 3
Which of the following is a complication of GERD?
Barrett’s esophagus
Zenker’s diverticulum
Diffuse esophageal spasm
Question 3 Explanation: 
GERD may predispose to Barrett's esophagus and cancer. All other options are independent disease entities. They are not complications of GERD.
Question 4
Which of the following statements is false?
Hiatal hernia contributes to the development of GERD.
Excessive reflux is defined as a pH <4 for >4% of the time
In most patients with GERD, baseline LES pressures are normal (10–35 mm Hg).
Endoscopy is indicated in all cases of GERD.
Question 4 Explanation: 
Endoscopy is not indicated in all cases of GERD. Young patients who present with typical symptoms of GERD with ALARM symptoms can be treated empirically without investigation. Investigation is advisable if patients present in middle or late age, if symptoms are atypical or if a complication is suspected.
Question 5
True or False: PH Monitoring with intra-esophageal electrode is the GOLD STANDARD for diagnosing GERD.
Question 5 Explanation: 
Although we rarely order it, this is the GOLD standard for diagnosing GERD.
Question 6
A patient presents with reflux. When further questioned, he reports the regurgitation of small amounts of food back into his mouth. You notice he has very foul-smelling breath. What do you suspect?
Zenker's diverticulum
Peptic Ulcer Disease
Gastric Cancer
Pyloric stenosis
Question 6 Explanation: 
Zenker Diverticulum is an outpouching of the hypopharynx which causes foul smelling breath and regurgitation of solid foods.
There are 6 questions to complete.
Shaded items are complete.

References: Merck Manual · UpToDate

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