Gastroesophageal reflux disease: Clinical sciences

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Introduction0:00–0:25

Gastroesophageal reflux disease, or GERRD for short, is a chronic condition in which the lower esophageal sphincter becomes weak or relaxes at the wrong time.
This allows acidic content from the stomach to flow back up into the esophagus. Over time, exposure to gastric acid can irritate and damage the lining of the esophagus and cause a variety of symptoms which are commonly grouped into typical, atypical, and alarm symptoms.

Alarm symptoms0:25–3:21

Now if your patient presents with signs and symptoms suggestive of GERD, you should first perform an A B C DE assessment to determine if your patient is unstable or stable.
If unstable, stabilize their airway, breathing, and circulation. Next, obtain IV access and administer IV fluids.
And don't forget to put your patient on continuous vital sign monitoring. Finally, if you identify signs of active gastrointestinal bleeding such as melina or hematemesis, perform an emergent esophagogastroduodenoscopy or EGD.
Now let's go back and take a look at stable patients. In this case, start with a focused history and physical examination.
Individuals with GERD might report classic symptoms like heartburn, also known as pyrosis, acid regurgitation, or a sour or bitter taste in the back of the mouth.
Some might also experience non-specific symptoms such as chronic cough, hoarseness, or frequent throat clearing. On physical exam findings are usually normal.
However, in some cases you might notice subtle signs of acid damage such as dental erosion. If your patient reports any of these symptoms, suspect GERD.
Next, assess the patient for alarm signs and symptoms that warrant urgent evaluation for GERD complications. These include anemia, dysphagia or adenophagia, gastrointestinal bleeding, frequent vomiting, or unintentional weight loss.
If one or more alarm signs and symptoms are present, you should suspect a GERD complication and proceed with an urgent EGD with biopsies.
If the biopsy reveals friable erythematous epithelium with inflammatory cells consistent with erosive esophagitis, the diagnosis is GERD.
Management of course includes lifestyle modifications such as smoking cessation and reducing foods that trigger reflux symptoms such as tomatoes and alcohol.
However, the cornerstone of treatment is acid suppression, which typically involves proton pump inhibitors or PPIs such as omeprazole and histamine 2 receptor antagonists or H2 blockers such as famotidine.
Although both PPIs and H2 blockers reduce acid secretion, PPIs are the primary treatment because they relieve symptoms more effectively and promote better healing of oesophageal damage than H2 blockers.
Now here's a clinical pearl to keep in mind. For intermittent symptom relief, you can also opt for antacids such as magnesium hydroxide, which work by neutralizing stomach acid.
On the flip side, circlefate, a non-absorbable mucosal protective agent, is not commonly used in GERD treatment outside of special situations.

Typical GERD symptoms3:21–6:03

Finally, if your patient experiences recurrent symptoms or you need to evaluate the healing of the esophageal lining, consider repeating an EGD.
Now let's go back to EGD and biopsy because in some individuals erosive esophagitis can progress to more serious conditions.
During the procedure, you might detect an esophageal mass or stricture, while a biopsy might reveal columnar metaplasia or dysplasia, a finding known as Barrett's esophagus.
All these findings are suggestive of chronic GERD complications. In these individuals, again, encourage lifestyle modifications and initiate medical therapy with PPIs or H2 blockers.
Additional treatment options include endoscopic interventions like esophageal dilation to reduce stricture and endoscopic ablation for dysplasia.
Sometimes you'll have to consult your surgical team for esophageal resection of a mass. Finally, in individuals with Barrett's esophagus, repeated EGDs are essential to monitor the esophageal mucosa because metaplasia can progress to dysplasia, which is a precancerous stage, and eventually to esophageal adenocarcinoma.
Now that we've covered how to approach individuals with alarm signs and symptoms, let's take a step back and look at what to do when those features are absent.
In this case, your first step is to assess the type of GERD presentation. Now if your patient reports typical GERD symptoms such as heartburn, acid regurgitation, or sour or bitter taste in their mouth, and their physical examination is normal, suspect GERD with typical features.
But sometimes a person may report both typical and atypical GERD symptoms. Atypical symptoms can include chronic cough, hoarseness, frequent throat clearing, laryngitis, pharyngitis, or even sinusitis.
On physical exam you might find wheezing or signs of acid regurgitation in the mouth such as dental erosions or erythema.
In this case, you should suspect GERD with both typical and atypical features. In both groups, treatment starts with lifestyle modifications and an 8-week trial of PPIs.
After 8 weeks, assess the patient's response to treatment. If symptoms show an adequate response, diagnose GERD and continue encouraging lifestyle changes while closely monitoring for any recurrence.
On the other hand, if there's an inadequate response, or in other words, if symptoms persist during the trial or return after it ends, proceed with an EGD and biopsy.

Atypical GERD symptoms6:03–8:32

However, be sure to withhold PPI therapy for 2 to 4 weeks before the procedure because these medications can reduce visible signs of mucosal damage.
Now if EGD and biopsies reveal normal oesophageal mucosa with no pathology findings, perform a 24 hour esophageal impedance with pH monitoring.
This test measures the number and length of reflux events and the pH of the esophageal contents over a 24 hour period, which is then correlated with the patient's symptoms.
If the test results are abnormal, diagnose GERD. Similarly, if the EGD and biopsy reveal erosive esophagitis, diagnose GERD.
In both cases, initiate the management that relies on lifestyle modifications and acid suppressing medications. If a patient requires long-term use of PPIs to control symptoms, be sure to repeat the EGD and assess the esophageal mucosa.
On the flip side, if the EGD with biopsy reveals an oesophageal mass, stricture, or columnar metaplasia or dysplasia, diagnose a chronic complication of GERD and move forward with the appropriate treatment.
All right, now that we've covered how to approach individuals with both typical and atypical features of GEERD, let's shift our focus to cases where only atypical symptoms are present.
If your patient has atypical symptoms only, such as chronic cough, hoarseness, throat clearing, or laryngitis, pharyngitis, or sinusitis, and physical exam reveals wheezing or oropharyngeal changes such as dental erosions or erythema, suspect GERD with atypical features.
Here's your next clinical pearl. Before jumping into a GERD workup, make sure to check for other common causes of those atypical symptoms.
For example, if your patient has a chronic cough or wheezing, it's a good idea to rule out lung issues first before heading down the GERD path.
Once you've ruled out other possible causes, your next step is to confirm or rule out GEERD. In this case, you can skip the eight week PPI trial and go straight to an EGD with biopsy.
If no pathology is found in the EGD and biopsies, follow up with 24 hour esophageal impedance and pH monitoring. If the results are abnormal, or if the EGD shows erosive esophagitis, you can diagnose GERD and proceed with treatment.
This includes lifestyle changes and acid suppressing medications, and if needed, repeat the EGD if a patient requires long-term use of PPIs to control symptoms.

Review8:32–11:03

Now if EGD with biopsy reveals an oesophageal mass or stricture, columnar metaplasia or dysplasia, diagnose a chronic GERD complication and proceed with appropriate treatment of lifestyle modifications, medical therapy, endoscopic intervention, and surgical consultation with an EGD follow up as needed.
Here's your last clinical pearl. In patients with refractory GERD, another treatment option is anti-reflux surgery, most commonly laparoscopic fundoplication.
In this procedure, the fundus of the stomach is wrapped around the lower esophagus to reinforce the lower esophageal sphincter and increase its pressure.
Another option is magnetic sphincter augmentation or MSA. This involves placing titanium beads with magnetic cores around the distal esophagus, which helps strengthen the sphincter and reduce reflux.
All right, as a quick recap, if you suspect GERD, your first step is to assess for alarm signs and symptoms. If present, suspect GERD complications and proceed directly to urgent EGD with biopsy.
If alarm signs and symptoms are not present, the next step depends on the patient's clinical presentation. Individuals with typical GERD features or those who present with both typical and atypical features should first undergo an eight-week trial of proton pump inhibitors.
If symptoms resolve and are adequate during the trial, diagnose GERD. However, if there is an inadequate response, the next step is to perform an EGD with biopsy.
If the EGD shows erosive esophagitis, GERD is confirmed with findings such as a stricture, Barretts esophagus, or an esophageal mass.
A complication of chronic GERD is confirmed. On the flip side, if the EGD and biopsies are normal, then you should proceed with 24 hour esophageal impedance with pH monitoring.
In contrast, patients who present with only atypical symptoms without any typical GERD features should skip the PPI trial and proceed straight to an EGD with biopsy.
Again, you can diagnose GERD if the EGD reveals erosive esophagitis or if the 24 hour pH monitoring is abnormal. A complication of chronic GERD is confirmed if findings such as a stricture, Barrett's esophagus, or an esophageal mass are