Gastroesophageal reflux disease (GERD) affects at least 20% of Westerners and is characterized by heartburn and acid regurgitation. GERD occurs when the lower esophageal sphincter weakens, allowing stomach acid to flow back into the esophagus. Treatment involves lifestyle changes and over-the-counter or prescription medications like proton pump inhibitors to reduce acid production. For cases that do not respond well to medication, surgical procedures may be considered to strengthen the lower esophageal sphincter. Long-term use of proton pump inhibitors can potentially lead to side effects like bone fractures or pneumonia. Future research aims to develop new therapies targeting incomplete responders to proton pump inhibitors to improve treatment of GER

1. GERD IN
ADULTS
Photo by Steven Fruitsmaak / CC BY-SA 3.0

2. Contents
• Definition, signs, and symptoms
• Causes
• Control
• Diagnosis
• Mild/TypicalGERDTreatment
• Treatment of Atypical/ComplicatedGERDTreatment
• Long-term use of PPIs: Possible Issues
• Surgical Options
• Takeaways

3. DEFINITION, SIGNS AND
SYMPTOMS
Gastroesophageal reflux disease (GERD), of which
2 key symptoms are heartburn (54% of cases) and
regurgitation (29% of cases), affect at least 20%
ofWesterners.1 Other symptoms may include
tightness in chest/upper abdomen, recurring
sour/bitter taste, difficulty swallowing,
hoarseness, sore throat, coughing, wheezing, or
repeatedly clearing throat.2
1. Vaezi MF, Pandolfino JE, Vela MF, et al.: Clin. Gastroenter. Hepatol. 2017;15(8):1162-1172.; 2. Harvard Health. 2016;
https://www.health.harvard.edu/diseases-and-conditions/gastroesophageal-reflux-disease.

4. Causes
• The acid gatekeeper, the lower esophageal sphincter (LES), relaxes abnormally/becomes
weak and does not close properly
• If the stomach does not contract as it should, acid may seep into the esophagus
• Dry-mouth sufferers may also experience GERD symptoms
• Part of the stomach may poke through a hole in the diaphragm
– Hiatal hernia makes it difficult for the LES to function properly to prevent heartburn
• Difficulty swallowing/heartburn also occur when large numbers of white blood cells are
present in the esophagus
– Eosinophilic esophagitis can cause GERD symptoms and initially respond to the same
treatment
• Functional heartburn can be identified in a person experiencing the following continuous
symptoms, starting at least six months prior to diagnosis i.e., burning discomfort or pain
behind the breastbone, no evidence that symptoms are caused by acid reflux from the
stomach, absence of structural disorders that interfere with the movement of food down the
esophagus.
Photo by Olek Remesz/ Wikipedia (esophagus is marked in red)
1. Harvard Health. 2016; https://www.health.harvard.edu/diseases-and-conditions/gastroesophageal-reflux-disease.

5. CONTROL
Foods, certain drugs, and emotions may all impact/worsen
GERD e.g., caffeine-containing foods can loosen the LES and
trigger symptoms.Other factors may include eating patterns,
smoking, overweight and obesity, and pregnancy. Certain
medications may also trigger GERD e.g., progesterone-
containing drugs, aspirin, naproxen, alendronate, and some
antidepressants.
1. Harvard Health. 2016; https://www.health.harvard.edu/diseases-and-conditions/gastroesophageal-reflux-disease.

6. DIAGNOSIS
1. Epocrates. An Athena Health Company 2018;
https://online.epocrates.com/diseases/8234/Gastroesophageal-reflux-disease/Diagnostic-Tests.
PPI Trial – Symptom
improvement
Esophagastroduodenoscopy
– May show ulceration,
strictures, or Barrett
esophagus
Ambulatory pH monitoring –
pH < 4 for more than 4% of
time is abnormal
Esophageal manometry -May
suggest achalasia, esophageal
spasm, or other motor
disorders
Combined impedance-pH
testing – Will detect acid or
non-acid reflux events
Barium swallow – May exclude
other causes of dysphagia
Esophageal capsule
endoscopy – May show
esophagitisor Barrett
esophagitis

7. Mild/
Typical
GERD
Treatment
1. Epocrates. An Athena Health Company. Gastroesphageal reflux disease. 2018;
https://online.epocrates.com/diseases/8241/Gastroesophageal-reflux-disease/Treatment-
Approach.
An endoscopic diagnosis may
guide the basis of treatment
i.e., acid suppression
Treatment may
include proton-
pump inhibitors
Antacids
H2 antagonists
may also be
considered in
patients with
night-time
evidence of reflux
Although not fully
evaluated, lifestyle
changes are
recommended
e.g., weight loss,
smoking cessation,
head-of-bed
elevation, and
elimination of
certain foods if
individual derives
benefit

8. Treatment
of Atypical/
Compli-
cated
Symptoms
1. Epocrates. An Athena Health Company. Gastroesphageal reflux disease. 2018;
https://online.epocrates.com/diseases/8241/Gastroesophageal-reflux-disease/Treatment-
Approach.
Patients with symptoms such as dysphagia/GI
bleeding are candidates for endoscopies. So are
those with symptoms who have lasted > 5
years/who are older than 40 years of age.
Investigations are ongoing to find effective and
safe promotility agents to treat any associated
dysmotility. Patients with symptoms when not
on PPIs, those with erosive esophagitis or
Barrett’s esophagus or typically candidates for
PPIs.
Responders may need guided,
long-term PPI support.
Attempts should be made to
stop/reduce dose to the
minimum to retain
symptomatic control.

9. Long-Term
Use of
PPIs:
Possible
Issues
1. Epocrates. An Athena Health Company. 2018;
https://online.epocrates.com/diseases/8241/Gastroesophageal-reflux-disease/Treatment-
Approach.
• Community-acquired pneumonia (short-term use)
• Elevated risk of bone fractures (long-term use)
Depending on duration, PPI usage has been linked to:
• Possible adverse outcomes when using clopidogrel + PPIs
Evidence of decreased efficacy with clopidogrel
Has been associated with hypomagnesemia
Risk factor for Clostridium difficile-associated diarrhea

10. Surgical Options
1. Epocrates. 2018; https://online.epocrates.com/diseases/8241/Gastroesophageal-reflux-disease/Treatment-Approach.
Who benefits
Mainly for people who have had a
good response to PPIs but who do
not wish to take long-term
medical treatment
FundoplicationTypes
(Equivalent Symptom
Control)
Laparoscopic Nissen (total)
Toupet (270º)
Anterior (180º)
Other Minimally Invasive
Approaches
Magnetic sphincter augmentation
with beads has been shown to
have similar efficacy results to
laparoscopic Nissen
fundoplication in some trials
Select patients with hiatal hernias
<2 cm benefit most from this
approach, but dysphagia is a
possible side effect.

11. TAKE-
AWAYS
Overlapping
Symptoms
Other conditions,
including functional
dyspepsia,
gastroparesis and
eosinophilic esophagitis
can complicate
diagnosis.
PPI Response
PPI partial responders
now comprise a major
proportion of patients
seen by
gastroenterologists in
the clinical setting.
ClinicalTrial
Outcomes
Clinical trials of
combination therapy
with a PPI and a
motility modifying
agent have produced
disappointing result,
perhaps partly due to
enrollment of patients
without the most
appropriate symptom
profile.
Future
Future intervention
trials in GERD should
target patients with
objective criteria for
GERD and incomplete
response to PPI
treatment.
Endpoints must include
objective assessment of
PROs and quality of life.
PRO = patient-reported outcomes; AGA 2018.
https://www.gastro.org/news/white-paper-provides-insight-into-drug-development-
for-gastroesophageal-reflux-disease-
gerd?utm_source=TrendMD&utm_medium=cpc&utm_campaign=American_Gastroente