gerd case study slideshare

Gastroesophageal reflux disease

Raika Jamali M.D.

Gastroenterologist and hepatologist

Sina Hospital

Tehran University of Medical Sciences

Definition of GERD according to �Geneva Workshop

• The term GERD should be used for individuals exposed to the risk of physical complications of reflux, or in whom reflux causes significant impairment of health related well-being or QoL, after adequate reassurance of the benign nature of their symptoms

Pathogenic Factors in GERD

• Heartburn and Regurgitation
• Dysphagia and Odynophagia (stricture and severe esophagitis)
• Barrett’s esophagus
• Esophageal adenocarcinoma
• Noncardiac chest pain
• E.N.T Complications
• Sore Throat
• Hoarseness/Laryngitis
• Globus sensation
• Throat Clearing
• Chronic Otitis media and Sinusitis
• Dental erosions
• Laryngeal cancer
• Pulmonary complicationc
• Chronic dry cough
• Aspiration Pneumonia
• Bronchiectasis
• Pulmonary Fibrosis
•   Miscellaneous
• Dyspepsia (nausea, vomiting, abdominal Pain)
• Anorexia, Wt. Loss
• Anemia, Fatigue
• Burning Mouth
• Sleep disturbances

Clinical Manifestations of GERD

Indications for diagnostic testing in suspected GERD

• Uncertain diagnosis
• Atypical symptoms ( chest pain, ENT, Pulmonary)
• Symptoms associated with complications (dysphagia, odynophagia, unexplained weight loss, bleeding, anemia)
• Inadequate response to therapy
• Recurrent symptoms
• Prior to anti-reflux surgery

Diagnostic studies in GERD

• Diagnosis and Evaluation of GERD is based on Clinical Presentation and Diagnostic tests.There is no real gold standard, each test answers a part of the question:
• Barium swallow: test of choice for evaluating DYSPHAGIA
• EGD: If there is any DAMAGE or COMPLICATION
• pH monitoring : if there is pathologic ACID REFLUX
• Manometry: If there is any FUCTIONAL MOTILITY ABNORMALITY predisposing to reflux, and before surgery
• Empiric trial of acid suppression a PRACTICAL approach
• Intra luminal Electrical Impedance: if there is ANY REFLUX AND SYMPTOM CORRELATION

INCOMPETENT LES

HIATUS HERNIA

Endoscopy Findings in GERD

Gastroentrology; 98: A100, 1990

LOS ANGELES CLASSIFICATION OF MUCOSAL DAMAGE

• A- one or more mucosal break <5mm
• B- one or more mucosal break >5mm
• C- mucosal break contiguous between tops of 2 or more folds but involving <75% of esophageal circumference
• D- same as C but >75% of circumference

The goal of GERD management

• Symptom control
• Improve patients’ health-related quality of life
• Promote mucosal healing (pH>4>12-15 hrs/24h)
• Prevent complications and symptom relapse

Medical therapy for GERD

• Life style modification
• Antisecretory therapy
• - H2 Blockers
• Promotility therapy

H 2 -RA (standard dose)

H 2 -RA (anti-reflux dose)

PPI Pharmacology and Optimal Dosing

• Short half life 0.5-2hr
• Incompletely absorbed, needs acidic environment
• Accumulate at the cannalicular surface of parietal cell
• Bound irreversibly to activated proton pumps
• Inhibits 70% of the active proton pumps

Pharmacodynamic effects of PPIs

• PPIs inhibit meal stimulated, night and day acid secretion
• Use before breakfast, if 2nd dose needed before dinner
• Takes several days to reach steady state, sooner with bid1st week
• Faster steady state in pts with corpus predominant HP gastritis

Johnson et al. Am J Gastroenterol 2000

Maintenance of Healing of Erosive Esophagitis� (n = 318)

esomeprazole 40 mg

esomeprazole 20 mg †

esomeprazole 10 mg

* P < 0.001 vs placebo

% patients in remission

Duration of treatment (months)

Hierarchy of PPI use

• PPI once daily, may substitute ppi,
• 40% failure
• PPI plus H2 RA at bed time
• PPIs bid or double the dose
• PPI bid plus H2RA at bed time
• PPI+ Prokinetics, diabetics or narcotic user
• PPI + TLESR reducer, Baclofen, DGER
• PPI+ pain modulators, Tricyclics, SSRIs, Trazadone, NCCP

TREATMENT GUIDELINES BASED ON EGD FINDINGS

• NERD treat with ppi till better, then use on demand or intermittent (except elderly)
• Erosive Esophagitis Rx till heals, and continue Rx
• Barrett’s esophagus Rx for good
• Peptic stricture dilate and Rx
• Extra-esophageal manifestations

Side effects of PPIs

• Headache, nausea, abdominal pain, diarrhea
• Fundic gland polyps
• ? B12 and Iron malabsorption, concern, not proven
• Increased risk of gram negative pneumonia in ICU, odd ratio 1.8,
• Two fold increase in C-Difficile colitis ( hospitalized, children, on antibiotics, immune suppressed )
• Increased salmonella and campylobacter gastroenteritis
• Increased risk of bacterial infection (reduced PMN activity)
• Increased risk of hip fracture , odd ratio 2.0 (calcium malabsorption)
• PPIs induced interstitial nephritis
• Reduced thyroxine absorption

GERD in Elderly Patients

• GI tract changes with age:
• -Decrease normal peristalsis and increased nontransmitted and simultaneous contractions
• - Decrease saliva
• - increase prevalence of HH
• - Increase swallowing time due to decrease muscle mass
• - Multiple medications that lowers LESP
• - Use of NSAIDs
• Decline of severe heartburn in spite of severe GERD
• Elderly pts >65 may present with anorexia, wt. loss , anemia, dysphagia,respiratory symptoms and chest pain.
• Incresed incidence of:
• - Erosive Esophagitis (37% in >70 vs 17% in <21)
• - Barrett’s Esophagus
• - Esophageal Adenocarcinoma
• EGD is indicated in all elderly pts with GERD symptoms
• Long term PPI if heartburn, HH, and EE originally

Omeprazole requirement in �GERD

• 65% omeprazole 20mg/d
• 20% omeprazole 20mg bid
• 21% Omeprazole 40mg bid

Some reasons why PPIs may fail to control gastric acidity

• Improper dosing time, see if taken with food or antacid
• Weakly acidic reflux
• Bile reflux
• Nocturnal reflux
• Significant intersubject variability in bioavailability of PPIs which may be even further when taken with food
• Acid reducing effect of PPIs is reduced in Helicobacter pylori negative patients
• Acid Hypersecretors (rare)
• Rapid metabolizers of PPIs by cytochrome P-450 cyp 2c isoenzyme
• Incorrect diagnosis
• Eosinophilic esophagitis
• Visceral hypersensitivity
• Psychological comorbidity
• Drugs such as aspirin, NSAIDs and other drugs known to cause direct topical injury
• Factors including gastric stasis, ineffective peristalsis.
• Patients with GERD often have symptoms including bloating, distention,nausea which may be unmasked by PPI even though the classic reflux symptoms have improved

Impedance Technology Fundamentals

Intraluminal Catheter

AC Current Generator

The Impedance Scale

Esophageal Lining

Low Conductivity = High impedance

High Conductivity = Low impedance

MultiChannel Intraluminal Impedance

Bolus Entry

Bolus Movement

Impedance pH and Manometry

• Impedance determines refluxate presence, distribution, clearing time, liquid, gas or mixed
• MII pH shows GER contents
• Acid reflux (pH<4.0)
• Non-acid reflux (pH>4.0 and up to 1 pH point drop)
• Minor acid reflux (pH>4.0 but 2 pH point drop)
• Acid re-reflux (pH <4.0 and may not change)
• MII Manometry determines bolus transfer of liquids and solids

Clinical indications of combined MII-pH testing

• Patients with persistent symptoms on bid, PPI therapy (refractory GERD, reason for GI referral)
• Patients with ? GERD related ENT and Pulmonary symptoms
• Patients with reflux symptoms and achlorhydria (I.e. atrophic
• Patients with reflux symptoms after surgical gastrectomy

Persistent heartburn on PPI

• In patients with persistent symptoms when on bid PPI Impedance pH studies reveals
• 20% have Acid reflux = drop in pH to < 4.0
• 40% Non-Acid reflux = pH stays above 4.0
• and does not drop more than1 pH unit
• 40% No Reflux preceding symptoms

Symptoms Not Correlated with Reflux

GERD Diagnostic Algorithm�

Acid Reflux with Symptoms

Nonacid Reflux with Symptoms

Possible GERD Symptoms

Symptom Relief

Antireflux Medication Trial

Impedance-pH Monitoring

(On Medication)

Persistent Symptoms

New formulation of PPI

• IR-OME, naked omeprazole+Na bicarb, eliminates meal timing, no need for food, good for on demand rx
• Kapidex 60mg, dual delayed release Lansoprazole
• Tenatoprazole 40 mg, half-life 9.3 hrs, like40 mg bid esomeprazole
• S-Tenatoprazole-Na (STU-Na) 60mg effect on nocturnal heartburn present 5 days after D/C in it
• AGN201,9047 600mg acid stable product of omeprazole producing continuous metered absorption
• K competetive acid blocker, AZD0865 rapid onset, bid
• GABA-B agonist Baclofen, reduces TLESR, reduces all refluxes, specially nonacid reflux
• XP19986 prodrug of R-Baclofen 40 mg dose
• 5-HT4receptor agonist Tegaserod, prokinetic and sensitivity modulator, 6mg bid

Night time GERD

• Day and night GERD 65%, day only GERD 20% and night only GERD 13%
• Asthma, morning cough and phlegm is 2 to 3 times more common with nighttime GERD
• Predictors of nighttime gerd:
• Obesity (increased intragastric pressure, increase HH, dietary factors, ? Humoral factors), HTN (? Meds), Benzodiazepines ( lowers LESP), Carbonated beverages , Insomnia, Snoring, and sleeping during the day

GERD and Asthma

• Up to 70% of asthmatics complain of heartburn
• Prevalence of GERD in asthmatics is 30% to 80%.
• GERD produces or exacerbate asthma by reflex and reflux
• Asthma conversely produces or aggravate GERD by :
• Flattening diaphragm
• Relaxing LES (Flattening diaphragm and albuterol inhalers dose dependant decrease in LESP and peristalsis amplitude, anticholinergics)
• Increasing acid exposure of distal and proximal esophagus high dose steroids for more than 7 days)
• HH, supine position and dietary factors more frequent in asthmatics
• Pts with asthma>60 yo have 13x more chance of having GERD than healthy pts < 20 yo.
• EGD is normal in >60% of asthmatics

• My presentations

Auth with social network:

Download presentation

We think you have liked this presentation. If you wish to download it, please recommend it to your friends in any social system. Share buttons are a little bit lower. Thank you!

Presentation is loading. Please wait.

Gastro-Esophageal Reflux Disease (GERD)

Published by Lindsey Beasley Modified over 5 years ago

Similar presentations

Presentation on theme: "Gastro-Esophageal Reflux Disease (GERD)"— Presentation transcript:

Nursing Care of Patients WithUpper GI Disturbances

Cancer of the GI System. Esophageal cancer Pathogenesis: Rare Secondary to infiltration/structure alteration Most common at gastroesophageal junction.

Upper GI quiz PBL 28.

GASTROINTESTINAL Pathology I January 9, Gastrointestinal Pathology I Case 1.

Faculty of Allied Medical Sciences Histopathology and Cytology (MLHC-201)

Peptic Ulcer Disease Dr Maha Arafah. Objectives Upon completion of this lecture the students will : A] Understand the Pathophysiology of acute and chronic.

GENERAL THORACIC SURGERY CHAPTER 141

Oesophageal Tumours Dr M. Abrar Barakzai. Revision of basic tumour pathology Definitions Nomenclature – Benign versus Malignant – Histogenetic classification.

Dysphagia Dr. Raid Jastania.

January 8 th, 2014 MHD II GI PATHOLOGY I LABORATORY.

Gastrointestinal Diseases and Disorders Karen E. Hall, M.D., Ph.D. GRECC, Ann Arbor VA Health System University of Michigan Health System Contributors.

بسم الله الرحمن الرحيم GIT Diseases By Dr. Ghada Ahmed Lecturer of Pathology Benha Faculty of Medicine.

GASTRO INTESTINAL DISORDERS Dr.linda maher. GIT(GASTRO INESTINAL TRACT)  it is a tube with muscle walls throughout its length. it is lined by an epithelium.

Gastrointestinal Diseases Dr. Maha Arafah Pathology, 2013.

Histology of the upper Git

Gastroesophageal Reflux Disease (GERD)

Upper Gastrointestinal Diseases. Upper GI Diseases Esophagus Stomach Duodenum.

Gastric carcinoma.

Gastrointestinal system Part II The oesophagus. A muscular tube Conduction of food and drink Sphincters at top and bottom.

Esophagus cancer Dr Sanei Associated professor of pathology GI and Liver patholoogist.

About project

© 2024 SlidePlayer.com Inc. All rights reserved.

• AGA Journals
• AGA University
• AGA Research Foundation
• AGA Community
• AGA Job Board
• Create Account

Clinical Guidance

Our clinical guidelines and updates help you make the best evidence-based decisions for your patients.  

• Library AGA’s guidelines, practice updates and care pathways in one place.
• Guideline Toolkits Comprehensive resources for managing diseases.

Journals & Publications

Latest research and ideas from the GI field.

• Gastroenterology The premier journal in GI.
• Clinical Gastroenterology and Hepatology (CGH) The go-to resource in clinical GI.
• Cellular and Molecular Gastroenterology and Hepatology (CMGH) Impactful digestive biology research.
• Techniques and Innovations in Gastrointestinal Endoscopy (TIGE) Cutting-edge advances in GI endoscopy.
• Gastro Hep Advances Open access GI and hepatology journal.
• GI & Hepatology News AGA’s official newspaper.
• The New Gastroenterologist Insights for fellows and early career GIs.

Meetings & Learning

Earn CME, MOC and improve your skills.

• AGA University Your hub for the best in GI education – AGA Postgraduate Course, Tech Summit and more.
• Digestive Disease Week® The most prestigious GI meeting.
• Crohn's & Colitis Congress® The premier meeting on IBD.
• Maintenance of Certification Resources for maintaining certification.
• DDSEP® The leading self-assessment tool for GI.
• Inside Scope Podcast An AGA podcast with bite-sized education.

More than 16,000 professionals worldwide call AGA their professional home.

• Join AGA Join our diverse mix of professionals.
• Renew Membership Continue to receive exclusive benefits and discounts.
• Benefits Unrivaled by any other GI organization.
• Membership Directory Contact other AGA members.
• Recognition Awards We honor our esteemed members.
• Initiatives & Programs Advancing the science and practice of GI.
• Get Involved with AGA Help us achieve a world free from digestive diseases.
• Advocacy & AGA PAC Advancing public policies that support gastroenterology.

Practice Resources

Tools to maximize efficiency and help you deliver high-quality care.

• Practice Tools Cutting-edge resources to improve your patient care.
• New Technology & Techniques The latest innovations in GI.
• Quality & Performance Measures Support to meet reporting requirements.
• Reimbursement Tools to understand policies and advocate for reimbursement.
• GI Patient Center By specialists, for patients.

Research & Awards

Funding opportunities and other initiatives advancing discovery.

• Research Awards More than $2 million in annual research funding.
• Registries & Studies Data to support new techs and treatments.
• Gut Microbiome One of GI’s most promising areas of research.
• AGA Research Foundation Funding the future of gastroenterology.

Fellows & Early Career

Resources designed for early career gastroenterologists.

• Resources Resources for every stage of your career.
• Fellowship Match Information for programs and candidates.
• AGA GTE® The first training exam for GI programs and fellows.
• Mentoring Connect with prospective mentors.
• Job Board Find your next opportunity.

GERD and Refractory GERD: A Case Based Approach

Review of treatments GERD:

Download the session audio:

Download the PowerPoint presentation:

4930 Del Ray Avenue, Bethesda, MD 20814 301-654-2055

Connect with aga.

©   American Gastroenterological Association

• Privacy Overview
• Strictly Necessary Cookies
• Cookie Policy

This website uses cookies so that we can provide you with the best user experience possible. Cookie information is stored in your browser and performs functions such as recognising you when you return to our website and helping our team to understand which sections of the website you find most interesting and useful.

Strictly Necessary Cookie should be enabled at all times so that we can save your preferences for cookie settings.

If you disable this cookie, we will not be able to save your preferences. This means that every time you visit this website you will need to enable or disable cookies again.

More information about our Cookie Policy

Got any suggestions?

We want to hear from you! Send us a message and help improve Slidesgo

Top searches

Trending searches

49 templates

44 templates

61 templates

american history

85 templates

el salvador

34 templates

63 templates

Gastroesophageal Reflux Clinical Case

It seems that you like this template, gastroesophageal reflux clinical case presentation, free google slides theme, powerpoint template, and canva presentation template.

Clinical cases help medicine students understand better the symptoms, treatment and development of a disease. They’re also very valued in the international scientific community, as they foster communication between professionals so they can learn new techniques and practises. This clinical case is focused on Gastroesophageal reflux disease (GERD). What symptomatology does it have? What treatments are now available and how are they applied? These slides have all the resources you need for explaining medical concepts in a visual and clear way!

Features of this template

• 100% editable and easy to modify
• 27 different slides to impress your audience
• Contains easy-to-edit graphics such as graphs, maps, tables, timelines and mockups
• Includes 500+ icons and Flaticon’s extension for customizing your slides
• Designed to be used in Google Slides, Canva, and Microsoft PowerPoint
• 16:9 widescreen format suitable for all types of screens
• Includes information about fonts, colors, and credits of the resources used

How can I use the template?

Am I free to use the templates?

How to attribute?

Attribution required If you are a free user, you must attribute Slidesgo by keeping the slide where the credits appear. How to attribute?

Register for free and start downloading now

Related posts on our blog.

How to Add, Duplicate, Move, Delete or Hide Slides in Google Slides

How to Change Layouts in PowerPoint

How to Change the Slide Size in Google Slides

Related presentations.

Premium template

Unlock this template and gain unlimited access

GASTROESOPHAGEAL REFLUX DISEASE

Mar 14, 2019

2.09k likes | 4.42k Views

GASTROESOPHAGEAL REFLUX DISEASE. Tiberiu Hershcovici , MD Director, Gastrointestinal Motility Lab Hadassah University Hospital. DEFINITION.

Share Presentation

• erosive esophagitis
• typical symptoms
• clinical presentation
• infrequent reflux symptoms
• clinical presentation atypical symptoms

Presentation Transcript

GASTROESOPHAGEAL REFLUX DISEASE TiberiuHershcovici, MD Director, Gastrointestinal Motility Lab Hadassah University Hospital

DEFINITION • According to the Montreal International Consensus Group1: GERD is defined as a condition that develops when the reflux of stomach contents causes troublesome reflux-associated symptoms. • While GERD is commonly diagnosed in clinical practice based on symptoms alone, it has been demonstrated that esophageal symptoms are not stimulus specific and thus heartburn could result from non-reflux related stimuli. Vakil N, et al. The American Journal of Gastroenterology 2006;101(8):1900-20

CLASSIFICATION • Patients with GERD are further classified based on upper endoscopy results, into: • erosive esophagitis, if visible mucosal breaks in the distal esophagus are present- 20-30% • nonerosivereflux disease (NERD), if the mucosal breaks are absent- 60-70% • Esophageal complications of erosive esophagitis are: • ulceration • stricture • Barrett’s esophagus • adenocarcinomaof the esophagus.

EPIDEMIOLOGY • Population-based studies suggest that GERD is a common condition with a prevalence of 10–30% in Western Europe and North America. • GERD is less commonly seen in the Asia-Pacific region.

EPIDEMIOLOGY • The prevalence of GERD and GERD-related disorders has been steadily increasing in the US, Western Europe, Australia and Asia. • An opposing trend time was observed between 1970 and 1995 in the prevalence of peptic ulcer disease and GERD. • The rates of peptic ulcer and gastric cancer fell while at the same time the rates of GERD and esophageal adenocarcinoma rose significantly.

CAUSES AND RISKS FACTORS • Age: prevalence of GERD increases with age, older patients are more likely to develop less symptomatic but more severe disease • Cigarette smoking • Alcohol • Coffee • High fat diet • Food products such as chocolate, peppermint, citrus juicesbut not carbonated beverages • Medications: narcotics, calcium channel blockers etc.

GERD -OBESITY • Obesity is associated with: • 1.5- 2-fold increase risk for GERD symptoms and erosive esophagitis • 2- 2.5-fold increase risk for esophagealadenocarcinoma • Mechanisms proposed to explain the close relationship between increased BMI and GERD include: • increased gastroesophageal pressure gradient • increased prevalence of hiatalhernia • increased prevalence of transient lower esophageal sphincter relaxations (TLESR)

RELATIONSHIP BETWEEN HELICOBACTER PYLORI AND GERD • Some studies suggested that H. pylori infectionconferred protection from GERD and its eradication was associated with an increased risk of developing GERD. • A more recent meta analysis of twelve trials revealed no association between H. pylori eradication in patients with duodenal ulcer and: • development of erosive esophagitis, • appearance of new symptomatic GERD, • worsening of symptoms in patients with pre-existing GERD. Laine L, et al. The American Journal of Gastroenterology 2002;97(12):2992-7.

PATHOGENESIS • DYSFUNCTION OF THE LES • HIATAL HERNIA

DYSFUNCTION OF THE LES • GER occurs predominantly during transient lower esophageal sphincter relaxation (TLESR), • TLESR is a spontaneous (not preceded by a swallow), prolonged relaxation of the LES (>10 sec). It is triggered primarily by gastric fundicrelaxation and mediated by a vago-vagalreflex. • Although recent trials found no increased rate of TLESR’s in patients with GERD, TLESR was more likely to be associated with an acid reflux event in patients with GERD as compared to healthy controls. • This may be caused by increased compliance of the esophago-gastric junction in GERD patients.

HIATAL HERNIA

HIATAL HERNIA • The presence of a hiatal hernia, particularly if it is large (≥5 cm) is associated with increased severity of GERD . • The prevalence of hiatal hernia increases with the severity of esophageal mucosal involvement. • 20-30% in NERD patients • 95% in patients with long segment Barrett’s esophagus • Displacement of LES from the cruraldiaphragm into the chest: • reduces LES basal pressure • loss of the intra-abdominal LES segment • reduced threshold for TLESR in response to gastric distension

PATHOGENESIS –OTHER FACTORS • Esophageal mucosal defense mechanisms • Esophageal clearance – peristaltic dysfunction • Gastric acid secretion • Duodenogastroesophageal (bile) reflux • Acid pocket –related to hiatal hernia • Gastric dysmotility

OTHER CAUSES OF EROSIVE ESOPHAGITIS

CLINICAL PRESENTATION-TYPICAL SYMPTOMS • Heartburn: a sensation of discomfort or burning behind the sternum rising up to the neck, made worse after meals and eased by antacids. • Acid Regurgitation: the perception of flow of refluxed gastric content into the mouth or hypopharynx.

CLINICAL PRESENTATION-ATYPICAL SYMPTOMS • Angina-like chest pain-non cardiac chest pain • Globus sensation • Chronic cough • Hoarseness • Asthma

CLINICAL PRESENTATION • GERD symptom frequency or severity does not correlate with the extent of esophageal mucosal involvement in patients with erosive esophagitis. • Heartburn severity and intensity are similar in patients with erosive esophagitis and NERD. • In the elderly patient with GERD, heartburn and acid regurgitation are less frequent than in younger subjects. • In contrast, atypical symptoms such as vomiting, anorexia, dysphagia, respiratory symptoms, belching, dyspepsia, hoarseness, and postprandial fullness are more common presentations in elderly.

DIAGNOSTIC METHODS • Clinical evaluation • The proton pump inhibitor (PPI) test • Upper endoscopy • Ambulatory 24-hour esophageal pH monitoring

DIAGNOSTIC METHODS • Clinical evaluation • The proton pump inhibitor (PPI) test: • a short course (1–4 weeks) of high-dose PPI given twice daily for the diagnosis of GERD in patients with typical, atypical or extraesophageal manifestations of GERD. • If symptoms disappear with therapy and then return when medication is stopped, GERD can be assumed and no further testing is required. • Sensitivity: from 66% to 89%, • Specificity: from 35% to 73%.

UPPER ENDOSCOPY • The gold standard procedure for diagnosing erosive esophagitis, GERD complications, and Barrett’s esophagus. • Allows an assessment of the degree of esophageal mucosal injury, and tissue sampling can be performed if necessary. • Sensitivity: 30–50% in patients with typical symptoms of GERD, as most patients with GERD have NERD. • Specificity: 9095%.

AMBULATORY 24-HOUR ESOPHAGEAL pH MONITORING • Allows assessment of : • 24-hour esophageal acid exposure • the temporal relationship between patient symptoms and acid reflux events

TREATMENT-GOALS • Adequate relief of GERD symptoms • Healing of erosive esophagitis if present • Maintenance of mucosal healing • Improvement of quality of life

LIFESTYLE MODIFICATIONS • Adequate for patients with mild and infrequent reflux symptoms • Weight loss • Cessation of smoking • Elevation of head of the bed • Avoidance of aggravating foods

PROTON PUMP INHIBITORS • For patients with erosive esophagitis :effective control of reflux symptoms (77%) and a high rate of healing of esophagitis (84%). • The proportion of NERD patients responding to a standard dose of PPI is approximately 2030% lower than in patients with erosive esophagitis. • A once-daily morning dosing of PPI, half an hour before a meal, is generally the most appropriate initial therapy, but may fail in up to 30% of patients.

HISTAMINE TYPE 2 RECEPTOR ANTAGONISTS • Standard doses have been proven to be effective in controlling symptoms and in healing mild to moderate erosive esophagitis. • Tachyphylaxis develops quickly with H2RAs, limiting their regular use in clinical practice. • The main appeal of H2RAs is their rapid effect on GERD symptoms, unsurpassed by any of the currently available PPIs. • Nighttime use for refractory symptoms-currently unproven

TLESR REDUCERS • Gamma-aminobutyric acid B (GABAB ) receptor agonists: • Baclofen • Arbaclofenplacarbil • Lesogaberan • Metabotropic glutamate receptor 5 (mGluR5) antagonists • ADX10059

PROMOTILITY AND PROKINETIC DRUGS • May improve gastroesophageal reflux by: • increasing LES basal pressure • restoring esophageal peristalsis • facilitating gastric emptying • The benefit of these compounds in controlling heartburn and in healing erosive esophagitis has been very modest, primarily because of lack of effect on TLESR.

ANTIREFLUX SURGERY • Laparoscopic Nissenfundoplication remains the most commonly performed operation and consists of a 360° wrap of the gastric fundus around the distal esophagus • Results in augmentation of LES basal pressure and a decrease in the rate of TLESR. • Relieves reflux symptoms and heals erosive esophagitis. • However: Barrett’s esophagus does not regress.

Management algorithm

CLINICAL STRATEGIES • The step-up approach initiates patients on the least effective antireflux modality and upgrades treatment if satisfactory control of symptoms is not achieved. • The step-down approach initiates patients on the most potent antireflux modality and downgrades patients to a therapeutic modality that still controls their symptoms effectively. • The step-in approach initiates and maintains patients on the most potent antireflux modality. It is the most popular therapeutic strategy in clinical practice. • On-demand or intermittent PPI therapy: in patients with NERD and potentially in those with mild erosive esophagitis.

REFRACTORY GERD • Patients who failed to obtain satisfactory symptomatic response after a course of standard-dose PPI. • Any attempt to narrow the definition of refractory GERD might exclude many true sufferers

The PPI Failure DilemmasWhat Constitutes PPI Failure? • Failure of PPI once a day – No GERD indications for PPI twice daily – Drug development – Third-party payers and institutions • Failure of PPI twice daily – Clinically relevant • Symptoms cutoff •  Complete •  Partial

Erosive esophagitis Nonerosive reflux disease Barrett’s esophagus 40%–50% 25%–30% 20% PPI Failure The Reported Rate of Symptomatic Failure in Therapeutic Trials of GERD Patients

Psychological comorbidity • Compliance • Improper dosing time • Eosinophilic esophagitis (?) • Functional heartburn (esophageal hypersensitivity) • Weakly acidic reflux • Duodenogastroesophageal reflux • Residual acid reflux • Reduced PPI bioavailability • Rapid PPI metabolism • PPI resistance • Others • Delayed gastric emptying • Concomitant functional bowel disorder Putative Underlying Mechanisms for PPI Failure Fass & Sifrim. Gut 2009;58:295-309

Distribution of Adherence to Proton Pump Inhibitor Treatment Over Time Van Soest et al. Aliment Pharmacol Ther 2006;24:377-385)

Suboptimal Proton Pump Inhibitor Dosingin PPI Failure Patients N = 100 Gunaratnam et al. Aliment Pharmacol Ther 2006;23(10):1473-1477

Psychological comorbidity • Compliance • Improper dosing time • Eosinophilic esophagitis (?) • Functional heartburn (esophageal hypersensitivity) • Weakly acidic reflux • Duodenogastroesophageal reflux • Residual acid reflux • Reduced PPI bioavailability • Rapid PPI metabolism • PPI resistance • Others • Delayed gastric emptying • Concomitant functional bowel disorder The Persistent Reflux Hypothesis Fass & Sifrim. Gut 2009;58:295-309

Terms You Need to Know

How Common is Residual Acid Reflux in Patients Who Failed PPI Once or Twice Daily? N = 79 56 N = 40 75 Charbel et al. Am J Gastroenterol 2005;100(2):283-289.

5% N=184 33% 40% 22% Results of Combined pH and Bilitec Monitoring in Symptomatic GERD Patients While on PPI Therapy Karamanolis et al. Dig Dis Sci 2008;53:2387-2393

PPI once daily (2 months) Failure Review proper PPI dosingtime and compliance Failure Switch to another PPI (2 months) Failure Failure PPI twice daily (am &pm) for 2 months Failure Esophageal impedance + pH Positive forweakly acidic reflux Negative Positive for acid reflux Pain modulatorsTricyclicsSSRIsTrazodone Review againPPI dosing timeand compliance TLESR Reducers Pain modulators Antireflux surgery Alarm symptoms Upper endoscopy Treat mucosal findings H2RA qhsTLESR reducersPain modulators Hershcovici and Fass. Best Prac Res Clin Gastroenterol (in press)

EPIDEMIOLOGY • 7% of the US adult population has erosive esophagitis whereas in Europe and Asia the prevalence has been estimated to range between 2–10%. • Furthermore, erosive esophagitis is usually milder in Asia (predominantly Los Angeles grade A and B) and complications are relatively uncommon.

• More by User

Gastroesophageal Reflux Disease

Gastroesophageal Reflux Disease. Howard J. McGowan, Maj, USAF, MC. Objectives. Definition of GERD Epidemiology of GERD Pathophysiology of GERD Clinical Manisfestations Diagnostic Evaluation Treatment Complications. Definition. American College of Gastroenterology (ACG)

2.48k views • 38 slides

Gastroesophageal Reflux Disease. Scott Stolte, Pharm.D. Shenandoah University. Overview of GERD. Definition Symptoms or mucosal damage produced by the abnormal reflux of gastric contents into the esophagus Classic symptom is frequent and persistent heartburn

1.76k views • 48 slides

Gastroesophageal reflux disease

Gastroesophageal reflux disease. Dr. Navin Kumar Assistant Professor. GERD. Defined as troublesome symptoms or complications that result from the reflux of gastric contents into the esophagus or beyond into the oral cavity or lung . Troublesome is defined by consensus as

1.44k views • 33 slides

Gastroesophageal Reflux Disease. Rajeev Jain, MD November 27, 2006. Outline. Definition Epidemiology Pathophysiology Diagnosis Treatment Management. Definition. No gold standard Montreal Definition

1.08k views • 47 slides

Gastroesophageal Reflux Disease: Beyond Heartburn

Gastroesophageal Reflux Disease: Beyond Heartburn. Annette Y. Kwon, M.D. Edward W. Holt, M.D. October 1, 2011. Gastroesophageal Reflux Disease. The scope of the problem What is the working definition? What is the pathophysiology? What is laryngopharyngeal reflux?

1.36k views • 33 slides

GastroEsophageal Reflux Disease (GERD)

GastroEsophageal Reflux Disease (GERD). Marijo Čukelj Mentor: A. Žmegač Horvat. Definition. prolonged reflux of hydrochloric acid and pepsin in esophagus, oral cavity and respiratory system chronic and relapsing condition

517 views • 13 slides

GASTROESOPHAGEAL REFLUX DISEASE. Tiberiu Hershcovici , MD Director, Gastrointestinal Motility Lab Hadassah University Hospital . DEFINITION .

1.45k views • 44 slides

Gastroesophageal Reflux Disease. “a prevalent and chronic condition in which reflux of the stomach contents into the oesophagus causes a range of troublesome symptoms (including heartburn, acid regurgitation and epigastric pain) and complications”. Gastroesophageal Reflux Disease (GERD).

891 views • 15 slides

Gastroesophageal Reflux Disease (GERD)

Gastroesophageal Reflux Disease (GERD) . By: Joe Hollis &amp; Spencer Poprawski. Table of Contents . Overview of GERD (definition of the disorder) Signs and Symptoms (diagnosis) Treatment of GERD Risk Factors Tests Video . Overview of GERD .

688 views • 11 slides

GASTROESOPHAGEAL REFLUX DISEASE. .

GASTROESOPHAGEAL REFLUX DISEASE. . Definitions of Reflux. Clinical manifestations of reflux of stomach &amp; duodenal contents into the esophagus. Characterized by any combination of symptoms, radiologic, endoscopic, or pathologic changes. In its milder forms, is common .

900 views • 38 slides

Gastroesophageal Reflux Disease in Infants

Gastroesophageal Reflux Disease in Infants. GERD is a very common and usually benign physiological event in infants.

1.27k views • 79 slides

GASTROESOPHAGEAL REFLUX DISEASE (GERD)

GASTROESOPHAGEAL REFLUX DISEASE (GERD). Ahmed A. Elberry, MD. Anatomy of the stomach:. Incidence:. GERD is the most common GIT disorder (over 1.0 million out patient visits to physicians every year!)

3.69k views • 25 slides

GASTROESOPHAGEAL REFLUX DISEASE. Definitions of Reflux. Clinical manifestations of reflux of stomach &amp; duodenal contents into the esophagus. Characterized by any combination of symptoms, radiologic, endoscopic, or pathologic changes. In its milder forms, is common .

878 views • 38 slides

Gastroesophageal Reflux Disease (GERD). * Definition : inflammation of the lower part of the esophagus due to abnormal reflux of gastric contents into the esophagus Often chronic and relapsing.

665 views • 22 slides

Gastroesophageal Reflux Disease (G.E.R.D.)

Gastroesophageal Reflux Disease (G.E.R.D.). Rory Loveland Paramedic class ’08-’09. What is GERD. Loosening of the lower esophageal sphincter (LES). Allows gastric acid to splash into the esophagus. Refluxed stomach acid touches the lining of the esophagus causing a burning sensation.

530 views • 13 slides

Gastroesophageal Reflux Disease (GERD). Presented by: Rachel Lang April 15, 2003 ASC 823 C. GERD. Often called reflux It is the recurring backflow of acid from the stomach into the esophagus. FACTS. According to the U.S. Department of Health and Human Services :

588 views • 15 slides

gastroesophageal reflux disease GERD

gastroesophageal reflux disease GERD. Department of gastroenterology, 1 st hospital of jilin university Tongyu Tang. Definition. American College of Gastroenterology (ACG)

2.75k views • 32 slides

317 views • 15 slides

• Barry R. Katz, M.D.
• Raaj K. Popli, M.D.
• Sanjay K. Reddy, M.D.
• Harry H. Shephard, M.D.
• Jorge A. Zapatier, M.D.
• Robert A. Shultz, D.O.
• Zachary I. Field, M.D.
• Hanna Agard, APRN
• Jeanine Febres, APRN
• Naomi Ringer, APRN
• Andrea Alegria Roa, APRN
• Accepted Insurances
• Patient Portal

Case Study: Self Diagnosis, Denial and Danger With GERD

In a previous blog, we introduced you to GERD patient, Elena , our DDC Orlando case study. She continued to endure worsening heartburn and acid reflux for years.  Yet she had barely mentioned her self-diagnosed GERD problem to her doctor.  She tried to shrug it off as indigestion, dyspepsia and just a bad stomach.

Here at DDC Orlando, in Dr. Sanjay Reddy’s words, “Not all GERD is just dyspepsia.”  As we continue Elena’s case study over several more blogs, you will see that not every case of GERD simply signifies indigestion.  Likewise, no case should be self-diagnosed because of a magazine article or a friend’s story.

Case Study:  Patient faces Denial, Takes the First Steps

Case Study in GERD shows a dangerous tendency to self-diagnose.

It is true that most patients with GERD can be successfully treated with medications and lifestyle changes.  However, self-diagnosis of GERD can be medically dangerous because the symptoms of GERD can indicate more serious digestive problems.

In a recent interview, DDC Orlando’s Dr. Sanjay Reddy stated, “Chronic heartburn and acid reflux can mean more than “just” GERD.  Gastro Esophageal Reflux Disease itself can be the body’s way of sending alarm signals to indicate more serious problems.”  This is exactly the reason your primary doctor might refer you to Digestive Disease Consultants of Orlando.  With a careful examination, case history and state-of-the-art testing, we can interpret the alarm signals from your body.  We need to know if your GERD symptoms are just dyspepsia, like most patients.   Or if we should investigate more serious possibilities.

Perhaps, like our case study, Elena, you do not know about all the other possibilities such as Barrett’s Esophagus or the beginnings of esophageal cancer.  In the mind and experience of a patient, the symptoms of those diseases might seem like a straight-forward case of GERD.

At DDC Orlando, when patients exhibit GERD symptoms, doctors work to discern and monitor your risk of a condition that can result in cancer without proper treatment. GERD is not always simply dyspepsia.  In the words of experts, “It is essential for individuals who suffer persistent heartburn or other chronic and recurrent symptoms of GERD to seek an accurate diagnosis , to work with their physician, and to receive the most effective treatment available.”

Case Study:  Elena’s Denial and Excuses for Avoiding Diagnosis

Doctor explains GERD to DDC Orlando Patient

Toughness:  Her parents raised her to be strong.  Years of conditioning to be tough had taught her to grin and bear it.  So she developed a high tolerance for pain when her throat burned or her chest ached.  She avoided the doctor and months stretched into years.  Like many people who deal daily with acid reflux, she blamed it on dyspepsia.

She was in denial that there could be anything more severe than indigestion interrupting her life.  She refused to let GERD take more than a few moments of her time.  This mind-set worked for a while, but as in many case studies, symptoms grew very severe.  Finally, it became obvious to Elena that the over-the-counter antacids did not have the power to treat her illness.

Timidity:   Elena could not be considered an introverted person.  However, she had a deep-seated shyness about discussing bodily functions.  Even admitting her diarrhea embarrassed her.  Additionally, her friends had told her horror stories about the type of testing her condition might require. ( Rest assured, DDC Orlando will be addressing that issue in the near future. )

Case Study:  Elena and the Lifestyle Changes—Her Baby-Steps

After a few more attacks l ike the one at her Birthday dinner , our case study patient’s family became concerned. Elena’s  husband hugged her as he said, “Three trips to the emergency room in two months?  Hon, something’s wrong.  I took the liberty of making you an appointment.  Keep it or change it, but you can’t go on like this.”

She kept the appointment with her primary care doctor.  Based on her description of her reflux and heartburn symptoms, he diagnosed GERD.  He immediately suggested life-style and dietary changes. (She thought, “Tell me something I don’t know.  I’ve already started changing my life. I know some of my triggers .  I am keeping a food diary.)

He also wrote prescriptions for stronger medications than over-the-counter antacids and booked her for a re-check in six weeks.  She smiled weakly when the doctor gave her several brochures about GERD lifestyle changes.  Our case study dreaded trying to lose her extra 38 pounds of body weight.

Case Study Quiz:  Find the Anti-GERD Lifestyle Changes in Elena’s Story Below!

We challenge you to find the lifestyle changes woven into the following case-study scenario:

Elena drove home slowly and fought sadness because now GERD was a real medical diagnosis .  As she picked up her prescriptions at the pharmacy, she hated the idea of depending on her new pills to control it.  Then she desperately wanted a cigarette, but she had quit two weeks ago because she knew they were a trigger.  They literally hurt her throat and chest.  She smiled grimly.  A good strong cup of coffee would improve her mood, she thought.  But it wasn’t worth the choking hot lava in the throat, the reflux.  Caffeine was another one of the first triggers she discovered .  She had not had a cup in three weeks, since her last trip to the emergency room.

Case Study Scenario:  GERD vs. Family life

Upon her return home, Elena’s 6-year-old daughter Ashleigh met her at the door,

“Mommy, Mommy, Daddy turned your bed into a slide,” she shrilled.

We re-join patient Elena’s story of her diagnosis of GERD.  To enrich your understanding, we suggest you read or review the introduction of her case study in our one of our previous blogs.   Before the dramatic episode on her birthday , which resulted in an emergency room visit, Elena had never seriously discussed her chronic heartburn and reflux with her primary physician.  Her knowledge of the condition came from conversations with friends and a few magazine articles.

Case Study:  The Patient’s Top Three Excuses for Avoiding a Discussion of GERD

Time:   Elena is a busy mom of three with her own part-time real estate job.  Our case study patient, Elena, had a hectic life and a full schedule.  She declared, “I just don’t have time to go see the doctor every time I have a belly ache or heartburn.”

Case Study Patient With GERD finds hope with family support.

Elena could see the head of the bed had been raised  on pretty polished wooden blocks.  Our case study patient started to smile.  Her husband, still holding an electric drill from his bed-tilting project, strode into the room and hugged her.

14-year-old Lisa popped her head around the kitchen doorway, “Hi, Mom!  I made Baked Parmesan Chicken Breasts for dinner.  You’ll love them. They’re crispy even without skin!” Elena’s 9-year-old son, Mike chimed in, “And Dad made me eat the rest of those cookies so you wouldn’t be tempted !”  Elena laughed, hugged, and stopped feeling sad. “Yeah,” added Mike, as if to explain the cookies, “We read all about Gerdie on the Internet.” … And that is how our DDC Orlando GERD case study patient named her condition! 

Please join us at this blog next week for all the answers to the above case study quiz .  You’ll find out more about Elena’s lifestyle changes.  Also, learn why, six weeks after diet, medication and lifestyle changes, she ended up in the emergency room again with GERD symptoms.

Gastroesophageal Reflux Disease Clinical Presentation

• Author: Marco G Patti, MD; Chief Editor: BS Anand, MD  more...
• Sections Gastroesophageal Reflux Disease
• Practice Essentials
• Pathophysiology
• Epidemiology
• Physical Examination
• Approach Considerations
• Upper Gastrointestinal Endoscopy
• Esophageal Manometry
• Ambulatory 24-Hour pH Monitoring
• Imaging in Gastroesophageal Reflux Disease
• Nuclear Medicine Gastric Emptying Study
• Intraluminal Esophageal Electrical Impedance
• Lifestyle Modifications
• Pharmacologic Therapy
• Surgical Care
• Medication Summary
• Proton Pump Inhibitors
• Potassium-Competitive Acid Blockers
• H2-Receptor Antagonists
• Prokinetics
• Questions & Answers
• Media Gallery

Gastroesophageal reflux disease (GERD) is associated with a set of typical (esophageal) symptoms, including heartburn, regurgitation, and dysphagia. (However, a diagnosis of GERD based on the presence of typical symptoms is correct in only 70% of patients.) In addition to these typical symptoms, abnormal reflux can cause atypical (extraesophageal) symptoms, such as coughing, chest pain, and wheezing.

The American College of Gastroenterology (ACG) published updated guidelines for the diagnosis and treatment of GERD in 2005. According to the guidelines, for patients with symptoms and history consistent with uncomplicated GERD, the diagnosis of GERD may be assumed and empirical therapy begun. Patients who show signs of GERD complications or other illness or who do not respond to therapy should be considered for further diagnostic testing. [ 7 ]

A history of nausea, vomiting, or regurgitation should alert the physician to evaluate for delayed gastric emptying.

Patients with GERD may also experience significant complications associated with the disease, such as esophagitis, stricture, and Barrett esophagus. Approximately 50% of patients with gastric reflux develop esophagitis.

Typical esophageal symptoms

Heartburn is the most common typical symptom of GERD. It is felt as a retrosternal sensation of burning or discomfort that usually occurs after eating or when lying supine or bending over.

Regurgitation is an effortless return of gastric and/or esophageal contents into the pharynx. Regurgitation can induce respiratory complications if gastric contents spill into the tracheobronchial tree.

Dysphagia occurs in approximately one third of patients. Patients with dysphagia experience a sensation that food is stuck, particularly in the retrosternal area. Dysphagia can be an advanced symptom and can be due to a primary underlying esophageal motility disorder, a motility disorder secondary to esophagitis, or stricture formation.

Atypical extraesophageal symptoms

Coughing and/or wheezing are respiratory symptoms resulting from the aspiration of gastric contents into the tracheobronchial tree or from the vagal reflex arc producing bronchoconstriction. Approximately 50% of patients who have GERD-induced asthma do not experience heartburn.

Hoarseness results from irritation of the vocal cords by the gastric refluxate and is often experienced by patients in the morning.

Reflux is the most common cause of noncardiac chest pain, accounting for approximately 50% of cases. Patients can present to the emergency department with pain resembling a myocardial infarction. Reflux should be ruled out (using esophageal manometry and 24-hour pH testing if necessary) once a cardiac cause for the chest pain has been excluded. Alternatively, a therapeutic trial of a high-dose proton pump inhibitor (PPI) can be tried.

Additional atypical symptoms from abnormal reflux include damage to the lungs (eg, pneumonia, asthma, idiopathic pulmonary fibrosis), vocal cords (eg, laryngitis, cancer), ear (eg, otitis media), and teeth (eg, enamel decay).

Giannini EG, Zentilin P, Dulbecco P, Vigneri S, Scarlata P, Savarino V. Management strategy for patients with gastroesophageal reflux disease: a comparison between empirical treatment with esomeprazole and endoscopy-oriented treatment. Am J Gastroenterol . 2008 Feb. 103(2):267-75. [QxMD MEDLINE Link] .

Katz PO. Medical therapy for gastroesophageal reflux disease in 2007. Rev Gastroenterol Disord . 2007 Fall. 7(4):193-203. [QxMD MEDLINE Link] .

Fass R, Sifrim D. Management of heartburn not responding to proton pump inhibitors. Gut . 2009 Feb. 58(2):295-309. [QxMD MEDLINE Link] .

Fass R. Proton pump inhibitor failure--what are the therapeutic options?. Am J Gastroenterol . 2009 Mar. 104 suppl 2:S33-8. [QxMD MEDLINE Link] .

Heidelbaugh JJ, Goldberg KL, Inadomi JM. Overutilization of proton pump inhibitors: a review of cost-effectiveness and risk [corrected]. Am J Gastroenterol . 2009 Mar. 104 suppl 2:S27-32. [QxMD MEDLINE Link] .

Dial MS. Proton pump inhibitor use and enteric infections. Am J Gastroenterol . 2009 Mar. 104 suppl 2:S10-6. [QxMD MEDLINE Link] .

DeVault KR, Castell DO. Updated guidelines for the diagnosis and treatment of gastroesophageal reflux disease. Am J Gastroenterol . 2005 Jan. 100(1):190-200. [QxMD MEDLINE Link] .

Gallup Organization. Heartburn Across America: A Gallup Organization National Survey . Princeton, NJ: Gallup Organization; 1988.

Richter JE. Surgery for reflux disease: reflections of a gastroenterologist. N Engl J Med . 1992 Mar 19. 326(12):825-7. [QxMD MEDLINE Link] .

Chen CL, Robert JJ, Orr WC. Sleep symptoms and gastroesophageal reflux. J Clin Gastroenterol . 2008 Jan. 42(1):13-7. [QxMD MEDLINE Link] .

Sveen S. Symptom check: is it GERD?. J Contin Educ Nurs . 2009 Mar. 40(3):103-4. [QxMD MEDLINE Link] .

Mittal RK, Rochester DF, McCallum RW. Sphincteric action of the diaphragm during a relaxed lower esophageal sphincter in humans. Am J Physiol . 1989 Jan. 256(1 Pt 1):G139-44. [QxMD MEDLINE Link] .

Mittal RK, McCallum RW. Characteristics of transient lower esophageal sphincter relaxation in humans. Am J Physiol . 1987 May. 252(5 Pt 1):G636-41. [QxMD MEDLINE Link] .

Mittal RK, Rochester DF, McCallum RW. Effect of the diaphragmatic contraction on lower oesophageal sphincter pressure in man. Gut . 1987 Dec. 28(12):1564-8. [QxMD MEDLINE Link] . [Full Text] .

Stein HJ, DeMeester TR. Outpatient physiologic testing and surgical management of foregut motility disorders. Curr Probl Surg . 1992 Jul. 29(7):413-555. [QxMD MEDLINE Link] .

Kahrilas PJ, Dodds WJ, Hogan WJ, Kern M, Arndorfer RC, Reece A. Esophageal peristaltic dysfunction in peptic esophagitis. Gastroenterology . 1986 Oct. 91(4):897-904. [QxMD MEDLINE Link] .

Buttar NS, Falk GW. Pathogenesis of gastroesophageal reflux and Barrett esophagus. Mayo Clin Proc . 2001 Feb. 76(2):226-34. [QxMD MEDLINE Link] .

Hampel H, Abraham NS, El-Serag HB. Meta-analysis: obesity and the risk for gastroesophageal reflux disease and its complications. Ann Intern Med . 2005 Aug 2. 143(3):199-211. [QxMD MEDLINE Link] . [Full Text] .

Herbella FA, Sweet MP, Tedesco P, Nipomnick I, Patti MG. Gastroesophageal reflux disease and obesity. Pathophysiology and implications for treatment. J Gastrointest Surg . 2007 Mar. 11(3):286-90. [QxMD MEDLINE Link] .

Merrouche M, Sabate JM, Jouet P, et al. Gastro-esophageal reflux and esophageal motility disorders in morbidly obese patients before and after bariatric surgery. Obes Surg . 2007 Jul. 17(7):894-900. [QxMD MEDLINE Link] .

Murray L, Johnston B, Lane A, et al. Relationship between body mass and gastro-oesophageal reflux symptoms: The Bristol Helicobacter Project. Int J Epidemiol . 2003 Aug. 32(4):645-50. [QxMD MEDLINE Link] . [Full Text] .

Pandolfino JE, El-Serag HB, Zhang Q, Shah N, Ghosh SK, Kahrilas PJ. Obesity: a challenge to esophagogastric junction integrity. Gastroenterology . 2006 Mar. 130(3):639-49. [QxMD MEDLINE Link] .

El-Serag HB, Graham DY, Satia JA, Rabeneck L. Obesity is an independent risk factor for GERD symptoms and erosive esophagitis. Am J Gastroenterol . 2005 Jun. 100(6):1243-50. [QxMD MEDLINE Link] .

Tutuian R,. Adverse effects of drugs on the esophagus. Best Pract Res Clin Gastroenterol . 2010 Apr. 24(2):91-7. [QxMD MEDLINE Link] .

Kim SH. Esophageal mucosal impedance assessment: clinical usefulness for diagnosis of gastroesophageal reflux disease. J Neurogastroenterol Motil . 2024 Jul 30. 30 (3):253-4. [QxMD MEDLINE Link] . [Full Text] .

Galmiche JP, Hatlebakk J, Attwood S, et al. Laparoscopic antireflux surgery vs esomeprazole treatment for chronic GERD: the LOTUS randomized clinical trial. JAMA . 2011 May 18. 305(19):1969-77. [QxMD MEDLINE Link] .

Bhatia J, Parish A. GERD or not GERD: the fussy infant. J Perinatol . 2009 May. 29 suppl 2:S7-11. [QxMD MEDLINE Link] .

Levine MS, Rubesin SE. Diseases of the esophagus: diagnosis with esophagography. Radiology . 2005 Nov. 237(2):414-27. [QxMD MEDLINE Link] .

Lages RB, Fontes LHS, Barbuti RC, Navarro-Rodriguez T. Esophageal mucosal impedance assessment for the diagnosis of gastroesophageal reflux disease. J Neurogastroenterol Motil . 2024 Jul 30. 30 (3):352-60. [QxMD MEDLINE Link] . [Full Text] .

Ponce J, Garrigues V, Agreus L, et al. Structured management strategy based on the Gastro-oesophageal Reflux Disease (GERD) Questionnaire (GerdQ) vs. usual primary care for GERD: pooled analysis of five cluster-randomised European studies. Int J Clin Pract . 2012 Sep. 66(9):897-905. [QxMD MEDLINE Link] .

Woodcock J. Statement alerting patients and health care professionals of NDMA found in samples of ranitidine [news release]. September 13, 2019. US Food and Drug Administration. Available at https://www.fda.gov/news-events/press-announcements/statement-alerting-patients-and-health-care-professionals-ndma-found-samples-ranitidine . 2019 Jun; Accessed: October 15, 2020.

US Food and Drug Administration. FDA requests removal of all ranitidine products (Zantac) from the market [news release]. April 1, 2020. Available at https://www.fda.gov/news-events/press-announcements/fda-requests-removal-all-ranitidine-products-zantac-market . Accessed: October 15, 2020.

Yang YX, Lewis JD, Epstein S, Metz DC. Long-term proton pump inhibitor therapy and risk of hip fracture. JAMA . 2006 Dec 27. 296(24):2947-53. [QxMD MEDLINE Link] . [Full Text] .

Kellerman R, Kintanar T. Gastroesophageal reflux disease. Prim Care . 2017 Dec. 44(4):561-73. [QxMD MEDLINE Link] .

US Food and Drug Administration Press Announcements. FDA approves first generic versions of Aciphex delayed-release tablets to treat GERD. US Food and Drug Administration. Available at https://www.fda.gov/NewsEvents/Newsroom/PressAnnouncements/ucm374329.htm . Accessed: November 12, 2013.

Agency for Healthcare Research and Quality. Comparative effectiveness of management strategies for gastroesophageal reflux disease - executive summary. AHRQ pub. no. 06-EHC003-1. December 2005. Available at https://effectivehealthcare.ahrq.gov/healthInfo.cfm?infotype=rr&ProcessID=1&DocID=42 . Accessed: September 27, 2010.

Rassameehiran S, Klomjit S, Hosiriluck N, Nugent K. Meta-analysis of the effect of proton pump inhibitors on obstructive sleep apnea symptoms and indices in patients with gastroesophageal reflux disease. Proc (Bayl Univ Med Cent) . 2016 Jan. 29(1):3-6. [QxMD MEDLINE Link] .

Phathom Pharmaceuticals. Phathom Pharmaceuticals announces FDA approval of VOQUEZNA (vonoprazan) tablets for the treatment of erosive GERD and relief of heartburn associated with erosive GERD in adults [news release]. Available at https://investors.phathompharma.com/news-releases/news-release-details/phathom-pharmaceuticals-announces-fda-approval-voqueznar . November 1, 2023; Accessed: November 9, 2023.

Phathom Pharmaceuticals announces positive topline results from PHALCON-EE pivotal phase 3 erosive esophagitis trial. Phathom Pharmaceuticals. Available at https://investors.phathompharma.com/news-releases/news-release-details/phathom-pharmaceuticals-announces-positive-topline-results-0 . October 18, 2021; Accessed: November 9, 2023.

Laine L, DeVault K, Katz P, Mitev S, Lowe J, Hunt B, et al. Vonoprazan versus lansoprazole for healing and maintenance of healing of erosive esophagitis: a randomized trial. Gastroenterology . 2023 Jan. 164 (1):61-71. [QxMD MEDLINE Link] . [Full Text] .

Phathom Pharmaceuticals. Phathom Pharmaceuticals announces FDA approval of VOQUEZNA (vonoprazan) tablets for the relief of heartburn associated with non-erosive GERD in adults [news release]. Available at https://investors.phathompharma.com/news-releases/news-release-details/phathom-pharmaceuticals-announces-fda-approval-voqueznar-0 . July 18, 2024; Accessed: July 19, 2024.

Laine L, Spechler S, Yadlapati R, et al. Vonoprazan is efficacious for treatment of heartburn in non-erosive reflux disease: a randomized trial. Clin Gastroenterol Hepatol . 2024 May 14. [QxMD MEDLINE Link] . [Full Text] .

Brooks M. FDA OKs Voquezna for heartburn relief in nonerosive gastroesophageal reflux disease. Medscape Medical News. Available at https://www.medscape.com/viewarticle/fda-oks-voquezna-heartburn-relief-nonerosive-2024a1000dal . July 18, 2024; Accessed: July 19, 2024.

Boerema I. Hiatus hernia: repair by right-sided, subhepatic, anterior gastropexy. Surgery . 1969 Jun. 65(6):884-93. [QxMD MEDLINE Link] .

Allison PR. Hiatus hernia: (a 20-year retrospective survey). Ann Surg . 1973 Sep. 178(3):273-6. [QxMD MEDLINE Link] . [Full Text] .

Varshney S, Kelly JJ, Branagan G, Somers SS, Kelly JM. Angelchik prosthesis revisited. World J Surg . 2002 Jan. 26(1):129-33. [QxMD MEDLINE Link] .

Nissen R, Rossetti M, Siewert R. [20 years in the management of reflux disease using fundoplication]. Chirurg . 1977 Oct. 48(10):634-9. [QxMD MEDLINE Link] .

Kazerooni NL, VanCamp J, Hirschl RB, Drongowski RA, Coran AG. Fundoplication in 160 children under 2 years of age. J Pediatr Surg . 1994 May. 29(5):677-81. [QxMD MEDLINE Link] .

Dallemagne B, Weerts JM, Jehaes C, Markiewicz S, Lombard R. Laparoscopic Nissen fundoplication: preliminary report. Surg Laparosc Endosc . 1991 Sep. 1(3):138-43. [QxMD MEDLINE Link] .

Nilsson G, Larsson S, Johnsson F. Randomized clinical trial of laparoscopic versus open fundoplication: blind evaluation of recovery and discharge period. Br J Surg . 2000 Jul. 87(7):873-8. [QxMD MEDLINE Link] .

Wenner J, Nilsson G, Oberg S, Melin T, Larsson S, Johnsson F. Short-term outcome after laparoscopic and open 360 degrees fundoplication. A prospective randomized trial. Surg Endosc . 2001 Oct. 15(10):1124-8. [QxMD MEDLINE Link] .

Somme S, Rodriguez JA, Kirsch DG, Liu DC. Laparoscopic versus open fundoplication in infants. Surg Endosc . 2002 Jan. 16(1):54-6. [QxMD MEDLINE Link] .

Rangel SJ, Henry MC, Brindle M, Moss RL. Small evidence for small incisions: pediatric laparoscopy and the need for more rigorous evaluation of novel surgical therapies. J Pediatr Surg . 2003 Oct. 38(10):1429-33. [QxMD MEDLINE Link] .

Rothenberg SS. The first decade's experience with laparoscopic Nissen fundoplication in infants and children. J Pediatr Surg . 2005 Jan. 40(1):142-6; discussion 147. [QxMD MEDLINE Link] .

Pascoe E, Falvey T, Jiwane A, Henry G, Krishnan U. Outcomes of fundoplication for paediatric gastroesophageal reflux disease. Pediatr Surg Int . 2016 Apr. 32(4):353-61. [QxMD MEDLINE Link] .

Lundell L, Miettinen P, Myrvold HE, et al. Continued (5-year) followup of a randomized clinical study comparing antireflux surgery and omeprazole in gastroesophageal reflux disease. J Am Coll Surg . 2001 Feb. 192(2):172-9; discussion 179-81. [QxMD MEDLINE Link] .

Spechler SJ. Epidemiology and natural history of gastro-oesophageal reflux disease. Digestion . 1992. 51 suppl 1:24-9. [QxMD MEDLINE Link] .

Anvari M, Allen C, Marshall J, et al. A randomized controlled trial of laparoscopic Nissen fundoplication versus proton pump inhibitors for treatment of patients with chronic gastroesophageal reflux disease: One-year follow-up. Surg Innov . 2006 Dec. 13(4):238-49. [QxMD MEDLINE Link] .

Grant AM, Wileman SM, Ramsay CR, et al. Minimal access surgery compared with medical management for chronic gastro-oesophageal reflux disease: UK collaborative randomised trial. BMJ . 2008 Dec 15. 337:a2664. [QxMD MEDLINE Link] . [Full Text] .

El-Serag HB. Time trends of gastroesophageal reflux disease: a systematic review. Clin Gastroenterol Hepatol . 2007 Jan. 5(1):17-26. [QxMD MEDLINE Link] .

Grant AM, Cotton SC, Boachie C, et al. Minimal access surgery compared with medical management for gastro-oesophageal reflux disease: five year follow-up of a randomised controlled trial (REFLUX). BMJ . 2013 Apr 18. 346:f1908. [QxMD MEDLINE Link] . [Full Text] .

Rebecchi F, Allaix ME, Giaccone C, Ugliono E, Scozzari G, Morino M. Gastroesophageal reflux disease and laparoscopic sleeve gastrectomy: a physiopathologic evaluation. Ann Surg . 2014 Nov. 260(5):909-14; discussion 914-5. [QxMD MEDLINE Link] .

Oor JE, Roks DJ, Unlu C, Hazebroek EJ. Laparoscopic sleeve gastrectomy and gastroesophageal reflux disease: a systematic review and meta-analysis. Am J Surg . 2016 Jan. 211(1):250-67. [QxMD MEDLINE Link] .

US Food and Drug Administration. FDA approves LINX Reflux Management System to treat gastroesophageal reflux disease. Available at https://www.fda.gov/NewsEvents/Newsroom/PressAnnouncements/ucm296923.htm .

Zhang H, Dong D, Liu Z, He S, Hu L, Lv Y. Revaluation of the efficacy of magnetic sphincter augmentation for treating gastroesophageal reflux disease. Surg Endosc . 2016 Sep. 30(9):3684-90. [QxMD MEDLINE Link] .

Schizas D, Mastoraki A, Papoutsi E, et al. LINX ® reflux management system to bridge the "treatment gap" in gastroesophageal reflux disease: a systematic review of 35 studies. World J Clin Cases . 2020 Jan 26. 8(2):294-305. [QxMD MEDLINE Link] . [Full Text] .

[Guideline] Katz PO, Dunbar KB, Schnoll-Sussman FH, Greer KB, Yadlapati R, Spechler SJ. ACG Clinical Guideline for the Diagnosis anCG Clinical guideline for the diagnosis and management of gastroesophageal reflux diseased Management of Gastroesophageal Reflux Disease. Am J Gastroenterol . 2022 Jan 1. 117 (1):27-56. [QxMD MEDLINE Link] . [Full Text] .

Kramer JR, Shakhatreh MH, Naik AD, Duan Z, El-Serag HB. Use and yield of endoscopy in patients with uncomplicated gastroesophageal reflux disorder. JAMA Intern Med . 2014 Mar. 174(3):462-5. [QxMD MEDLINE Link] .

Mattioli S, Lugaresi ML, Di Simone MP, et al. The surgical treatment of the intrathoracic migration of the gastro-oesophageal junction and of short oesophagus in gastro-oesophageal reflux disease. Eur J Cardiothorac Surg . 2004 Jun. 25(6):1079-88. [QxMD MEDLINE Link] .

Osterwell N. GERD: high-risk patients get endoscopic short shrift. January 27, 2014. Medscape Medical News by WebMD. Available at https://www.medscape.com/viewarticle/819754 . Accessed: February 3, 2014.

Scheffer RC, Samsom M, Haverkamp A, Oors J, Hebbard GS, Gooszen HG. Impaired bolus transit across the esophagogastric junction in postfundoplication dysphagia. Am J Gastroenterol . 2005 Aug. 100(8):1677-84. [QxMD MEDLINE Link] .

Talley NJ, Napthali KE. Endoscopy in symptomatic gastroesophageal reflux disease: scoping out whom to target. JAMA Intern Med . 2014 Mar. 174(3):465-6. [QxMD MEDLINE Link] .

Telem DA, Altieri M, Gracia G, Pryor AD. Perioperative outcome of esophageal fundoplication for gastroesophageal reflux disease in obese and morbidly obese patients. Am J Surg . 2014 Aug. 208(2):163-8. [QxMD MEDLINE Link] .

Liu L, Li S, Zhu K, et al. Relationship between esophageal motility and severity of gastroesophageal reflux disease according to the Los Angeles classification. Medicine (Baltimore) . 2019 May. 98(19):e15543. [QxMD MEDLINE Link] .

Ratcliffe EG, Jankowski JA. Gastroesophageal reflux disease and Barrett esophagus: an overview of evidence-based guidelines. Pol Arch Intern Med . 2019 Aug 29. 129(7-8):516-25. [QxMD MEDLINE Link] . [Full Text] .

Popescu AL, Ionita-Radu F, Jinga M, Gavrila AI, Savulescu FA, Fierbinteanu-Braticevici C. Laparoscopic sleeve gastrectomy and gastroesophageal reflux. Rom J Intern Med . 2018 Dec 1. 56(4):227-32. [QxMD MEDLINE Link] . [Full Text] .

[Guideline] Hunt R, Armstrong D, Katelaris P, et al. World Gastroenterology Organisation Global Guidelines: GERD global perspective on gastroesophageal reflux disease. J Clin Gastroenterol . 2017 Jul. 51(6):467-78. [QxMD MEDLINE Link] . [Full Text] .

[Guideline] Gyawali CP, Carlson DA, Chen JW, Patel A, Wong RJ, Yadlapati RH. ACG clinical guidelines: clinical use of esophageal physiologic testing. Am J Gastroenterol . 2020 Sep. 115(9):1412-28. [QxMD MEDLINE Link] . [Full Text] .

• Gastroesophageal Reflux Disease. Relationship of the phrenoesophageal ligament to the diaphragm and esophagus.
• Gastroesophageal Reflux Disease. Arterial blood supply and lymphatic drainage of the esophagus.
• Gastroesophageal Reflux Disease. This image demonstrates peptic esophagitis.
• Gastroesophageal Reflux Disease. Reflux esophagitis is demonstrated on barium esophagram.
• Gastroesophageal Reflux Disease. Gastroesophageal reflux disease (GERD)/Barrett esophagus/adenocarcinoma sequence.
• Gastroesophageal Reflux Disease. Endoscopy demonstrating intraluminal esophageal cancer.
• Gastroesophageal Reflux Disease. The image is a representation of concomitant intraesophageal pH and esophageal electrical impedance measurements. The vertical solid arrow indicates commencement of a nonacid gastroesophageal reflux (GER) episode (diagonal arrow). The vertical dashed arrow indicates the onset of a normal swallow.
• Gastroesophageal Reflux Disease. Nissen fundoplication.
• Gastroesophageal Reflux Disease. Laparoscopic Nissen fundoplication.
• Gastroesophageal Reflux Disease. This radiograph shows a hiatal hernia.

Contributor Information and Disclosures

Marco G Patti, MD Surgeon, UNC Hospitals Multispecialty Surgery Clinic Marco G Patti, MD is a member of the following medical societies: American Association for the Advancement of Science , American College of Surgeons , American Gastroenterological Association , American Medical Association , American Surgical Association , Association for Academic Surgery , Pan-Pacific Surgical Association, Society for Surgery of the Alimentary Tract , Society of American Gastrointestinal and Endoscopic Surgeons , Southwestern Surgical Congress , Western Surgical Association Disclosure: Nothing to disclose.

BS Anand, MD Professor, Department of Internal Medicine, Division of Gastroenterology, Baylor College of Medicine BS Anand, MD is a member of the following medical societies: American Association for the Study of Liver Diseases , American College of Gastroenterology , American Gastroenterological Association , American Society for Gastrointestinal Endoscopy Disclosure: Nothing to disclose.

Piero Marco Fisichella, MD Assistant Professor of Surgery, Stritch School of Medicine, Loyola University; Director, Esophageal Motility Center, Loyola University Medical Center.

Piero Marco Fisichella is a member of the following medical societies: American College of Surgeons , American Medical Association , Association for Academic Surgery , Society for Surgery of the Alimentary Tract , and Society of American Gastrointestinal and Endoscopic Surgeons

Disclosure: Nothing to disclose.

Fernando AM Herbella, MD, PhD, TCBC Affiliate Professor, Attending Surgeon in Gastrointestinal Surgery, Esophagus and Stomach Division, Department of Surgery, Federal University of Sao Paulo, Brazil; Private Practice; Medical Examiner, Sao Paulo's Medical Examiner's Office Headquarters, Brazil

Fernando AM Herbella, MD, PhD, TCBC is a member of the following medical societies: Society for Surgery of the Alimentary Tract

John Gunn Lee, MD Director of Pancreaticobiliary Service, Associate Professor, Department of Internal Medicine, Division of Gastroenterology, University of California at Irvine School of Medicine

John Gunn Lee, MD is a member of the following medical societies: American College of Gastroenterology , American College of Physicians , American Gastroenterological Association , and American Society for Gastrointestinal Endoscopy

Thomas F Murphy, MD Chief of Abdominal Imaging Section, Department of Radiology, Tripler Army Medical Center

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Medscape Salary Employment

Manish K Varma, MD Chief of Interventional Radiology, Department of Radiology, Tripler Army Medical Center

Manish K Varma, MD is a member of the following medical societies: American College of Radiology , American Roentgen Ray Society , and Radiological Society of North America

Noel Williams, MD Professor Emeritus, Department of Medicine, Dalhousie University, Halifax, Nova Scotia, Canada; Professor, Department of Internal Medicine, Division of Gastroenterology, University of Alberta, Edmonton, Alberta, Canada

Noel Williams, MD is a member of the following medical societies: Royal College of Physicians and Surgeons of Canada

What would you like to print?

• Print this section
• Print the entire contents of
• Print the entire contents of article

• Gastroesophageal Reflux Disease
• Gastroesophageal Reflux Disease (GERD) Imaging
• Fast Five Quiz: Gastroesophageal Reflux Disease Management
• Fast Five Quiz: Gastroesophageal Reflux Disease (GERD)
• Fast Five Quiz: Gastroesophageal Reflux Disease Practice Essentials
• Pediatric Gastroesophageal Reflux
• Reflux Laryngitis
• How Does Diet Affect Gastroesophageal Reflux Disease?
• FDA OKs Voquezna for Heartburn Relief in Nonerosive Gastroesophageal Reflux Disease
• The Case for Biomarker Testing in Gastroesophageal Cancer

• Drug Interaction Checker
• Pill Identifier
• Calculators

• 2001/s/viewarticle/991918 AGA Update Provides Guidance on Extraesophageal Gastroesophageal Reflux Disease

• 2001/viewarticle/how-does-diet-affect-gastroesophageal-reflux-disease-2024a100061vnews news How Does Diet Affect Gastroesophageal Reflux Disease?

Warning: The NCBI web site requires JavaScript to function. more...

An official website of the United States government

The .gov means it's official. Federal government websites often end in .gov or .mil. Before sharing sensitive information, make sure you're on a federal government site.

The site is secure. The https:// ensures that you are connecting to the official website and that any information you provide is encrypted and transmitted securely.

• Publications
• Account settings
• Browse Titles

NCBI Bookshelf. A service of the National Library of Medicine, National Institutes of Health.

StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2024 Jan-.

StatPearls [Internet].

Gastroesophageal reflux disease.

Catiele Antunes ; Abdul Aleem ; Sean A. Curtis .

Affiliations

Last Update: July 3, 2023 .

• Continuing Education Activity

Gastroesophageal reflux disease (GERD) is a condition that develops when there is a retrograde flow of stomach contents back into the esophagus. It can present as non-erosive reflux disease or erosive esophagitis. This activity illustrates the evaluation and treatment of GERD and highlights the role of the interprofessional team in improving care for patients with this condition.

• Explain the pathophysiology of gastroesophageal reflux disease.
• Describe the signs and symptoms of a patient with gastroesophageal reflux disease.
• Describe the tests used to diagnose gastroesophageal reflux disease.
• Describe the importance of improving coordination among interprofessional team members to enhance the delivery of care for patients with gastroesophageal reflux disease.
• Introduction

Gastroesophageal reflux disease (GERD) is a chronic gastrointestinal disorder characterized by the regurgitation of gastric contents into the esophagus. It is one of the most commonly diagnosed digestive disorders in the US with a prevalence of 20%, resulting in a significant economic burden in direct and indirect costs and adversely affects the quality of life [1] [2] . GERD is caused by multiple different mechanisms that can be intrinsic, structural, or both, leading to the disruption of the esophagogastric junction barrier resulting in exposure of the esophagus to acidic gastric contents. Clinically, GERD typically manifests with symptoms of heartburn and regurgitation. It can also present in an atypical fashion with extra-esophageal symptoms such as chest pain, dental erosions, chronic cough, laryngitis, or asthma [3] [4] . Based on endoscopic and histopathologic appearance, GERD is classified into three different phenotypes: non-erosive reflux disease (NERD), erosive esophagitis (EE), and Barrett esophagus (BE) [5] . NERD is the most prevalent phenotype seen in 60-70% of patients followed by erosive esophagitis and BE seen in 30% and 6-12% of patients with GERD, respectively. [1] [5] [6] . Over the years, the mainstay in the management of GERD has been lifestyle modifications, and proton pump inhibitors (PPIs). However, medically refractory GERD is becoming increasingly common, requiring a tailored approach in the management of GERD.

Currently, there is no known cause to explain the development of GERD. Over the years, several risk factors have been identified and implicated in the pathogenesis of GERD. Motor abnormalities such as esophageal dysmotility causing impaired esophageal acid clearance, impairment in the tone of the lower esophageal sphincter (LES), transient LES relaxation, and delayed gastric emptying are included in the causation of GERD [7] . Anatomical factors like the presence of hiatal hernia or an increase in intra-abdominal pressure, as seen in obesity are associated with an increased risk of developing GERD [7] . A meta-analysis by Hampel H  et al.  concluded that obesity was associated with an increased risk of developing GERD symptoms, erosive esophagitis, and esophageal carcinoma [8] . The ProGERD study by Malfertheiner,  et al . evaluated the predictive factors for erosive reflux disease in more than 6000 patients with GERD and noted that the odds ratio for the erosive disease increased with the body mass index (BMI) [9] . Several other risk factors have been independently associated with the development of GERD symptoms that include age ≥50 years, low socioeconomic status, tobacco use, consumption of excess alcohol, connective tissue disorders, pregnancy, postprandial supination, and different classes of drugs which include anticholinergic drugs, benzodiazepines, NSAID or aspirin use, nitroglycerin, albuterol, calcium channel blockers, antidepressants, and glucagon [10] [11] [12] .

• Epidemiology

GERD is one of the most common gastrointestinal disorders, with a prevalence of approximately 20% of adults in western culture. A systematic review by El-Serag  et al.  estimated the prevalence of GERD in the US between 18.1% to 27.8%. However, the true prevalence of this disorder could be higher because more individuals have access to over-the-counter acid, reducing medications [2] [13] [2] . The prevalence of GERD is slightly higher in men compared to women [14] . A large meta-analysis study by Eusebi  et al.  estimated the pooled prevalence of GERD symptoms to be marginally higher in women compared with men (16.7% (95% CI 14.9% to 18.6%) vs. 15.4% (95% CI 13.5% to 17.4%) [12] . Women presenting with GERD symptoms are more likely to have NERD than men who are more likely to have erosive esophagitis [15] . However, men with longstanding symptoms of GERD have a higher incidence of Barrett's esophagus (23%) compared to women (14%) [16] .

• Pathophysiology

The pathophysiology of GERD is multifactorial and is best explained by various mechanisms involved, including the influence of the tone of the lower esophageal sphincter, the presence of a hiatal hernia, esophageal mucosal defense against the refluxate and esophageal motility.

Impaired Lower Esophageal Sphincter (LES) Function and Transient Lower Esophageal Sphincter Relaxations (TLESRs)

The LES is a 3-4 cm tonically contracted smooth muscle segment located at the esophagogastric junction (EGJ) and, along with the crural diaphragm forms the physiological EGJ barrier, which prevents the retrograde migration of acidic gastric contents into the esophagus [17] . In otherwise healthy individuals, LES maintains a high-pressure zone above intragastric pressures with transient relaxation of the LES that occurs physiologically in response to a meal facilitating the passage of food into the stomach. Patients with symptoms of GERD may have frequent transient LES relaxations (TLESRs) not triggered by swallowing, resulting in exceeding the intragastric pressure more than LES pressures permitting reflux of gastric contents into the esophagus [18] . The exact mechanism of increased transient relaxation is unknown, but TLESRs account for 48-73% of GERD symptoms [19] . The LES tone and TLESRs are influenced by factors such as alcohol use, smoking, caffeine, pregnancy, certain medications like nitrates, and calcium channel blockers [18] .

Hiatal hernia

Hiatal hernia is frequently associated with GERD and can exist independently without causing any symptoms. Nonetheless, the presence of hiatal hernia plays a vital role in the pathogenesis of GERD as it hinders the LES function [20] . Patti et al. reported that patients with proven GERD with or without a small hiatal hernia had similar LES function abnormalities and acid clearance. However, patients with large hiatal hernias were noted to have shorter and weaker LES resulting in increased reflux episodes. It was also pointed out that the degree of esophagitis was worse in patients with large hiatal hernias [21] . A study evaluating the relationship between hiatal hernia and reflux esophagitis by Ott  et al.  demonstrated the presence of hiatal hernia in 94% of patients with reflux esophagitis [22] . 

Impaired esophageal mucosal defense against the gastric refluxate

The esophageal mucosa comprises various structural and functional constituents that function as a protective defense barrier against the luminal substances encountered with GERD [18] . This defensive barrier can be breached by prolonged exposure to the refluxate, which consists of both acidic gastric contents (hydrochloric acid and pepsin) and alkaline duodenal contents (bile salts and pancreatic enzymes) leading to mucosal damage. The influence of gastroparesis on GERD is unknown. It is believed that delayed gastric emptying contributes to GERD symptoms due to gastric distention and increased exposure to the gastric refluxate [18] .

Defective esophageal peristalsis

Normally, the acidic gastric contents that reach the esophagus are cleared by frequent esophageal peristalsis and neutralized by salivary bicarbonate [23] [18] . In a prospective study by Diener  et al ., 21% of patients with GERD were noted to have impaired esophageal peristalsis leading to decreased clearance of gastric reflux resulting in severe reflux symptoms and mucosal damage [24] .

• Histopathology

The esophageal squamous epithelium serves to function as a protective defense barrier against the retrograde migration of refluxate. Disruption of this epithelial defense is a common phenomenon in GERD and NERD [25] . The histopathological features of GERD are not unique to this condition due to minimal biopsy criteria for diagnosis and varying sensitivity and specificity in the diagnosis [26] .In fact, the histopathologic diagnosis of GERD is made based on an array of microscopic findings that include features of inflammation, basal cell hyperplasia, papilla elongation, and dilatation of intercellular spaces [26] .

• History and Physical

The typical clinical presentation of GERD is heartburn and regurgitation. However, GERD can also present with various other symptoms that include dysphagia, odynophagia, belching, epigastric pain, and nausea [27] . Heartburn is defined as a retrosternal burning sensation or discomfort that may radiate into the neck and typically occurs after the ingestion of meals or when in a reclined position [28] . Regurgitation is a retrograde migration of acidic gastric contents into the mouth or hypopharynx [28] . GERD presentation is considered to be atypical when patients present with extraesophageal symptoms such as chest pain, chronic cough, asthma, laryngitis, dental erosions, dysphonia, and hoarseness, and globus sensation [3] [4] . 

The diagnosis of GERD is imprecise as there is no gold standard test available. The diagnosis of GERD is made solely based on presenting symptoms or in combination with other factors such as responsiveness to antisecretory therapy, esophagogastroduodenoscopy, and ambulatory reflux monitoring.

Proton pump inhibitor (PPI) trial

GERD can be presumptively diagnosed in most patients presenting with typical symptoms of heartburn and regurgitation [29] . Unless there are no associated alarm symptoms that include dysphagia, odynophagia, anemia, weight loss, and hematemesis, most patients can be initiated on empiric medical therapy with proton pump inhibitors(PPIs) without further investigations with a response to treatment confirming the diagnosis of GERD [29] . However, a meta-analysis published literature by Numans et al. refuted the accuracy of this empiric PPI trial diagnostic strategy [30] .

Esophagogastroduodenoscopy (EGD)

Patients presenting with typical GERD symptoms associated with any one of the alarm symptoms should be evaluated with an EGD to rule out complications of GERD. These include erosive esophagitis, Barrett's esophagus, esophageal stricture, and esophageal adenocarcinoma or rule out peptic ulcer disease. Distal esophageal biopsies are not routinely recommended to make a diagnosis of GERD as per the current American College of Gastroenterology (ACG) guidelines [29] . Patients with a high index of suspicion for coronary artery disease presenting with GERD symptoms should undergo evaluation for underlying cardiovascular disease. In contrast, patients presenting with noncardiac chest pain suspected due to GERD should have a diagnostic assessment with an EGD and pH monitoring before initiation of PPIs [31] . Current ACG guidelines recommend against screening for Helicobacter pylori infection in patients with GERD symptoms [29] .

Radiographic studies

Radiographic studies like barium radiographs can detect moderate to severe esophagitis, esophageal strictures, hiatal hernia, and tumors. However, their role in the evaluation of GERD is limited and should not be performed to diagnose GERD [29] .

Ambulatory esophageal reflux monitoring

Medically refractory GERD is increasingly common, and patients often have normal endoscopy evaluation as PPIs are incredibly effective in healing esophagitis caused by the refluxate. Ambulatory esophageal reflux monitoring can assess the correlation of symptoms with abnormal acid exposure. It is indicated in medically refractory GERD and in patients with extraesophageal symptoms suspicious for GERD. Ambulatory reflux (pH or in combination with impedance) monitoring employs the utility of a telemetry pH capsule or a transnasal catheter. It is the only available test that detects pathological acid exposure, frequency of reflux episodes, and correlation of symptoms with reflux episodes [29] . Current practice guidelines recommend mandatory preoperative ambulatory pH monitoring in patients without evidence of erosive esophagitis [29] .

• Treatment / Management

The goals of managing GERD are to address the resolution of symptoms and prevent complications such as esophagitis, BE, and esophageal adenocarcinoma. Treatment options include lifestyle modifications, medical management with antacids and antisecretory agents, surgical therapies, and endoluminal therapies.

Lifestyle Modifications

Lifestyle modifications are considered to be the cornerstone of any GERD therapy. Counseling should be provided about the importance of weight loss given that underlying obesity is a significant risk factor for the development of GERD, and studies have shown that weight gain in individuals with a normal BMI has been associated with the development of GERD symptoms [32] . Individuals should also be counseled about avoiding meals at least 3 hours before bedtime and maintaining good sleep hygiene as it has been shown that minimal disturbances in sleep are associated with suppression of TLESRs, resulting in decreased reflux episodes [27] [33] . Studies have also shown improvement in GERD symptoms and pH monitoring studies with the elevation of the head end of the bed. Diet modification with the elimination of chocolate, caffeine, and spicy foods, citrus, and carbonated beverages in GERD is controversial and is not routinely recommended as per current ACG guidelines [29] .

Medical Therapy

Medical therapy is indicated in patients who do not respond to lifestyle modifications. Medical therapy is comprised of antacids antisecretory agents like histamine (H2) receptor antagonists (H2RAs) or PPI therapy and prokinetic agents. Currently, there are two US Food and Drug Administration (FDA) approved H2RAs (famotidine and cimetidine) available in the US and are available over-the-counter. The other commonly used H2RA known as ranitidine has been recalled as a potential health hazard or safety risk due to an unexpected impurity in the active ingredient. The less commonly known prescription-only H2RA nizatidine has also been recalled as well due to similar concerns. In the US, there are six PPIs that are currently available, of which three (omeprazole, lansoprazole, and esomeprazole) are available over-the-counter, and the remaining three (pantoprazole, dexlansoprazole, and rabeprazole) are prescription-only medications. Of the available medical options, PPI therapy is considered to be the most effective for both erosive and non-erosive GERD based on multiple large-scale studies. These studies have also shown improved symptom control, healing of underlying esophagitis, and decreased relapse rates compared to H2RAs [34] [35] . ACG guidelines recommend PPI therapy be initiated at once a day dosing before the first meal of the day [29] . Patients with incomplete responses to once-daily dosing can be treated with twice-daily dosing or adjustment of dose timing, specifically in patients with nighttime symptoms [29] . As needed, bedtime administration of H2RAs is recommended for individuals with nighttime symptoms not optimized with maximal PPI therapy [29] . The role of prokinetic agents such as metoclopramide and domperidone in GERD is limited due to lack of data and also due to their profound adverse effects on the central nervous system and cardiovascular system.

Surgical therapy

Patients who present with either medically refractory GERD, noncompliance, or experience side effects with medical therapy, underlying large hiatal hernia, or individuals who desire to discontinue long-term medical treatment can be considered for surgical management [36] . The available surgical options for GERD are laparoscopic Nissen fundoplication, Laparoscopic anterior 180° fundoplication (180° LAF), or bariatric surgery in obese patients [29] . Laparoscopic Nissen fundoplication has been the gold standard surgical treatment in the management of GERD patients. However, given the rapid prevalence of obesity in the United States, gastric bypass surgery is becoming the most common surgical treatment for GERD [29] . It should be considered in obese patients with symptoms of GERD who prefer surgical therapy [27] [29] [36] [29] [27] . Current ACG guidelines recommend performing preoperative ambulatory pH monitoring in patients without erosive esophagitis and esophageal manometry to rule out achalasia or undiagnosed scleroderma-like esophagus prior to surgical therapy [29] . Two large meta-analyses comparing medical therapy with surgical therapy reported contrary conclusions with one reporting improvement of symptoms of GERD after surgery compared with medical therapy and the other reporting considerable uncertainty in the benefits of surgical therapy compared to medical therapy [37] [37] [37] . However, patients undergoing fundoplication are at risk for developing postoperative adverse events that include bloating, which is seen in 15 to 20% of patients, dysphagia, and belching. The most common bariatric surgeries performed are Roux-en-Y gastric bypass (RYGB), laparoscopic adjustable gastric banded plication (LAGP), and sleeve gastrectomy [36] . Studies have shown that the resulting weight loss from surgical management of obesity has had positive effects on GERD. Of all the bariatric surgeries available, RYGB has proven to be the most effective bariatric surgery for reducing GERD symptoms [36] . It is recommended as the bariatric procedure of choice in patients with severe GERD preoperatively [36] .

Endoluminal Therapy

In the era of minimally invasive surgery techniques, many different types of endoscopic therapies have been developed for GERD management. Most of them were discontinued after failing to demonstrate long-term efficacy. The current available endoluminal therapies include magnetic sphincter augmentation (MSA) and transoral incision-less fundoplication using the EsophyX  (EndoGastric Solutions, Redmond, WA, United States) [29] .   A recent meta-analysis by Gerson et al. that included data from 233 patients demonstrated that subjects who underwent TIF 2.0 procedure had improved esophageal pH, decreased need for PPIs, and significant improvement in the quality of life at three years after TIF 2.0 procedure [38] . Another prospective study by Testoni et al. demonstrated TIF with EsophyX as an effective long-term treatment option for patients with symptomatic GERD with associated hiatal hernia less than 2 cm. A meta-analysis comparing Nissen fundoplication and magnetic sphincter augmentation that included data from 688 patients with 415 who underwent MSA and the rest who were treated with Nissen fundoplication concluded that MSA was an effective therapeutic option for GERD as short-term outcomes with magnetic sphincter augmentation appeared to be comparable to Nissen fundoplication [39] .

• Differential Diagnosis
• Coronary artery disease
• Eosinophilic esophagitis (EoE)
• Non-ulcer dyspepsia
• Rumination syndrome
• Esophageal diverticula
• Gastroparesis
• Esophageal and gastric neoplasm
• Peptic ulcer disease (PUD)
• Complications

Erosive Esophagitis (EE)

EE is characterized by erosions or ulcers of the esophageal mucosa [28] . Patients may be asymptomatic or can present with worsening symptoms of GERD. The degree of esophagitis is endoscopically graded using the Los Angeles esophagitis classification system, which employs the A, B, C, D grading system based on variables that include length, location, and circumferential severity of mucosal breaks in the esophagus [40] .

Esophageal Strictures

Chronic acid irritation of the distal esophagus can result in scarring of distal the esophagus leading to the formation of a peptic stricture. Patients can present with symptoms of esophageal dysphagia or food impaction. ACG guidelines recommend esophageal dilation and continue PPI therapy to prevent the need for repeated dilations [29] .

Barrett Esophagus

This complication occurs as a result of chronic pathological acid exposure to the distal esophageal mucosa. It leads to a histopathological change of the distal esophageal mucosa, which is normally lined by stratified squamous epithelium to metaplastic columnar epithelium. Barrett's esophagus is more commonly seen in Caucasian males above 50 years, obesity, and history of smoking and predisposes to the development of esophageal adenocarcinoma [28] . Current guidelines recommend the performance of periodic surveillance endoscopy in patients with a diagnosis of Barrett's esophagus [41] .

• Enhancing Healthcare Team Outcomes

The majority of patients presenting with typical symptoms of GERD are usually recognized and managed by primary care providers. Patients with medically refractory GERD and alarm symptoms are generally referred to gastroenterologists.  The management of GERD requires an interprofessional approach involving primary care providers, gastroenterologists, otolaryngologists, pulmonologists, bariatric surgeons, and pharmacists.  Primary care physicians should obtain a good history to evaluate for any alarm symptoms or intrinsic cardiac causes and should promptly refer patients for further cardiac evaluation.  Considering lifestyle modifications are the cornerstone of GERD management, patients should be counseled about weight loss, tobacco and alcohol cessation, and avoidance of late meals.  Bariatric surgery should be discussed with morbidly obese patients presenting with GERD symptoms and should be promptly referred for bariatric surgery evaluation.  Otolaryngologists and pulmonologists should consider GERD in their differentials when evaluating patients presenting with atypical symptoms that include chronic cough, laryngitis, asthma, and hoarseness.  Cases of patients with medically refractory GERD should be discussed in a multidisciplinary approach with the surgeons, pharmacists, and endoscopy nurses. Complications of GERD should be promptly recognized, evaluated, and treated to prevent long-term morbidity. This interprofessional approach helps in the management of GERD, resulting in improved patients outcomes and increased quality of life.

• Review Questions
• Access free multiple choice questions on this topic.
• Comment on this article.

Disclosure: Catiele Antunes declares no relevant financial relationships with ineligible companies.

Disclosure: Abdul Aleem declares no relevant financial relationships with ineligible companies.

Disclosure: Sean Curtis declares no relevant financial relationships with ineligible companies.

This book is distributed under the terms of the Creative Commons Attribution-NonCommercial-NoDerivatives 4.0 International (CC BY-NC-ND 4.0) ( http://creativecommons.org/licenses/by-nc-nd/4.0/ ), which permits others to distribute the work, provided that the article is not altered or used commercially. You are not required to obtain permission to distribute this article, provided that you credit the author and journal.

• Cite this Page Antunes C, Aleem A, Curtis SA. Gastroesophageal Reflux Disease. [Updated 2023 Jul 3]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2024 Jan-.

In this Page

Bulk download.

• Bulk download StatPearls data from FTP

Related information

• PMC PubMed Central citations
• PubMed Links to PubMed

Similar articles in PubMed

• Gastroesophageal Reflux Disease (GERD). [StatPearls. 2024] Gastroesophageal Reflux Disease (GERD). Azer SA, Hashmi MF, Reddivari AKR. StatPearls. 2024 Jan
• Review AGA Clinical Practice Update on the Personalized Approach to the Evaluation and Management of GERD: Expert Review. [Clin Gastroenterol Hepatol. 2022] Review AGA Clinical Practice Update on the Personalized Approach to the Evaluation and Management of GERD: Expert Review. Yadlapati R, Gyawali CP, Pandolfino JE, CGIT GERD Consensus Conference Participants. Clin Gastroenterol Hepatol. 2022 May; 20(5):984-994.e1. Epub 2022 Feb 2.
• Review ARE THE PERSISTENT SYMPTOMS TO PROTON PUMP INHIBITOR THERAPY DUE TO REFRACTORY GASTROESOPHAGEAL REFLUX DISEASE OR TO OTHER DISORDERS? [Arq Gastroenterol. 2018] Review ARE THE PERSISTENT SYMPTOMS TO PROTON PUMP INHIBITOR THERAPY DUE TO REFRACTORY GASTROESOPHAGEAL REFLUX DISEASE OR TO OTHER DISORDERS? Azzam RS. Arq Gastroenterol. 2018 Nov; 55Suppl 1(Suppl 1):85-91. Epub 2018 Oct 4.
• Multimodality evaluation of patients with gastroesophageal reflux disease symptoms who have failed empiric proton pump inhibitor therapy. [Dis Esophagus. 2013] Multimodality evaluation of patients with gastroesophageal reflux disease symptoms who have failed empiric proton pump inhibitor therapy. Galindo G, Vassalle J, Marcus SN, Triadafilopoulos G. Dis Esophagus. 2013 Jul; 26(5):443-50. Epub 2012 Aug 2.
• Algorithmic approach to patients presenting with heartburn and epigastric pain refractory to empiric proton pump inhibitor therapy. [Dig Dis Sci. 2011] Algorithmic approach to patients presenting with heartburn and epigastric pain refractory to empiric proton pump inhibitor therapy. Roorda AK, Marcus SN, Triadafilopoulos G. Dig Dis Sci. 2011 Oct; 56(10):2871-8. Epub 2011 Apr 22.

Recent Activity

• Gastroesophageal Reflux Disease - StatPearls Gastroesophageal Reflux Disease - StatPearls

Your browsing activity is empty.

Activity recording is turned off.

Turn recording back on

Connect with NLM

National Library of Medicine 8600 Rockville Pike Bethesda, MD 20894

Web Policies FOIA HHS Vulnerability Disclosure

Help Accessibility Careers

• Remote Access
• Save figures into PowerPoint
• Download tables as PDFs

Chapter 34:  Gastroesophageal Reflux Disease: A Burning Question Level II

Brian A. Hemstreet

• Download Chapter PDF

Disclaimer: These citations have been automatically generated based on the information we have and it may not be 100% accurate. Please consult the latest official manual style if you have any questions regarding the format accuracy.

Download citation file:

• Search Book

Jump to a Section

Learning objectives, patient presentation.

• CLINICAL PEARL
• Full Chapter
• Supplementary Content

Instructors can request access to the Casebook Instructor's Guide on AccessPharmacy. Email User Services ( [email protected] ) for more information.

After completing this case study, the reader should be able to:

Describe the clinical presentation of gastroesophageal reflux disease (GERD), including typical, atypical, and alarm symptoms.

Discuss appropriate diagnostic approaches for GERD, including when patients should be referred for further diagnostic evaluation.

Recommend appropriate nonpharmacologic and pharmacologic measures for treating GERD.

Develop a treatment plan for a patient with GERD, including both nonpharmacologic and pharmacologic measures and monitoring for efficacy and toxicity of selected drug regimens.

Outline a patient education plan for proper use of drug therapy for GERD.

Chief Complaint

“I’m having a lot of heartburn. These pills I have been using have helped a little but it’s still keeping me up at night.”

Janet Swigel is a 68-year-old woman who presents to the GI clinic with complaints of heartburn four to five times a week over the past 5 months. She also reports some regurgitation after meals that is often accompanied by an acidic taste in her mouth. She states that her symptoms are worse at night, particularly when she goes to bed. She finds that her heartburn worsens and she coughs a lot at night, which keeps her awake. She has had difficulty sleeping over this time period and feels fatigued during the day. She reports no difficulty swallowing food or liquids. She has tried OTC Prevacid 24HR once daily for the past 3 weeks. This has reduced the frequency of her symptoms to 3–4 days per week, but they are still bothering her.

Atrial fibrillation × 12 years

Asthma × 10 years

Type 2 DM × 5 years

HTN × 10 years

Patient is married with three children. She is a retired school bus driver. She drinks one to two glasses of wine 4–5 days per week. She does not use tobacco. She has commercial prescription drug insurance.

Father died of pneumonia at age 75; mother died at age 68 of gastric cancer

Diltiazem CD 120 mg PO once daily

Hydrochlorothiazide 25 mg PO once daily

Metformin 500 mg PO twice daily

Aspirin 81 mg PO daily

Fluticasone/salmeterol DPI 100 mcg/50 mcg one inhalation twice daily

Peanuts (hives)

Get Free Access Through Your Institution

Pop-up div successfully displayed.

This div only appears when the trigger link is hovered over. Otherwise it is hidden from view.

Please Wait

Case Studies

CR, a 44-year-old man, comes to the pharmacy looking for a remedy for his heartburn. He reports that his heartburn has been bothering him for the past few weeks, and he complains of an acidic taste in his mouth and a burning feeling in his throat about twice a week. CR does not complain of any other related symptoms, such as pain when swallowing. CR has a box of omeprazole (Prilosec) in his hand. He asks if it would be the best product to help alleviate his symptoms.

As the pharmacist, how would you respond?

EF is a 30-year-old woman who comes to the pharmacy with dry, demarcated lesions in linear streaks, with some vesicles, on her hands, arms, and face. She says she was gardening yesterday for a few hours and must have touched poison ivy. EF says she tried to hide it with makeup to go to work this morning, but it only made it worse. She exclaims, “I cannot stand the itching anymore.” Upon questioning, you find out that she has had similar lesions before, but they were less extensive and not as bothersome. EF asks if there is pharmacy product that could help. She has no significant medical history and is not taking any prescription or OTC medications.

As the pharmacist, what would you recommend?

Case 1: Based on his reported symptoms, CR likely suffers from mild/ episodic gastroesophageal reflux disease (GERD), so he is a candidate for self-treatment. OTC proton pump inhibitors (PPIs) such as omeprazole, lansoprazole, and esomeprazole are appropriate for self-treatment of GERD for up to 14 days. However, before you recommend these products, you should educate CR that OTC omeprazole, lansoprazole, and esomeprazole are not intended for immediate relief of heartburn. These drugs have a slow onset but a long duration of action, and CR may have to take one of these drugs for 1 to 4 days before he feels better. CR should be cautioned to speak to his doctor if his symptoms do not resolve after 2 weeks or his heartburn worsens.

Alternatively, CR could try a histamine2 (H2)-receptor antagonist such as ranitidine, cimetidine, famotidine, or nizatidine. H2-receptor antagonists have a different mechanism of action than PPIs and provide relief of heartburn more quickly than PPIs. H2-receptor antagonists can be taken prophylactically before meals to prevent GERD.

CR might also consider taking an antacid, including calcium carbonate, sodium bicarbonate, magnesium hydroxide/aluminum hydroxide, or bismuth subsalicylate. These agents have the fastest onset of action, but they provide only symptomatic relief of heartburn and have the shortest duration of action.

Case 2: Allergic contact dermatitis is an inflammatory skin reaction to a foreign substance, such as urushiol in the sap of the poison ivy plant. Sensitized patients can develop clinical symptoms such as erythema, intense itching, and formation of plaques and vesicles within 4 to 96 hours after exposure to an allergen.

EF appears to have severe contact dermatitis. She is not a candidate for self-treatment because of the facial involvement of her dermatitis and the presence of vesicles and intense itching. If left untreated, allergic contact dermatitis resolves within 1 to 3 weeks; however, it can cause significant discomfort. EF should be referred to her primary care provider to obtain a prescription for an oral corticosteroid, such as prednisone to decrease itching, and perhaps a high-potency topical corticosteroid such as clobetasol propionate 0.05% cream, which is generally not applied to the face. A 21-day course of oral prednisone (starting at 1 mg/kg/day and tapered over 3 weeks) is appropriate and can significantly reduce symptoms, including itching.

EF should be told to keep the area clean and to avoid scratching and using makeup, as they can irritate the skin. In addition, nonpharmacologic treatments, including the application of cold compresses, can be recommended. EF might try using astringents such as aluminum acetate (Burrow’s solution) or calamine to reduce inflammation and promote drying, and healing of the lesions.

Read the answers

function showAnswer() {document.getElementById("answer").style.display = 'block';document.getElementById("link").style.display = 'none';}

Dr. Coleman is professor of pharmacy practice, as well as codirector and methods chief at Hartford Hospital Evidence-Based Practice Center, at the University of Connecticut School of Pharmacy.

Public Employees Claim Breach of Contract to Cover Medication Costs

Proposed Bill Requires States to Use Opioid Settlement Funds to Address the Opioid Epidemic

Product News: August 2024

Winrevair From Merck

Integration of Palliative Pharmacists to Elevate Oncologic Care

Safe Opioid Prescribing, Storage Are Crucial

2 Commerce Drive Cranbury, NJ 08512

609-716-7777