Table of Contents

I. Introduction
II. Causes of GERD
• Lower esophageal sphincter dysfunction
• Impaired esophageal peristalsis
• Increased intragastric pressure
• Increased abdominothoracic pressure gradient
• Excess gastric acid secretion (Zollinger–Ellison syndrome)
III. Diagnosis of GERD
• Clinical, Endoscopic and pH-Metric Criteria
• Consideration of Non-Gastrointestinal Diagnoses
• Esophagogastroduodenoscopy (EGD)
IV. Treatment of GERD
• Medications for Acid Suppression
• Lifestyle changes
• Weight Reduction
• Food and Event Avoidance
V. Epidemiology of GERD
• Symptom-Based Diagnosis
• Prevalence of GERD in Pediatric Populations
• Prevalence of “Dyspeptic” Symptoms Across the Globe

Gastroesophageal reflux disease (GERD) occurs when the reflux of stomach contents causes troublesome symptoms or complications [1]. A common medical problem which can be chronic as well with up to 40% of the population experiencing its symptoms at least once per month.

A ring of muscle called the lower oesophageal sphincter (LES) normally keeps the top of the stomach closed. It relaxes and opens while swallowing. GERD happens when the LES relaxes and opens up even when there is no swallowing. This allows the stomach contents to flow back up the esophagus. GERD is the more serious, chronic form of GER, or gastroesophageal reflux. No gender-related factor has been noted and both the sexes equally experience GERD. GERD isn’t usually life-threatening, but it can result in complications.

About 20 percent of the U.S. population experiences GERD, according to the National Institute of Diabetes and Digestive and Kidney Diseases. According to the American College of Gastroenterology, more than 60 million people in the United States have heartburn at least once a month, and more than 15 million experience it every single day.

The symptoms can range from heartburn and regurgitation to cough and hoarseness. Reflux-induced symptoms, erosive esophagitis, and long-term complications may have severely deleterious effects on daily activities, work productivity, sleep, and quality of life. Most of the patients respond to medical treatment however, the diagnosis and treatment for few may be challenging. It is a global disease due to its prevalence around the world, with an increasing prevalence in many developing countries. For East Asia prevalence estimates are currently consistently lower than 10% [2].

Symptom evaluation is the key to the diagnosis of GERD. This is equally true for the effectiveness of the treatment therapy. The presence of heartburn and/or regurgitation symptoms two or more times a week is suggestive of GERD [3].  GERD is a sensorimotor disorder associated with impairment of the normal antireflux mechanisms (e.g., lower esophageal sphincter function, phrenicoesophageal ligament), with changes in normal physiology (e.g., impaired esophageal peristalsis, increased intragastric pressure, increased abdominothoracic pressure gradient) or, very rarely, excess gastric acid secretion (Zollinger–Ellison syndrome) and Dysphagia. The disease is also characterized by atypical symptoms which may also occur, with or without the common symptoms. Atypical symptoms include epigastric pain or chest pain, which may mimic ischemic cardiac pain. Cough and the other respiratory symptoms may mimic asthma/respiratory or laryngeal disorders. A minority of GERD patients have multiple unexplained symptoms, which may be associated with psychological distress [4]. Some studies have systematically investigated the association between GERD and anxiety disorders and noted a high correlation.

A careful history is a basis for the symptomatic diagnosis of GERD. Although investigations are not required in order to establish a diagnosis of GERD, clinical, endoscopic and pH-metric criteria provide a comprehensive characterization of the disease. The symptoms are very close to other gastrointestinal related problems hence the proper initial evaluation is imperative. It is also important to consider other, non-gastrointestinal diagnoses, especially ischemic heart disease. For epidemiological studies, diagnostic questionnaire tools (reflux disease questionnaires, RDQs) have been developed. However, diagnosis by a family practitioner or gastrointestinal specialist has a better sensitivity and specificity. For a few selected cases Esophagogastroduodenoscopy (EGD) is also performed for identifying or excluding significant structural lesions. Also, EGD is usually carried out in regions where the frequency of ulcer disease and the concern about malignancy are high, as in most of Asia [5].

Few considerations for the patients under GRD treatment are comorbidities (e.g., with calcium channel blockers, anticholinergics, and nonsteroidal anti-inflammatory drugs (NSAIDs) treatment [6]. Some medications (e.g., bisphosphonates, antibiotics, potassium supplements) may cause upper gastrointestinal tract injury and exacerbate reflux-like symptoms or reflux-induced injury. In pregnancy, GERD can be reliably diagnosed on the basis of symptoms alone. For atypical symptoms, other possibilities including H. pylori–related diseases and NSAID- induced symptoms are also ruled out. An initial H. pylori test-and-treat strategy or endoscopy are also considered in regions with a high prevalence of H. pylori infection [7]. Radiological examinations, Oesophageal pH or pH-impedance monitoring and oesophageal manometry are seldom required.

In general GERD management follows a stepwise approach. GERD management includes lifestyle interventions, reduction of oesophageal luminal acid by neutralization or by suppression of gastric acid secretion or, rarely, antireflux surgery. The primary goals of treatment are to relieve symptoms & prevent its recurrence, improve quality of life, heal oesophagitis in the most cost-effective manner. Infrequent heartburn which is <2 per week should be treated by self- care with an antacid. They offer quick but mild relief, to proton pump inhibitors (PPIs), which effectively suppress stomach acid and help heal esophagus. Alginate–antacid combinations are useful and are superior to antacids alone. It may take a few trial and error to figure out which foods trigger GERD, and whether unlimited consumption items is non-problematic. Sometimes it’s necessary to completely eliminate a food from the regular diet. Too much food intake at a time or lying down too soon after eating also could be partially blamed for the symptoms. Avoidance of food or event, the cause that trigger symptoms may be helpful. Weight reduction for overweight patients may also reduce the frequency of symptoms. Patients with frequent symptoms should be assessed for longer-term therapy. The self -treatment by over-the-counter or lifestyle measures failure needs physicians attention. Treatment may fail because the patient does not actually have GERD. On the other hand, treatment might be inadequate to address the severity of the GERD.

Most epidemiological studies of the condition are symptom-based [8] and robust epidemiological studies are still lacking. There are also few data regarding the prevalence of GERD in pediatric populations. As symptom-based diagnosis is challenging, the epidemiological data on the prevalence of gastroesophageal reflux symptoms (GERS) are probably flawed. Because the description and nomenclature of reflux symptoms vary between regions, and in part because upper gastrointestinal symptoms (“dyspeptic” symptoms) may be described similarly by patients who have a variety of upper gastrointestinal diagnoses, including peptic ulcer disease, nonulcer dyspepsia, dysmotility, or GERD [9]. Nonetheless, it is instructive to report the prevalence of “dyspeptic” symptoms across the globe, as these data affect the pretest probability that upper gastrointestinal symptoms are attributable to gastroesophageal reflux.

The high prevalence of GERD, and hence of troublesome symptoms, has significant societal consequences, impacting adversely on work productivity and many other quality- of-life aspects for individual patients.


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