Gastroesophageal Reflux Disease

Retrograde flow of gastric contents into the esophagus causing troublesome symptoms/complications, from transient LES relaxation, hiatal hernia, or impaired clearance.

Classified: non-erosive reflux disease (NERD most common), erosive esophagitis (Los Angeles grade A-D), Barrett's esophagus (premalignant metaplasia).

Heartburn (worse postprandial/lying flat/bending), regurgitation.

Atypical: chronic cough, laryngitis, asthma exacerbation, dental erosion, chest pain (exclude cardiac cause first).

Alarm features as per Dyspepsia entry.

Clinical for typical symptoms without alarm features, empirical PPI trial reasonable.

Endoscopy if alarm features, age ≥55 new onset, or refractory. 24-hour pH/impedance monitoring: atypical symptoms, treatment-refractory, or pre-surgical evaluation.

Manometry: motility/pre-surgical workup.

Differentials: cardiac chest pain (exclude first), PUD, eosinophilic esophagitis (young, dysphagia, food impaction, atopy), achalasia, esophageal malignancy, functional heartburn.

• Lifestyle: weight loss, elevate head of bed, avoid large/late meals, reduce triggers (fatty, spicy, caffeine, alcohol, chocolate, citrus), smoking cessation

• PPI; first-line: omeprazole 20-40mg od, 30-60 min before breakfast; 4-8 week trial, step down to lowest effective/on-demand dose

• H2RA (famotidine): add-on for nocturnal breakthrough

• Alginates (Gaviscon): adjunct for post-prandial breakthrough

• Refractory: reassess adherence/timing before assuming failure; investigate before dose escalation beyond standard

• Barrett's: PPI therapy, surveillance colonoscopy per dysplasia grade

• Surgical fundoplication: for refractory disease, patient preference to avoid long-term medication, large hiatal hernia, or PPI-refractory regurgitation ; requires pre-op manometry/pH studies

Referral: gastroenterology for alarm features, refractory symptoms, Barrett's surveillance, surgical consideration.