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Creating a PowerPoint Presentation on GERD

Definition and Diagnostic Criteria

GERD is defined as a condition that develops when reflux of stomach contents causes troublesome symptoms and/or complications, where "troublesome" means symptoms that adversely affect an individual's well-being. 1

• GERD becomes a disease (rather than physiologic reflux) when:

  • Reflux esophagitis is present (Los Angeles grades A-D), OR 1
  • Symptoms occur ≥2 days per week with moderate severity, significantly impairing quality of life, OR 1
  • Risk of long-term complications exists (stricture, Barrett's esophagus, adenocarcinoma) 1

• The Los Angeles classification system should be used to grade erosive esophagitis, with Grade B or higher constituting confirmatory evidence of erosive reflux disease 2

• Distinguish GERD from episodic heartburn: episodic heartburn of insufficient frequency or severity (after reassurance of benign nature) does not meet the definition of GERD 1

Clinical Presentation and Symptoms

Predominant heartburn is the feature that best identifies GERD, with patients having normal endoscopy responding better to PPI therapy than those with predominant dyspepsia. 1

• Typical symptoms (highest specificity for GERD):

  • Heartburn (burning sensation in chest/throat) 1, 3
  • Acid regurgitation 1, 3
  • Sour taste or burping 4

• Atypical symptoms:

  • Chest pain 5
  • Dysphagia (requires urgent endoscopy to rule out adenocarcinoma, as severe reflux symptoms increase adenocarcinoma risk 40-fold) 1
  • Nausea/vomiting 1
  • Epigastric pain 1

• Extraesophageal manifestations (association established but causation variable):

  • Chronic cough 1
  • Laryngeal hoarseness and dysphonia 1
  • Asthma 1
  • Dental erosions/caries 1
  • Sinus disease, ear disease, post-nasal drip, throat clearing 1

• Critical caveat: Patients with extraesophageal reflux may not complain of heartburn or regurgitation, requiring clinician vigilance 1

Pathophysiology and Risk Factors

• Mechanisms of reflux:

  • Increased transient lower esophageal sphincter relaxations 6
  • Reduced esophageal clearance and protective factors (salivation, effective peristalsis) 6
  • Changes in intra-abdominal to intra-thoracic pressure gradients 6

• Major risk factors:

  • Obesity (strong association with GERD prevalence) 1, 5, 7
  • Western lifestyle and diet 7
  • Genetic predisposition (parental GERD substantially increases risk) 8
  • Lack of exercise 5
  • Hiatal hernia (large hiatal hernia defines severe GERD phenotype) 2

• Brain-gut axis: Stress and anxiety trigger and worsen GERD symptoms through neural, hormonal, and immunological pathways, leading to increased perception of reflux symptoms even without changes in actual acid exposure 6

Diagnostic Approach

In the absence of alarm symptoms, typical symptoms (heartburn and acid regurgitation) allow presumptive diagnosis and initiation of empiric PPI therapy. 3, 9

• Alarm symptoms requiring immediate endoscopy:

  • Dysphagia 1
  • Gastrointestinal bleeding 8
  • Bilious or consistently forceful vomiting 8
  • Fever with abdominal tenderness or distension 8
  • Unintentional weight loss 4

• Diagnostic testing indications:

  • Suboptimal response or early symptomatic relapse after PPI therapy 4
  • Failed one trial (up to 12 weeks) of PPI therapy for suspected extraesophageal manifestations 1
  • Older patients with new-onset symptoms 4

• Testing modalities:

  • Upper endoscopy with Los Angeles classification grading, hiatal hernia measurement, Hill grade assessment, and Barrett's esophagus evaluation using Prague classification 2
  • Ambulatory pH monitoring: acid exposure time (AET) ≥6.0% on ≥2 days confirms pathologic GERD 2
  • pH-impedance monitoring while on acid suppression to evaluate ongoing acid or non-acid reflux in non-responders 1

• Severe GERD phenotype criteria (requiring long-term PPI or anti-reflux intervention):

  • Los Angeles Grade C or D esophagitis, OR 2
  • AET >12.0%, OR 2
  • DeMeester Score ≥50, OR 2
  • Bipositional reflux pattern, OR 2
  • Large hiatal hernia 2

Management Strategies

Lifestyle Modifications

Weight loss should be advised for overweight or obese patients with esophageal GERD syndromes (Grade B recommendation). 1

• Head of bed elevation for patients troubled with heartburn or regurgitation when recumbent 1

• Individualized modifications (tailor to specific patient circumstances):

  • Avoiding late meals 1
  • Avoiding trigger foods (coffee, alcohol, chocolate, fatty foods, citrus, carbonated drinks, spicy foods) 1
  • Smoking cessation 1

• Stress-reducing activities: mindfulness, relaxation techniques, diaphragmatic breathing to reduce symptoms exacerbated by anxiety 6

• Important limitation: Insufficient evidence to broadly advocate lifestyle changes for all patients (as opposed to selected patients) 1

Medical Therapy

Proton pump inhibitors (PPIs) remain the medical treatment of choice for GERD. 9

• Lansoprazole dosing (representative PPI):

  • Adults: 15 mg once daily for symptomatic GERD (up to 8 weeks); 30 mg once daily for erosive esophagitis (up to 8 weeks, may extend 8-16 weeks if needed) 4
  • Pediatric (1-11 years): 15 mg once daily (≤30 kg) or 30 mg once daily (>30 kg) for up to 12 weeks 4
  • Pediatric (12-17 years): 15 mg once daily for non-erosive GERD or 30 mg once daily for erosive esophagitis (up to 8 weeks) 4
  • Severe hepatic impairment: 15 mg once daily 4

• Administration: Take before meals; swallow whole without crushing or chewing; take at least 30 minutes prior to sucralfate 4

• PPI safety considerations (use lowest effective dose for shortest duration):

  • Acute tubulointerstitial nephritis (discontinue if suspected) 4
  • Clostridium difficile-associated diarrhea 4
  • Bone fractures (hip, wrist, spine) with multiple daily doses and long-term use (≥1 year) 4
  • Cutaneous and systemic lupus erythematosus 4
  • Cyanocobalamin (Vitamin B12) deficiency with >3 years use 4
  • Hypomagnesemia (≥3 months use, most cases after 1 year) 4

• Alternative agents:

  • Antacids (may be used concomitantly with PPIs) 4
  • H2-receptor antagonists 3
  • Alginate-containing antacids 1

• Prokinetic agents: Insufficient evidence to support routine use (metoclopramide has 11-34% adverse effect rate including extrapyramidal reactions) 1

• Neuromodulators and cognitive-behavioral therapy: May serve a role in management of extraesophageal reflux symptoms 1

Surgical and Endoscopic Therapy

Fundoplication may be considered for patients who have failed pharmacologic treatment or are at severe risk of aspiration, but lack of response to PPI therapy predicts lack of response to surgery. 1

• Surgical indications:

  • Failed medical therapy with objective evidence of GERD 1
  • Severe risk of aspiration of gastric contents 1

• Pre-operative requirements:

  • Objective diagnosis of GERD confirmed 1
  • Shared decision-making with realistic understanding of potential complications and symptom recurrence 1
  • Adequate counseling about preserved peristalsis requirements 1

• Contraindications to surgery:

  • Conditions mimicking GERD (cyclic vomiting, rumination, gastroparesis, eosinophilic esophagitis) must be ruled out 1
  • PPI non-responders (poor surgical outcome predictor) 1

Special Populations

Pediatric GERD

• Infants: Distinguish physiologic reflux (peaks at 4 months affecting ~50% of infants, declines to 5-10% by 12 months) from GERD requiring treatment 8

• "Happy spitter": Effortless, painless regurgitation not affecting growth requires only parental education and reassurance, not medication 1

• Troublesome symptoms suggesting GERD in infants:

  • Feeding refusal 8
  • Recurrent vomiting 8
  • Poor weight gain 8
  • Irritability and sleep disturbance 8
  • Arching during feedings 8

• Protective factor: Exclusive breastfeeding is protective against GERD in infancy 8

• Children >1 year and adolescents: Present similarly to adults with heartburn as common symptom 6

• High-risk pediatric conditions: Neurologic impairment, obesity, history of esophageal atresia, chronic respiratory disorders 6

Psychological Comorbidities

• Patient education about brain-gut axis should be provided early in treatment to explain how stress and anxiety influence GERD symptoms 6

• PTSD and GERD: Chronic stress leads to visceral hypersensitivity, altered esophageal motility, and reduced refluxate clearance 6

• Combined approach: Addressing both reflux symptoms and psychological factors may be more effective than treating GERD alone 6

• Psychological interventions: Cognitive behavioral therapy, esophageal-directed hypnotherapy, diaphragmatic breathing exercises 6

• Low-dose antidepressants: May serve dual purposes treating both psychological symptoms and esophageal hypersensitivity 6

Complications and Long-Term Surveillance

• Major complications:

  • Erosive esophagitis 3
  • Peptic stricture 3
  • Barrett's esophagus (requires surveillance per Prague classification) 2, 3
  • Esophageal adenocarcinoma (40-fold increased risk with severe reflux symptoms) 1, 3
  • Pulmonary disease 3

• Surveillance strategy: Combining endoscopic findings with pH monitoring data informs decisions regarding PPI optimization, need for anti-reflux procedures, and long-term surveillance 2

• Borderline GERD: Can be managed with lowest effective PPI dose or on-demand therapy 2

Key Clinical Pitfalls

• Do not equate esophageal eosinophilia with GERD: Eosinophilic esophagitis, infections, connective tissue disorders, and drug hypersensitivity must be excluded 1

• Extraesophageal symptom improvement on PPI: May result from mechanisms other than acid suppression and should not be regarded as confirmation of GERD 1

• Multiple PPI trials: After one failed trial (up to 12 weeks), consider objective testing rather than additional PPI trials, which are low yield 1

• Symptomatic response does not preclude gastric malignancy: Consider additional diagnostic testing in adults with suboptimal response or early symptomatic relapse 4

• GERD is not effective diagnosis in infants <1 year: May harm them; do not use this diagnosis in this age group 4