Epidemiology

Etiology

Smoking, caffeine and alcohol consumption
- All three substances decrease LES tone. Alcohol and caffeine also stimulate gastric acid secretion, which, in combination with frequent TLESRs, increases the risk of esophageal mucosal injury from the gastric refluxate.
Stress
Obesity
Pregnancy
- GERD is present in up to 80% of pregnancies. The underlying pathophysiology involves increased abdominal pressure, decreased LES tone (due to high estrogen and progesterone levels during pregnancy), and prolonged gastric emptying as a result of reduced gastric motility.
Scleroderma
Sliding hiatal hernia: ≥ 90% of patients with severe GERD
Asthma

Typical Sx:
- Heartburn (pyrosis): Retrosternal burning sensation, often postprandial and worse when supine.
- Regurgitation: Effortless return of acidic contents into the pharynx.
- Water brash (hypersalivation), sour taste in the mouth.
Atypical/Extra-esophageal Sx:
- Chronic cough, chronic laryngitis (hoarseness), dental erosions, and non-cardiac chest pain.
  - Direct Injury: Microscopic amounts of refluxed acid and pepsin travel up into the throat and airways, causing direct inflammation and irritation.
  - Vagal Nerve Reflex: Acid in the distal esophagus triggers a nerve reflex (via the vagus nerve) that results in a chronic cough and bronchoconstriction (worsening asthma) without direct aspiration.
- Can trigger or worsen asthma.
Alarm features (warrant prompt endoscopy):
- Dysphagia (difficulty swallowing) or Odynophagia (painful swallowing).
- Unexplained weight loss.
- GI bleeding (hematemesis) or iron deficiency anemia.

Ambulatory 24-hr pH monitoring: Gold standard for confirming abnormal acid reflux, especially if EGD is normal but symptoms persist.
Biopsy
X-ray: the esophagus courses between the trachea and vertebral bodies and is typically collapsed with no visible lumen.

Lifestyle/Dietary Modifications: Weight loss, elevating the head of the bed, avoiding meals 2-3 hours before bedtime, and avoiding trigger foods (e.g., fatty/spicy foods, alcohol, caffeine).
Medical Therapy:
- Antacids: For rapid, temporary relief of mild, intermittent symptoms.
  - Magnesium & Aluminum Hydroxide
    - Combination Rationale: Magnesium hydroxide and aluminum hydroxide are almost always co-formulated. This is done to balance their opposing side effects on bowel motility.
    - Side Effects:
      - Aluminum hydroxide: Causes constipation and can lead to hypophosphatemia with chronic use.
      - Magnesium hydroxide: Causes osmotic diarrhea.
- H2-Receptor Antagonists (H2RAs; e.g., Famotidine): For mild GERD.
- Proton Pump Inhibitors (PPIs; e.g., Omeprazole, Pantoprazole): First-line for moderate-to-severe symptoms and for healing erosive esophagitis.
Surgical Tx (Nissen fundoplication): Reserved for patients with refractory symptoms, large hiatal hernias, or those who wish to avoid long-term medical therapy.