gastro-oesophageal reflux disease
Contents
Primarily a clinical diagnosis — empiric PPI trial is both diagnostic and therapeutic. EGD for alarm features, PPI non-response, or screening for Barrett’s oesophagus in high-risk patients. Refractory symptoms require ambulatory reflux monitoring (pH-impedance off PPI) to distinguish true refractory GERD from functional heartburn. Anti-reflux surgery for objectively confirmed GERD with persistent symptoms despite optimised medical therapy.
diagnosis
Clinical diagnosis based on typical symptoms: heartburn and regurgitation ≥2 times/week.
Empiric PPI trial (standard dose, once daily, 30 min before breakfast × 8 weeks) is the first-line diagnostic and therapeutic step. Symptom response supports the diagnosis but is not specific — functional heartburn, eosinophilic oesophagitis, and gastroparesis can overlap.
No routine testing needed if typical symptoms, age <50, and no alarm features.
alarm features — EGD indicated
- Dysphagia or odynophagia
- Unintentional weight loss
- GI bleeding or iron deficiency anaemia
- Persistent vomiting
- Palpable mass or lymphadenopathy
EGD findings
| finding | significance |
|---|---|
| erosive oesophagitis (LA grade C–D) | confirms GERD — no further reflux testing needed |
| LA grade A–B | supportive but not conclusive (A can be normal) |
| Barrett’s oesophagus | confirms chronic GERD; enter surveillance |
| peptic stricture | complication of chronic reflux |
| normal mucosa | does not exclude GERD — most reflux disease is non-erosive |
Barrett’s screening
EGD screening for Barrett’s in patients with chronic GERD (>5 years) plus ≥3 risk factors:
- Age >50, male sex, White ethnicity, central obesity (waist >102 cm), smoking history, family history of Barrett’s or oesophageal adenocarcinoma
One-time screening — not repeated if negative.
PPI therapy
| setting | regimen |
|---|---|
| initial trial | standard dose once daily × 8 weeks |
| partial response | increase to twice daily × 8 weeks |
| erosive oesophagitis (LA C–D) | twice daily; repeat EGD at 8–12 weeks to confirm healing |
| maintenance (erosive or relapsing) | lowest effective dose once daily |
| non-erosive, symptom-controlled | step down → on-demand dosing |
~50% of PPI “failures” are timing or adherence issues. The dose must be taken 30–60 min before a meal — not at bedtime, not with food. Confirm this before escalating workup.
refractory GERD workup
Symptoms persisting despite 8 weeks of optimised twice-daily PPI. Step back and reconsider the diagnosis.
flowchart TD
A["Refractory symptoms on BID PPI"] --> B["Repeat EGD<br/>(on PPI)"]
B --> C{"Erosive oesophagitis<br/>or Barrett's?"}
C -->|Yes| D["Confirmed GERD<br/>escalate Rx or surgery referral"]
C -->|No| E["Stop PPI ×7 days<br/>ambulatory pH-impedance<br/>(off PPI)"]
E --> F{"AET >6%?"}
F -->|Yes| G["Confirmed GERD<br/>consider surgery"]
F -->|"1–6%<br/>(borderline)"| H["Correlate with<br/>symptom index (SI/SAP)"]
F -->|"<1%"| I["Not GERD<br/>→ functional heartburn<br/>or alternative Dx"]ambulatory reflux monitoring — Lyon Consensus 2.0
| parameter | conclusive GERD | borderline | normal |
|---|---|---|---|
| acid exposure time (AET) | >6% | 4–6% | <4% |
| reflux episodes/24h | >80 | 40–80 | <40 |
- pH-impedance (off PPI) is the preferred test for unproven GERD — detects acid and non-acid reflux
- Bravo wireless pH (off PPI) — 96h recording, better tolerability, but misses non-acid reflux
- On-PPI testing only if GERD already proven (e.g. prior erosive disease) and question is whether PPI adequately controls reflux
Both have normal AET. Reflux hypersensitivity has positive symptom–reflux correlation (SI ≥50% or SAP ≥95%) — symptoms are triggered by physiological reflux. Functional heartburn has no reflux correlation. Both respond to neuromodulators (TCAs, SSRIs), not to PPI escalation or surgery.
management beyond PPIs
| intervention | indication |
|---|---|
| H2RA at bedtime | add-on for nocturnal breakthrough (tachyphylaxis limits long-term use) |
| baclofen | refractory regurgitation or belching (reduces transient LOS relaxations) |
| potassium-competitive acid blockers (vonoprazan) | more potent acid suppression; available in Canada since 2024 |
| neuromodulators (low-dose TCA, SSRI) | functional heartburn, reflux hypersensitivity |
lifestyle
Evidence is modest but reasonable: weight loss if BMI elevated (strongest evidence), head-of-bed elevation, avoid eating within 3h of recumbency, reduce trigger foods only if patient identifies specific triggers.
anti-reflux surgery
Laparoscopic fundoplication (Nissen 360° or Toupet 270°) or magnetic sphincter augmentation (LINX).
Indications:
- Objectively confirmed GERD (erosive disease or abnormal pH study) with persistent symptoms despite optimised PPI
- Patient preference to discontinue long-term PPI with confirmed acid-mediated disease
- Large hiatal hernia with mechanical symptoms
- Medically refractory regurgitation (regurgitation responds less well to PPI than heartburn)
- High-resolution oesophageal manometry — rule out achalasia and absent peristalsis (contraindication to 360° wrap)
- Ambulatory pH study (if not already done) — do not operate on unproven GERD
- EGD — assess anatomy, rule out Barrett’s dysplasia
common traps
- Labelling refractory without optimising PPI timing — most “PPI failures” are dosing errors
- Skipping reflux testing before surgery — operating on functional heartburn produces poor outcomes
- Long-term twice-daily PPI without re-evaluation — step down to once daily or on-demand when possible
- Attributing atypical symptoms (cough, hoarseness, throat clearing) to GERD without typical symptoms — extraoesophageal GERD is a diagnosis of exclusion after ENT and pulmonary evaluation; empiric PPI for isolated throat symptoms has a high NNT
- Missing eosinophilic oesophagitis — biopsies from mid and distal oesophagus on EGD, especially if dysphagia or PPI-refractory
related: Barrett’s oesophagus · dysphagia · eosinophilic oesophagitis