Gastroesophageal reflux

Definition

• Chronic non-forceful reflux of stomach contents past lower esophageal sphincter, producing a variety of symptoms

Classification

• May be erosive or non-erosive (NERD)

Pathophysiology

• Decreased tone of lower esophageal sphincter that normally prevents regurgitation

Differential Diagnosis

• Heartburn symptoms
  • Myocardial ischemia
• Chronic cough
  • Asthma
  • Upper airway syndrome (post-nasal drip)

Management

• Stepwise management
• Step 1: lifestyle management
  • No food for 4h before sleeping
  • Eat upright, stay upright for 1h after meal
  • Avoidance of trigger foods, such as coffee, alcohol, spicy food
  • Sleep with elevated head of bed
• Step 2: proton pump inhibitor (PPI) therapy
  • Pantoprazole 40mg po daily 30 minutes before breakfast
• Step 3: twice-daily PPI
  • As above, but bid 30 minutes before breakfast and dinner
• Step 4: things for which there is no evidence
  • Consider further investigations such as 24h pH monitoring