Several mechanisms have been identified as etiologic factors in the development of GERD. Some of the common factors include LES relaxation, Hiatal hernia, esophageal peristalsis, increased intra-abdominal pressure, and lifestyle. Lower Esophageal Sphincter (LES) Relaxation The most common cause of GERD is the transient relaxation of lower esophageal sphincter (LES). The lower esophageal sphincter is located where the gut meets the esophagus and is responsible for preventing food and acidic fluids in the gut and out of the esophagus. Other LES pressure abnormalities such as reduction in resting lower esophageal sphincter (LES) pressure or the shorter length of LES also play a role in the development of GERD. Hiatal Hernia GERD can also be caused by hiatal hernia. Hiatal hernia may lead to dysfunctional LES, frequent transient LES relaxations, defective peristalsis, and increased esophageal acid exposure. Esophageal Peristalsis According to a study, about 20% of patients with GERD were shown to have an ineffective esophageal motility(IEM)[3]. This may lead to slower acid clearance, with more severe symptoms heartburn, respiratory symptoms, and mucosal injury in patients with IEM. Increased intra-abdominal pressure Increased intraabdominal pressure may be more apparent in obese people and pregnant women. Studies show a direct correlation between pressure, body mass index, and waist circumference.

Diagnosis of GERD is based on symptoms and clinical studies such as PPI trial, upper gastrointestinal endoscopy, PH monitoring, and barium swallow. Proton Pump Inhibitor (PPI) trial Proton pump inhibitors are commonly used for the treatment of GERD. Thus, if PPI course for 6-8 weeks relieves heartburn and regurgitation, this strongly suggests GERD. While this is not a very specific method, this test is more cost effective than other diagnostic tests. The diagnostic tests listed below are typically reserved for atypical or severe cases of GERD. Upper Gastrointestinal Endoscopy: Endoscopy, which is guiding a camera into the esophagus to view the tissue and search for damage is performed to confirm a clinical diagnosis of GERD. Many GERD patients do not have an esophageal damage making this test of limited value. However, endoscopy is the “gold standard” for ruling out associated pathologies such as eosinophilic esophagitis, gastritis, peptic ulcers, and Barrett esophagus. Ambulatory pH monitoring Ambulatory pH monitoring is considered the gold standard for diagnosing GERD. It quantifies the degree of reflux and allows for correlation between symptoms and episodes of reflux. Reflux monitoring may be useful in distinguishing etiologies driving a lack of response to PPI therapy. Barium Swallow: Barium swallow is where a patient drinks contrast dye and then an X-ray is performed to view structures of the esophagus.

Lifestyle Modification to Manage GERD should be used for all patients as a first step in treating GERD. Some lifestyle modification may help with the symptoms of GERD. Sleep with head elevated Avoid late night meals Avoid smoking and alcohol Avoid foods/drinks that lower LES such as chocolate, high acid foods like tomato, peppermint, fatty foods, spicy food,caffeine and carbonated beverages Weight loss in case of obese or overweight people as it is directly related to the severity of GERD symptoms. Medications for GERD: The most common treatment for GERD is the use of proton pump inhibitors or PPI, however H2 antagonist are also effective and have less side effects. In many cases a trial of H-2 receptors will be used for 2 weeks, and if symptoms of GERD still persist, then the patient will be switched into a PPI for 4-8 weeks. Proton Pump Inhibitors:  Commonly used PPIs include omeprazole, lansoprazole, rabeprazole, pantoprazole, and esomeprazole. PPIs work by suppressing the production of gastric acid thereby relieving the symptoms of GERD. PPI relieve heartburn but do not decrease the reflux episodes and so do not control regurgitation in a large percentage of patients. PPIs are associated with side effects of increased risk fractures, cardiac dysfunction, and gastrointestinal infections.

Radiofrequency ablation of the LES is used to decrease reflux episodes by increasing LES pressure and decreasing LES relaxations. A radiofrequency ablation technique called Stretta was found to be insignificant in GERD patients in a meta-analysis study (including 153 patients)[10]. Stretta was found to be associated with adverse effects such as pneumonia, gastroparesis, esophageal perforation, cardiac arrest, and even death. Surgery  is an option for patients with symptoms refractory to other treatments or for those who have further complications. Fundoplication is the anti-reflux surgery and is an effective treatment option. Fundoplication has been shown to improve quality of life in patients with chronic symptoms. The failure rate of fundoplication ranges from 3% to 16%. Surgery comes with its own complications including bloating, gas, dysphagia, and recurrent symptoms over time.  Moreover, failure of the anti-reflux surgery may require a revisional surgery. Laparoscopic fundoplication is the gold standard for surgical treatment of GERD. Different types of fundoplication include, Nissen, Anterior, and Toupet fundoplication. To make sure that surgery is the best option for treatment, it is important to take into account all the factors such as obesity.

Gastroesophageal reflux disease is a highly prevalent disease, but remains a common and challenging condition. Treatments should including lifestyle modification and if needed, medications. PPIs remain the mainstay of treatment of GERD. In more severse cases surgery is opted for.  Understanding the pathophysiology of GERD may help in the development of novel therapeutic approaches. Warning signs to watch out for include difficulty swallowing, vomiting, vomiting blood, palpable masses, severe chest pain, unexplained weight loss. Notify your doctor immediately if experience any of these symptoms.