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Gastroesophageal Reflux Disease

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Gastroesophageal reflux disease, or GERD, is a condition in which stomach contents, including acid, pepsin, and sometimes bile, flow backward into the esophagus due to dysfunction of the lower esophageal sphincter, or the LES.

Normally, the LES prevents reflux, but in GERD, it relaxes inappropriately, especially after meals, often triggered by gastric distention.

Risk factors include obesity, aging, pregnancy, and a sliding hiatal hernia. Substances like nicotine, alcohol, and anticholinergic drugs further weaken the LES tone.

Reflux episodes may reduce esophageal clearance, allowing stomach acid to remain in contact with the esophageal lining, leading to inflammation or esophagitis.

Chronic exposure can cause esophageal fibrosis, impaired motility, and Barrett esophagus, a condition in which the normal squamous epithelium is replaced by specialized columnar cells.

Common symptoms include heartburn, regurgitation, chest discomfort, dysphagia, hoarseness, and chronic cough, often worse after eating or when lying down.

Overview

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Gastroesophageal reflux disease (GERD) is the backward flow of stomach contents (acid, pepsin, or bile) into the esophagus, causing mucosal inflammation known as esophagitis. It results from failure of antireflux mechanisms, mainly the lower esophageal sphincter (LES), influenced by mechanical and physiological factors.

Etiology and Risk Factors

GERD develops when LES function is weakened or when intra-abdominal pressure increases. Risk factors include aging, obesity, and sliding hiatal hernia, which disrupt diaphragm support and alter the angle of His, making reflux more likely. Medications such as nicotine, anticholinergics, nitrates, and calcium channel blockers reduce LES tone. Episodes of reflux are often triggered by frequent transient LES relaxations, poor esophageal motility, delayed gastric emptying, and increased gastric pressure, which also promote reflux.

Pathophysiology

Normally, the LES maintains pressure (10–30 mmHg) to prevent reflux. In GERD, reduced tone, spontaneous relaxations, or impaired peristalsis weaken this barrier. Increased intra-abdominal pressure (e.g., coughing, pregnancy) worsens reflux. Prolonged exposure to refluxate, typically acid, pepsin, and bile, damages the mucosa, causing inflammation, erosion, and immune cell infiltration. Over time, chronic inflammation leads to fibrosis and thickening of the esophageal wall, further reducing LES function and perpetuating the disease cycle.

Clinical Manifestations and Complications

Common symptoms include heartburn and acid regurgitation, along with chest pain, difficulty swallowing (dysphagia), cough, hoarseness, and discomfort after meals, often worse when lying down or during activities that increase intra-abdominal pressure. Fibrotic healing may cause esophageal strictures, resulting in progressive dysphagia. Chronic irritation can also lead to bleeding, aspiration pneumonia, and Barrett esophagus—a condition in which the squamous lining of the esophagus is replaced by intestinal-type columnar cells. Barrett esophagus significantly raises the risk of developing esophageal adenocarcinoma, particularly in men and smokers.

Transcript

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