Understanding GERD
Gastroesophageal Reflux Disease (GERD) is a chronic condition where stomach acid flows back (refluxes) into the oesophagus, causing irritation and damage. Unlike occasional heartburn, GERD is persistent — occurring twice or more per week — and requires medical evaluation and treatment to prevent serious complications including Barrett's oesophagus and oesophageal cancer.
India has a rapidly rising prevalence of GERD, now affecting 18–30% of urban adults, linked to changing dietary habits, obesity, stress, and late eating.
Symptoms of GERD
Typical Symptoms
- Heartburn — burning sensation in chest after meals
- Acid regurgitation — sour/bitter taste in mouth
- Difficulty swallowing (dysphagia)
- Chest pain (non-cardiac)
- Sensation of food sticking in throat
- Worse when lying down or bending over
Atypical Symptoms (Often Missed)
- Chronic cough — especially at night
- Hoarseness of voice, sore throat
- Laryngitis (LPR — Laryngopharyngeal Reflux)
- Asthma worsening at night
- Dental erosions
- Globus sensation (lump in throat)
- Recurrent ear pain
⚠ Red Flag Symptoms Requiring Urgent Endoscopy: Difficulty swallowing, weight loss, vomiting blood, black tarry stools, anaemia, symptoms not responding to antacids. These may indicate complications or malignancy.
Complications of Untreated GERD
- Oesophagitis: Erosions and ulcers in oesophageal lining — causes painful swallowing
- Oesophageal stricture: Scarring narrows the oesophagus — causes progressive difficulty swallowing
- Barrett's oesophagus: Normal oesophageal lining replaced by intestinal-type tissue — precancerous condition requiring surveillance endoscopy
- Oesophageal adenocarcinoma: Barrett's → low-grade dysplasia → high-grade dysplasia → cancer. Increasing incidence worldwide
How We Diagnose GERD
- Upper GI Endoscopy: Direct visualisation of oesophageal lining — grades oesophagitis (LA Grade A–D), detects Barrett's, biopsies suspicious areas
- 24-hour pH-impedance monitoring: Gold standard — measures acid exposure time and symptom correlation over 24 hours
- Oesophageal Manometry: Measures lower oesophageal sphincter pressure — essential before anti-reflux surgery
- Barium swallow: Useful for detecting hiatus hernia, strictures
Treatment Options
Step 1: Lifestyle Modifications
- Lose weight if overweight (BMI >25 significantly worsens GERD)
- Elevate head of bed 15–20 cm — reduces nocturnal reflux
- Avoid eating within 3 hours of bedtime
- Avoid triggers: coffee, alcohol, spicy food, fried food, chocolate, mint, citrus
- Eat smaller, more frequent meals
- Quit smoking
Step 2: Medical Therapy
Proton Pump Inhibitors (PPIs): Omeprazole, Pantoprazole, Rabeprazole, Esomeprazole — the mainstay of GERD treatment. Taken 30–60 minutes before breakfast. Highly effective for healing oesophagitis. Long-term use requires annual review.
H2 Receptor Antagonists: Famotidine, Ranitidine — second-line agents, useful for breakthrough nighttime symptoms.
Antacids / Alginate combinations: For immediate symptom relief, not disease control.
Prokinetics: Domperidone, Mosapride — improve gastric emptying, reduce reflux episodes.
Step 3: Endoscopic and Surgical Options
Laparoscopic Nissen Fundoplication: Gold standard surgical cure for GERD. The upper stomach is wrapped around the lower oesophagus to reinforce the sphincter. 90–95% symptom-free at 10 years. Preferred for: young patients on lifelong PPIs, large hiatus hernia, PPI failure.
LINX Magnetic Sphincter: Minimally invasive — magnetic bead bracelet placed around lower oesophagus to prevent reflux. Preserves normal swallowing.
Barrett's Oesophagus Surveillance Protocol
Patients diagnosed with Barrett's oesophagus require regular surveillance endoscopy:
- Non-dysplastic Barrett's: Endoscopy every 3–5 years
- Low-grade dysplasia: Endoscopy every 6–12 months or radiofrequency ablation (RFA)
- High-grade dysplasia: Endoscopic mucosal resection (EMR) or surgery
Frequently Asked Questions
Is GERD a lifelong condition?
GERD is a chronic condition requiring ongoing management. With lifestyle changes + medical therapy, most patients achieve good symptom control. Surgical fundoplication can provide a long-term cure, eliminating the need for daily medication in most patients.
Are PPIs safe for long-term use?
PPIs are generally safe for most people. Long-term concerns include mild reductions in magnesium, calcium absorption, and possible small increases in C. difficile risk. Annual review with your doctor is recommended. The risk of untreated GERD (Barrett's, cancer) far outweighs the risks of appropriately dosed PPIs.
Does GERD cause cancer?
GERD → Barrett's oesophagus → cancer is a possible but not inevitable pathway. Only ~0.3% per year of Barrett's patients develop oesophageal cancer. However, the incidence of oesophageal adenocarcinoma is rising. Treating GERD and surveillance for Barrett's significantly reduces cancer risk.