What is Gastroesophageal Reflux - Dr.Adem Dervişoğlu, MD, Professor

Dr.Adem Dervişoğlu, MD, Professor

What is Gastroesophageal Reflux

Coming up of the stomach contents into the esophagus is described as gastroesophageal reflux. Gastroesophageal reflux is a physiological event that may occur up to 10-50 times a day, especially after meals and during certain periods of sleep. Gastroesophageal reflux disease (GERD) is the coming up of the highly acidic stomach content into the esophagus sometimes only causing symptoms or sometimes; along with the disease symptoms, causing histopathological changes in the esophagus known as reflux esophagitis. On the other hand, the presence of reflux-associated symptoms with no findings of injury in endoscopy is called non-erosive reflux disease.

Although gastroesophageal reflux disease is highly common and seen in almost 20% of the population, most patients do not consult a physician because they can obtain temporary relief by adopting simple dietary changes or taking antiacid medications. Therefore, its place in society is considered similar to an iceberg. It is thought that individuals seeing a physician for this disorder account for only 10-15% of all patients.


Complaints in gastroesophageal reflux disease occur at times and persist for long periods. Classic symptoms of GERD include heartburn; which is also called pyrosis, characterized by a burning sensation behind the sternum (breastbone) and regurgitation may occur less frequently. Burning (pyrosis) behind the sternum (breastbone) is the most common and most typical symptom of reflux, usually occurring after meals and relieved after taking antacid medications. Regurgitation is the arrival of acidic stomach contents into the mouth by bending or lying down after food intake. It is more difficult to treat compared to the treatment of classical retrosternal burning. Dysphagia (difficulty swallowing) has been reported in more than 30% of patients. Retrosternal burning is usually long-term. Dysphagia develops slowly and progressively in swallowing solid food. When a patient with long-term complaints of reflux begins to complain of dysphagia, it should suggest peptic strictures or esophageal cancer. Painful swallowing (odynophagia) and bleeding can rarely occur.

Besides these classic symptoms, GERD may also manifest with atypical symptoms. Upper respiratory tract symptoms; especially asthma and chronic cough are the most common among the atypical symptoms. Another atypical symptom in GERD is non-cardiac chest pain. There are no identifiable factors in 25-30% of patients to explain the angina pectoris-type pain. Reflux or esophageal motor dysfunction is responsible for the pain in about half of these patients. Laryngitis due to reflux is the most common manifestation with many laryngeal symptoms and signs.


The most important complications are massive hemorrhage, perforation, and strictures of the esophagus, and Barrett’s esophagus. Barrett’s esophagus is responsible for 80-100% of adenocarcinomas of the esophagus. Barrett’s esophagus increases the risk of developing adenocarcinoma by 75 folds compared to normal individuals.


First of all, a thorough medical history should be obtained for making the diagnosis. Symptoms are usually alleviated within 1-2 weeks of treatment with protective drugs for the gastric mucosa (proton pump inhibitors – PPI). The diagnosis can be made if the symptoms recover with treatment and if they restart with discontinuation of treatment. Further tests should be carried out in patients with atypical symptoms, in the presence of alarm symptoms (dysphagia, odynophagia, significant weight loss, bleeding, anemia, etc.) or in patients who do not respond to treatment.

Endoscopy is the most commonly used method for the diagnosis of reflux because it allows direct examination of the esophageal mucosa and tissue sampling for histopathological examination when necessary. Endoscopy should be performed immediately in patients with alarm findings, previous upper digestive tract bleeding (characterized by vomit that looks like coffee grounds and/or tarry and stinky defecation), difficulty swallowing (sensation of food getting stuck in the throat or chest, or behind the breastbone and often tried to pass by drinking water), pain, unexplained weight loss, anemia (requires further tests especially in men and in women when excessive menstrual bleeding does not explain the condition better), and in men older than 50 years of age having reflux complaints longer than 5 years.

Long-term (24 or 48 hours) pH monitoring is the next method to be used for making the diagnosis in patients having symptoms suggesting reflux but having no pathological findings in endoscopy.


Gastroesophageal reflux is a chronic disease. The goals of treatment can be summarized as achieving symptom relief and recurrence prevention (that is administering maintenance therapy), facilitation of patients’ adherence to treatment, prevention of serious complications, improving the quality of life, and achieving patient satisfaction.

Patients are advised to sleep with their heads propped up and avoid eating large amounts. They should eat small and frequent meals regularly, and cut back on fatty foods and chocolate. Patients are further advised to reduce consumption of tea and coffee, and stop the intake of alcoholic beverages, cola drinks, and soda. They should not lie down immediately after dinner but should keep a sitting position eat at least for an hour.  Moreover, patients should stop smoking and further weight gain.

Over the last three decades, the treatment strategy for GERD has changed significantly after the introduction of gastric mucosa protective drugs such as H2-receptor antagonists and later with the introduction of proton pump inhibitors (PPI). The superior gastric acid-blocking activity of PPI resulted in higher efficacy compared to H2-receptor antagonists. Therefore, PPI started to be widely used for the treatment of GERD. Up to 90% of GERD patients have no complaints as long as they receive PPIs.

Despite medical treatment, approximately 10-15% of GERD patients need surgery.

Surgical treatment is performed in non-compliant patients, patients not able to afford the optimal medical treatment, young patients (preferably non-obese patients), and in patients preferring surgical treatment to lifelong drug therapy. Surgery should particularly be considered in patients with recurrence of the symptoms within a year of appropriate PPI therapy and in patients with atypical symptoms not responding well to medical treatment. It should also be considered in patients; in whom a full correlation between symptoms and reflux is demonstrated based on pH-meter findings, and in patients with persistent bleeding and strictures despite endoscopic pneumatic dilatations. Unless dysplasia develops, Barrett’s esophagus is not an indication alone for surgery. Furthermore, surgical treatment does not reduce the risk of developing cancer.

The surgical method is fundoplication (Nissen fundoplication), which can be performed in a variety of ways. Laparoscopic surgery has been preferred to classical open surgeries in recent years because of the short duration of the intervention, short hospital stays, and posing minimal harm to the patient. The outcomes of laparoscopic surgery are successful in experienced hands (Laparoscopic Nissen Fundoplication).

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