GI NOTES

GERD and Barrett’s Esophagus

1. Definitions and presentation

GERD is reflux of gastric contents that causes troublesome symptoms or complications. Up to 1 in 5 adults in Western countries has weekly symptoms.

Type	Features
Typical	Heartburn and regurgitation
Atypical / extraesophageal	Chronic cough, hoarseness, throat clearing, asthma, dental erosions. Often not caused by reflux, so objective testing is important.
Alarm features	Dysphagia, weight loss, GI bleeding or anemia, persistent vomiting. Go straight to endoscopy.

Complications: erosive esophagitis, peptic stricture, Barrett’s esophagus, and esophageal adenocarcinoma.

2. Diagnostic approach

Test	What it shows	Interpretation
EGD	Esophagitis (LA grade A to D), Barrett’s, stricture	LA B, C, D are conclusive for GERD; LA A is borderline (Lyon 2.0).
Ambulatory pH (wireless 96 h preferred) off PPI	Acid exposure time (AET)	AET above 6% conclusive; below 4% normal; 4 to 6% borderline.
pH-impedance on PPI	Persistent reflux despite therapy	Use in proven GERD with refractory symptoms.
High-resolution manometry	Motility, hiatal hernia	Before anti-reflux surgery or endoscopic therapy; not a diagnostic test for GERD.

3. Treatment

Lifestyle

• Weight loss if overweight. It is the lifestyle step with the best evidence.
• Raise the head of the bed and avoid eating 2 to 3 hours before lying down for nocturnal symptoms.
• Avoid personal trigger foods; a blanket elimination diet is not needed. Stop smoking.

Acid suppression

• PPIs are superior to H2-receptor antagonists for healing esophagitis and controlling symptoms.
• Take the PPI 30 to 60 minutes before a meal. Go to twice daily only for partial response.
• Vonoprazan (potassium-competitive acid blocker) is FDA approved for healing and maintenance of erosive esophagitis and for non-erosive reflux disease. It can be used for severe (LA C or D) esophagitis.
• After healing of LA C or D esophagitis, Barrett’s, or a peptic stricture, continue maintenance PPI indefinitely.
• Deprescribing: if there is no clear long-term indication, try to taper. Associations with fractures, kidney disease and dementia come from observational data and are not proven causal.

Refractory GERD

1. Check adherence and timing of the PPI.
2. Confirm the diagnosis: if GERD was never proven, test off PPI. If GERD is proven, use pH-impedance on PPI.
3. Consider other diagnoses: functional heartburn, reflux hypersensitivity, rumination, EoE, achalasia, gastroparesis.
4. Options for proven, refractory or PPI-dependent GERD: laparoscopic fundoplication, magnetic sphincter augmentation, transoral incisionless fundoplication in selected patients, and Roux-en-Y gastric bypass when obesity is present.

4. Barrett’s esophagus

Who to screen

Consider a single screening endoscopy for people with chronic GERD symptoms plus 3 or more risk factors: male sex, age above 50, White race, tobacco use, obesity, or a first-degree relative with Barrett’s or esophageal adenocarcinoma. A swallowable, non-endoscopic capsule sponge device is an acceptable alternative.

Endoscopic technique

• Describe the segment using the Prague C and M criteria (circumferential extent and maximum extent in cm).
• Inspect carefully with high-definition white light and virtual chromoendoscopy.
• Seattle protocol: four-quadrant biopsies every 2 cm (every 1 cm if dysplasia is known or suspected), plus targeted biopsies of any visible lesion.
• Dysplasia must be confirmed by a second, expert GI pathologist.

Surveillance and treatment by histology

Histology	Management
Non-dysplastic, under 3 cm	Surveillance EGD every 5 years
Non-dysplastic, 3 cm or longer	Surveillance EGD every 3 years
Indefinite for dysplasia	Optimize PPI (twice daily) and repeat EGD in 3 to 6 months
Low-grade dysplasia (confirmed)	Endoscopic eradication therapy preferred; surveillance every 12 months is an alternative
High-grade dysplasia	Endoscopic resection of any visible lesion, then ablation (usually radiofrequency ablation)
Intramucosal cancer (T1a)	Endoscopic resection, then ablation of the remaining Barrett’s

• All patients with Barrett’s should take at least a once-daily PPI.
• Aspirin is not recommended solely to prevent progression.
• After complete eradication of intestinal metaplasia, surveillance continues. Recurrence is most often at the gastroesophageal junction, so biopsy the cardia.

5. High-yield pearls

• Normal endoscopy does not exclude GERD. Most patients with GERD have non-erosive disease.
• Do not start lifelong PPI therapy for atypical symptoms without objective evidence of reflux.
• A hiatal hernia larger than 3 cm and a hypotensive lower esophageal sphincter predict poor response to medical therapy.
• Do not take Barrett’s biopsies through active esophagitis. Treat the esophagitis first, because inflammation can mimic dysplasia.

References

• Katz PO, Dunbar KB, Schnoll-Sussman FH, et al. ACG Clinical Guideline for the Diagnosis and Management of Gastroesophageal Reflux Disease. Am J Gastroenterol. 2022;117(1):27-56.
• Shaheen NJ, Falk GW, Iyer PG, et al. Diagnosis and Management of Barrett’s Esophagus: An Updated ACG Guideline. Am J Gastroenterol. 2022;117(4):559-587.
• Gyawali CP, Yadlapati R, Fass R, et al. Updates to the modern diagnosis of GERD: Lyon Consensus 2.0. Gut. 2024;73(2):361-371.
• Targownik LE, Fisher DA, Saini SD. AGA Clinical Practice Update on De-Prescribing of Proton Pump Inhibitors. Gastroenterology. 2022;162(4):1334-1342.

For educational purposes only. This note does not replace clinical judgment or local protocols. Check doses against current labeling and institutional guidance.