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This is a clinician-written, evidence-based summary aligned to the USMLE Step 2 CK Content Outline. It is intended for medical students preparing for USMLE Step 2 CK. Management reflects current ACC/AHA, USPSTF, and APA guidelines. Always cross-reference with UpToDate, institutional protocols, and clinical judgment.
Key points
- Typical GERD = heartburn and acid regurgitation, usually worse after meals or lying down
- No alarm features: empiric once-daily PPI 30-60 minutes before breakfast for 8 weeks
- Alarm symptoms require upper endoscopy: dysphagia, weight loss, GI bleeding, anemia, vomiting, or odynophagia
- Barrett screening is targeted to chronic GERD plus risk factors such as male sex, age >50, White race, obesity, smoking, or family history
- Progressive dysphagia or weight loss is not uncomplicated reflux — evaluate for stricture or malignancy
Overview
GERD results from pathologic reflux of gastric contents across the lower esophageal sphincter, producing esophageal symptoms or mucosal injury. Mechanisms include transient LES relaxation, hiatal hernia, impaired clearance, delayed gastric emptying, obesity, pregnancy, and medications that reduce LES tone. Typical symptoms can be diagnosed clinically, but alarm features require endoscopic evaluation.
Epidemiology
GERD is one of the most common outpatient gastrointestinal disorders in the United States. Risk factors include obesity, pregnancy, hiatal hernia, smoking, alcohol, large late meals, and medications such as calcium-channel blockers, anticholinergics, nitrates, benzodiazepines, and opioids. Barrett esophagus is most common in older White men with long-standing reflux and central obesity.
Clinical Features
Symptoms
Burning retrosternal heartburn after meals or when supine
Sour or bitter regurgitation into the mouth
Nocturnal cough, hoarseness, throat clearing, or laryngitis
Non-cardiac chest pain after appropriate cardiac evaluation
Dysphagia, odynophagia, weight loss, hematemesis, melena, or iron deficiency anemia
Signs
Often normal physical examination
Epigastric tenderness may be present but is nonspecific
Dental enamel erosion or posterior pharyngeal erythema with chronic extraesophageal reflux
Pallor or orthostasis if occult bleeding from severe esophagitis
Investigations
First-line
Clinical diagnosisTypical heartburn/regurgitation without alarm features can be treated empirically without initial testing
Empiric PPI trialOmeprazole, pantoprazole, or equivalent once daily 30-60 minutes before breakfast for 8 weeks
Second-line
Upper endoscopy (EGD)Alarm symptoms, refractory symptoms, suspected complications, or Barrett screening in high-risk patients
Ambulatory pH monitoringBest confirmation when endoscopy is normal and diagnosis is uncertain; performed off PPI unless assessing refractory symptoms on therapy
Specialist
Esophageal manometryUsed before antireflux surgery and to exclude achalasia; not diagnostic for GERD
Barium esophagramUseful for strictures, rings, hiatal hernia, or dysphagia anatomy
Management
ACG Clinical Guideline for GERD 20221
Lifestyle and risk modification
- Weight loss if overweight or obese
- Avoid meals within 2-3 hours of bedtime; elevate head of bed for nocturnal symptoms
- Avoid individualized triggers such as fatty meals, chocolate, peppermint, caffeine, alcohol, or spicy foods if they provoke symptoms
- Smoking cessation and medication review for drugs that reduce LES tone
2
Medication strategy
- PPI once daily before breakfast for 8 weeks for typical symptoms
- If partial response: verify timing/adherence, then increase to BID before breakfast and dinner for 8-12 weeks
- H2 blocker such as famotidine for mild intermittent symptoms or nocturnal breakthrough
- Maintenance PPI at the lowest effective dose for severe erosive esophagitis, Barrett esophagus, peptic stricture, or recurrent symptoms
3
Refractory or complicated GERD
- EGD for persistent symptoms despite optimized PPI or any alarm feature
- Ambulatory pH or pH-impedance monitoring distinguishes acid reflux, non-acid reflux, and functional heartburn
- Antireflux surgery or magnetic sphincter augmentation only for objectively confirmed GERD
- Peptic stricture: endoscopic dilation plus long-term PPI
Complications
- Erosive esophagitis: Mucosal breaks that can bleed or cause pain.
- Peptic stricture: Progressive solid-food dysphagia from chronic scarring.
- Barrett esophagus: Intestinal metaplasia of distal esophagus and precursor to adenocarcinoma.
- Esophageal adenocarcinoma: Progressive dysphagia and weight loss are classic red flags.
- Extraesophageal disease: Chronic cough, laryngitis, asthma worsening, dental erosions.
USMLE Step 2 CK Exam Tips
- 1Typical heartburn + regurgitation + no alarm features = empiric PPI, not immediate endoscopy
- 2Dysphagia, weight loss, anemia, hematemesis, or melena = EGD first
- 3PPI timing matters: 30-60 minutes before meals
- 4Barrett screening is not for every reflux patient — think older White male with central obesity and chronic GERD
- 5GERD chest pain is diagnosed only after appropriate cardiac exclusion
- 6Achalasia mimics reflux but has dysphagia to solids and liquids plus bird-beak on barium swallow
- 7Long-term PPI is appropriate for severe erosive esophagitis, Barrett, or strictures
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