1.What is GERD? Gastroesophageal Reflux Disease (GERD) is a disease in which stomach contents reflux into the esophagus or places other than the esophagus (e.g., the pharynx, larynx, oral cavity, trachea, bronchus, lungs, etc.), and cause discomfort, and it is one of the most common gastroenterology diseases. 2, what are the symptoms of GERD, including esophageal symptoms and symptoms outside the esophagus esophageal symptoms: acid reflux (reflux): stomach contents (including gastric juice, celiac disease, etc.) is strongly acidic (mainly hydrochloric acid HCl), reflux to the esophagus and even the oral cavity, there is an irritating acidic or acidic odor. Heartburn: a burning or fiery sensation in the chest or behind the sternum, due to the irritation of the esophageal mucosa by the H+ in the reflux. Chest pain: retrosternal pain due to long-term irritation and damage to the esophagus from acidic gastric contents, leading to esophagitis and esophageal constriction due to H+ irritation of the esophagus, sometimes resembling angina. These typical symptoms often occur half an hour to an hour after eating, on an empty stomach or at night. Dysphagia: due to esophageal spasm, often intermittent, can occur with liquid or solid food; due to esophagitis with esophageal stenosis, dysphagia is progressively aggravated. Bleeding: It is often caused by severe esophagitis and esophageal ulcer, and may be manifested as vomiting of blood or/and black stools, and is more common in elderly patients. Extra-esophageal symptoms: symptoms of pharyngolaryngitis, stomatitis, tracheobronchitis, bronchial asthma, aspiration pneumonia, interstitial fibrosis caused by reflux of gastric contents into the pharynx, larynx, oral cavity and respiratory tract, such as sore throat, hoarseness, coughing, coughing up sputum and shortness of breath. 3.What types of GERD are there? How to differentiate? GERD is divided into three types according to its gastroscopic manifestations: reflux esophagitis (obvious congestion, edema, erosion or ulceration in the middle and lower esophagus), endoscopy-negative or non-erosive GERD (no obvious abnormality of the esophageal mucosa under normal gastroscopy) and Barrett’s esophagus (also known as columnar epithelial esophagus, i.e., columnar epithelial hyperplasia in the lower esophagus), which can only be differentiated with a gastroscopy. Gastroscopy is required to differentiate between the three types. The symptoms of the three types are similar, therefore, it is difficult to differentiate them based on symptoms alone. 4. What tests should be done for suspected GERD? For patients with typical symptoms, clinical diagnosis can be made and treatment can be given, and it is not necessary to check them all. However, for patients or hospitals that have the conditions, some tests are still necessary. Gastroscopy: It can be used to classify the disease according to the results of the examination, which can help to formulate a more reasonable treatment plan, and at the same time, it can be differentiated from esophageal cancer, peptic ulcer and other diseases. 24-hour esophageal pH monitoring: First, it is the gold standard for diagnosing the presence of GERD. However, it has certain pain and poor patient compliance, and not many of them are actually done in the clinic. Ultrasound of upper abdomen: mainly to identify with some common diseases of liver, gallbladder and pancreas. Barium meal of upper gastrointestinal tract: mainly to know whether there is esophageal stenosis and whether there is esophageal hiatal hernia. Electrocardiogram (ECG): to identify with angina pectoris when there is chest pain. Gastroscopy is the most important and commonly used for the above examinations. 5.Why does gastroesophageal reflux disease (GERD) occur? Gastroesophageal reflux disease (GERD) is a multifactorial disease, the causes and pathogenesis of which are described in detail in the relevant chapters of this book, such as “Basis and etiology”, and briefly, they include the following aspects: Firstly, the cardia at the junction of the gastroesophageal tube “fails to guard” due to a variety of reasons and cannot effectively prevent the gastric contents from refluxing. Firstly, due to various reasons, the cardia at the junction of gastroesophageal is “out of guard”, which can not effectively prevent the gastric contents from flowing back into the esophagus; secondly, due to various reasons, the contouring effect of the esophagus on the gastric contents flowing back into the esophagus is reduced; thirdly, the resistance of the esophagus to reflux material is reduced; and fourthly, due to various reasons, the pressure inside the stomach is increased, and the gastric content “breaks” the cardia and flows backward into the esophagus. 6.What is the main causative factor or damage factor of GERD? It is hydrochloric acid, bile salts and various digestive enzymes in stomach contents, especially H+. 7.What is the danger of GERD? GERD is one of the most common gastroenterological diseases, and studies have shown that its impact on the quality of life of the population is no less than that of hypertension and diabetes, which are common in the population. (1) It reduces the quality of life of the population. (2) It affects work and reduces work efficiency. (3) In the case of severe esophagitis combined with bleeding, it can endanger the patient’s life. (4) Repeated episodes of severe esophagitis can lead to esophageal strictures. (5) Esophageal adenocarcinoma can occur on the basis of severe esophagitis and Barrett’s esophagus. 8.What are the main diseases to be differentiated from GERD? (1) Gastric and duodenal ulcer, erosive gastritis, which should be identified by gastroscopy. (2) Biliary and pancreatic diseases, identified by biliary and pancreatic ultrasound, CT, MR examination. (3) Coronary heart disease, angina pectoris, see the cardiology clinic, identified by electrocardiogram, 24-hour electrocardiogram, and even coronary angiography, or proton pump inhibition can be given orally first, diagnostic treatment. (4) Esophageal cancer, esophageal foreign body, mycobacterial esophagitis, etc., identified by gastroscopy. (5) Other esophageal dyskinetic diseases, identified by esophageal manometry and other esophageal dynamics tests. 9. What are the goals of GERD treatment? Relief of symptoms, healing of inflammation, prevention of recurrence, and avoidance (on the basis of Barrett’s esophagus) of cancer. 10.What are the aspects of GERD treatment? Generally speaking, it includes three aspects, diet and lifestyle regulation, medication, and maintenance therapy. 11.What are the types of medications used to treat GERD? What are the effects? (1) Acid inhibitors, that is, drugs that inhibit gastric acid secretion, including H2 receptor antagonists (such as famotidine, etc.) and proton pump inhibitors (referred to as PPI, such as omeprazole, etc.), the role of long-lasting, easy to take, this type of drug is the most effective drugs for the treatment of gastroesophageal reflux disease, in particular, proton pump inhibitors, is currently listed as the first choice, and it is a good therapeutic effect thanks to its potent acid inhibition, reduce gastric juice, gastric acid secretion, significantly reduce the concentration of H+ in the reflux. (2) Acid suppressants, i.e. alkaline drugs that neutralize gastric acid, have a fast onset of action but a short duration of maintenance, and are only used for temporary relief of symptoms. (3) Mucosal protective agents, for patients with reflux esophagitis, can be used in combination with acid inhibitors, alone is less effective. (4) prokinetic agents, drugs to promote gastric emptying and esophageal peristalsis, such as morpholine, mosapride and so on. Theoretically, these drugs should have good efficacy, but the actual application of the effect alone is poor, can be used in combination with acid inhibitors. 12.Why is it necessary to maintain treatment for GERD? From the existing research, gastroesophageal reflux disease (GERD) is a kind of chronic recurrent disease, especially for the elderly patients, the recurrence rate after stopping the medication is more than 80%, and the elderly patients almost 100% recurrence. Therefore, maintenance therapy is needed. 13.What is the difference in the treatment of the three types of GERD? The dietary and lifestyle modifications as well as the medication regimen are the same for all three types of GERD (as mentioned above), the differences are: (1) Severe esophagitis (grade IV or D), which is prone to hemorrhage or esophageal stenosis, the standardized treatment can be prolonged up to 3 months, and then the gastroscopy can be repeated to find out whether there are any stenosis and other complications, and if there is any stenosis, endoscopic dilatation can be considered for the treatment. (2) Barrett’s esophagus, the gastroscopy should be reviewed after 2 months of standardized treatment and biopsy of the lesion, if there is no improvement, argon knife treatment can be done under endoscopy, and the biopsy pathology should be timely surgical treatment if there is severe heterogeneous hyperplasia or carcinoma. (3) Mild to moderate reflux esophagitis or endoscopy-negative gastroesophageal reflux disease, maintenance therapy after standardized treatment, without the need to review gastroscopy. 14.What are the indications for surgical treatment of GERD? (1) Severe reflux esophagitis with massive bleeding and ineffective active medical treatment. (2) Severe reflux esophagitis with esophageal stenosis, which is not relieved by active medical treatment and is not treated by endoscopic dilatation or is not suitable for endoscopic dilatation. (3)Barrett’s esophagus with severe heterogeneous hyperplasia or carcinoma. (4) Those who do not have the previous conditions, but the symptoms do not resolve grade by standardized treatment or the effect of maintenance treatment is not good, may consider doing open fundoplication, laparoscopic fundoplication, endoscopic suture, etc. These surgeries have a moderate effect in the near future, but the long-term effect is not necessarily satisfactory, so special care should be taken.