Gastroesophageal Reflux Disease

Entitlement Eligibility Guideline (EEG)

Date reviewed: 22 January 2025

Date created: February 2005

ICD-11 code: DA22

VAC medical code: 00911 Gastroesophageal reflux disease (GERD)

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Definition

Gastroesophageal reflux disease (GERD) is a chronic digestive disorder where stomach contents consistently refluxes into the esophagus. This reflux causes irritation, inflammation, and other troublesome symptoms.

The reflux of stomach contents into the esophagus is a normal physiological phenomenon. Reflux becomes abnormal when it causes esophageal injury or produces persistent symptoms that are troublesome to the individual.

Troublesome symptoms of GERD include, but are not limited to, persistent heartburn and regurgitation. GERD usually resolves with appropriate management, including initiation of proton pump inhibitor (PPI) medications.

For the purposes of this entitlement eligibility guideline (EEG), equivalent diagnoses for gastroesophageal reflux disease (GERD) include:

  • reflux esophagitis (RE)
  • non-erosive reflux disease (NERD).

Exclusions:

The following conditions are excluded from this EEG:

  • bile reflux (more commonly related to prior stomach/pylorus or gallbladder surgery)
  • infectious esophagitis
  • eosinophilic esophagitis
  • pill esophagitis
  • reflux hypersensitivity.

Note: The symptoms of GERD may overlap with those of other upper gastrointestinal conditions such as functional heartburn/dyspepsia. Consultation with a disability consultant or medical advisor is recommended when the diagnosis is unclear.

Diagnostic standard

A diagnosis from a qualified medical practitioner, nurse practitioner, or physician assistant (within their scope of practice) is required.

Symptoms must persist for at least three months and be present for at least six months prior to diagnosis.

GERD is primarily a clinical diagnosis treated with lifestyle, dietary modification and medication (most commonly a PPI medication). Individuals may be referred for further investigation to rule out other potential causes of symptoms when:

  • Classic symptoms of heartburn and regurgitation are not present.
  • PPI medication trial is ineffective.
  • There are other risk factors for complications such as Barrett’s esophagus or esophageal adenocarcinoma.
  • There are red flags such as initial presentation over 60 years old, difficulty swallowing known as dysphagia, pain with swallowing known as odynophagia, gastrointestinal (GI) bleeding, iron deficiency anemia, unintentional weight loss, or recurrent vomiting.

Investigations, when indicated, may include:

  • Upper GI endoscopy +/- biopsies, which involves using a scope (endoscope) to visualize the esophagus, stomach and duodenum.
  • Esophageal manometry, which involves inserting a probe into the esophagus to measure muscle contraction and look for motility problems.
  • Ambulatory esophageal pH monitoring, where a probe is placed in the esophagus to measure pH. A symptom diary is kept to correlate symptoms with acid exposure.
  • Esophageal impedance testing, which involves inserting an electrode into the esophagus to measure electrical currents and is often used in combination with pH or manometry testing.
  • Plain x-ray and barium swallow, with the advent of current techniques, these are less commonly used.

Anatomy and physiology

Anatomically, the esophagus passes through the diaphragm, where the crural muscle helps maintain the integrity of the lower esophageal sphincter (LES). The LES is a muscular valve that normally relaxes as food moves down the esophagus into the stomach, and tightens afterwards to keep contents in the stomach.

Normal digestion requires a combination of adequate salivation, normal swallowing and esophageal function along with:

  • coordinated muscle movements of the esophagus, called peristalsis
  • proper anatomic configuration of the gastroesophageal junction
  • proper functioning of the LES.

Any problem or deficiency of any or all of these three functions can lead to problematic GERD symptoms. The integrity of the LES can be affected temporarily by various foods, medication and/or can be permanently damaged by trauma or by certain surgical interventions.

The stomach is an acidic environment for digesting food. The stomach cells are well equipped to deal with this harsh environment, and saliva has a buffering action on acid. The esophageal mucosa is not as resilient and is more sensitive to acid exposure. As a result, when acid repeatedly refluxes from the stomach into the esophagus, it can lead to symptoms (classically heartburn and/or regurgitation. Figure 1: Gastroesophageal reflux disease).

Figure 1: Gastroesophageal reflux disease

Comparing a healthy stomach to a stomach affected by GERD. Left image: A healthy stomach with the lower esophageal sphincter closed, preventing acid from flowing back into the esophagus. Right image: A stomach affected by GERD where the lower esophageal sphincter is open, allowing acid reflux into the esophagus. Source: Veterans Affairs Canada (2024).

Clinical features

Gastroesophageal reflux is a common phenomenon and occurs physiologically in normal individuals, for instance when bending over after eating a large meal. For some people, the degree of reflux is either frequent or problematic enough to fit the criteria for a diagnosis of GERD.

Classically, the two main symptoms of GERD include:

  • heartburn, typically described as a burning sensation in the retrosternal area, most commonly after eating
  • regurgitation, the perception of flow of refluxed stomach contents into the mouth.

Other symptoms include, but are not limited to:

  • Difficulty swallowing (dysphagia) and, more rarely, pain with swallowing (odynophagia).
  • Chest pain or pressure, typically described as a squeezing or substernal burning sensation and radiating to the back, neck, jaw, or arms. The pain lasts from minutes to hours, often occurring after meals and can awaken people from sleep.
  • Increased salivation (also referred to as water brash) in response to reflux.
  • Globus sensation, the perception of a lump in the throat.

Other symptoms can occur when stomach contents reflux into the upper airway (mouth and throat), and can be aspirated into the larynx (voice box) or lungs:

  • hoarseness of the voice (laryngitis)
  • pulmonary aspiration.

Prolonged or severe GERD can result in complications (especially if untreated), where acid bathes the sensitive esophageal tissue, leading to erosions, esophagitis, and potentially esophageal ulcers. Complications include but are not limited to:

  • esophageal erosions
  • esophageal strictures (narrowing of parts of the esophagus due to scar tissue)
  • ulceration
  • iron deficiency anemia from occult bleeding
  • Barrett’s esophagus
  • esophageal cancer (adenocarcinoma).

Aspiration effects of GERD may include:

  • transient or long-term cough
  • shortness of breath
  • pneumonitis: Inflammation of lung tissue due to exposure to gastric contents.

In rare cases when the diagnosis of GERD is clear, and lifestyle interventions and medications are not controlling symptoms, surgery may be performed. The most common surgery is a laparoscopic Nissen fundoplication, which involves wrapping the top of the stomach around the lower esophagus to reinforce the lower esophageal sphincter (LES).

While the incidence of GERD has been reported to be almost equal in males and females, the male to female ratio appears to increase as the disease progresses. Males have a higher incidence of reflux esophagitis, Barrett’s esophagus and esophageal adenocarcinoma, while females present more typically with non-erosive reflux disease and report greater pain associated with symptoms.

Entitlement considerations

In this section

Section A: Causes and/or aggravation

For Veterans Affairs Canada (VAC) entitlement purposes, the following factors are accepted to cause or aggravate the conditions included in the Definition section of this EEG, and may be considered along with the evidence to assist in establishing a relationship to service. The factors have been determined based on a review of up- to-date scientific and medical literature, as well as evidence-based medical best practices. Factors other than those listed may be considered, however consultation with a disability consultant or medical advisor is recommended.

The timelines cited below are for guidance purposes. Each case should be adjudicated on the evidence provided and its own merits.

Factors

  1. Having a hiatus hernia at the time of clinical onset of GERD. Hiatus hernia means a herniation of part of the stomach into the thoracic cavity through the esophageal hiatus in the diaphragm.

  2. Undergoing intra-abdominal surgery in the area of the LES, the region immediately surrounding the intra-abdominal esophagus and the diaphragmatic crura, within several days of clinical onset or aggravation of GERD.

    Interference with the LES during certain surgical procedures, such as vagotomy, partial or total gastrectomy, and esophageal dilatation may play a role in the development of reflux esophagitis. Certain procedures for weight loss, such as sleeve gastrectomy, can predispose to GERD, whereas other procedures, such as Roux-en-Y gastric bypass, do not.

  3. Having been diagnosed with the certain medical conditions including some auto-immune disorders at the time of clinical onset or aggravation of GERD. The effects of these conditions on the esophagus can include reduced motility and LES dysfunction. These disorders include, but are not limited to:
    • scleroderma (systemic sclerosis)
    • mixed connective tissue disease
    • polymyositis
    • Sjogren syndrome
    • Zollinger-Ellison syndrome.
  4. Experiencing increased intra-abdominal pressure at the time of clinical onset or aggravation of GERD may result from, but is not limited to, obesity.

  5. Using medications from the specified list of medications in Appendix A, supported by the timeline of clinical onset or aggravation of GERD.

    If it is claimed a medication resulted in the clinical onset or aggravation of GERD, the following must be established:

    • The medication was prescribed to treat an entitled condition.
    • The individual was receiving the medication at the time of the clinical onset or aggravation of the GERD.
    • The current medical literature supports the medication can result in the clinical onset or aggravation of GERD.
    • The medication use is long-term, ongoing, and cannot reasonably be replaced with another medication, or the medication is known to have enduring effects after discontinuation.
  6. Diagnosed with alcohol use disorder.
  7. Inability to obtain appropriate clinical management of GERD.

Note: At the time of publication the health-related expert opinion and scientific evidence is insufficient to conclude that psychological stress, or specific psychiatric disorders such as anxiety disorders, depressive disorders, posttraumatic stress disorder, or feeding and eating disorders cause or permanently aggravate GERD.

Section B: Medical conditions which are to be included in the entitlement/assessment

Section B provides a list of diagnosed medical conditions which are considered for VAC purposes to be included in the entitlement and assessment of GERD.

  • Hiatus hernia
  • Barrett’s esophagus (columnar metaplasia)
  • Esophageal dysplasia reflux esophagitis (RE) or erosive esophagitis (e.g. esophageal erosions, ulcerations and stricture formation)
  • Non-erosive reflux disease (NERD)
  • Functional heartburn/dyspepsia
  • Postprandial distress syndrome
  • Epigastric pain syndrome

Section C: Common medical conditions which may result, in whole or in part, from gastroesophageal reflux disease and/or its treatment

Section C is a list of conditions which can be caused or aggravated by GERD and/or its treatment. Conditions listed in Section C are not included in the entitlement and assessment of GERD. A consequential entitlement decision may be considered where the individual merits and the medical evidence of the case support a consequential relationship. Conditions other than those listed in Section C may be considered; consultation with a disability consultant or medical advisor is recommended.

  • Asthma
  • Bronchiectasis
  • Aspiration pneumonitis
  • Dental erosion (only in exceptional circumstances when GERD has not been treated)
  • Esophageal adenocarcinoma

Note: For asthma, bronchiectasis, aspiration pneumonitis, and dental erosion, a confirmed diagnosis of GERD is required.

Related VAC guidance and policy:

Appendix A: Medications

The medications and/or classes of medications that may cause or aggravate GERD include, but are not limited to, the below list.

Note: Individual medications may belong to a class of medications. The effects of a specific medication may vary from the class. The effects of the specific medication should be considered.

  • Anticholinergics including, but not limited to (Note: this group does not include drugs with anticholinergic side effects):
    • benztropine (Cogentin)
    • trihexyphenidyl (Artane)
    • flavoxate (Urispas)
    • oxybutynin (Ditropan)
    • orphenadrine.
  • Calcium channel blockers:
    • amlodipine (Norvasc)
    • diltiazem (Tiazac)
    • felodipine (Plendil)
    • flunarizine
    • nifedipine (Adalat, Procardia)
    • nimodipine
    • verapamil (Isoptin).
  • Tricyclic antidepressants (Note: this group does not include selective serotonin reuptake inhibitor [SSRI] antidepressants or serotonin and norepinephrine reuptake inhibitor [SNRI] antidepressants):
    • amitriptyline (Elavil)
    • clomipramine (Anafranil)
    • desipramine
    • doxepin
    • imipramine (Impril, Tofranil, Tripamine)
    • nortriptyline (Aventyl, Norventyl)
    • trimipramine (Surmontil).
  • Theophylline
  • Hormone replacement therapy (HRT) with estrogen alone (Note: this does not include combination therapy of estrogen plus progesterone).
  • Non-steroidal anti-inflammatory drug (NSAID) use: where NSAID use is required on a permanent and ongoing basis:
    • celecoxib (Celebrex)
    • diflunisal
    • etodolac
    • flurbiprofen (Ansaid)
    • ibuprofen (Advil, Motrin)
    • indomethacin (Indocid)
    • ketoprofen
    • meloxicam (Mobicox)
    • nabumetone
    • naproxen (Aleve, Anaprox, Naprosyn)
    • nepafenac (Nevanac)
    • piroxicam (Feldene)
    • sulindac
    • tenoxicam
    • tiaprofenic acid
    • diclofenac (Arthrotec, Cambia).

Note: Topical NSAIDs, such as pennsaid and voltaren, should be adjudicated on the evidence provided and its own merits. Consultation with a disability consultant or medical advisor is recommended.

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