Pathogenesis of GERD is mainly concerned with a defective antireflux barrier to gastric and duodenal contents. Transient lower oesophageal sphincter relaxation is thought to be the main mechanism by which reflux is permitted, but the mucosal exposure time to the refluxate, the nature of the refluxed material and oesophageal clearance are important mechanisms. The Internist only sees the 'tip of the iceberg' as far as GERD is concerned, and generally these are severe resistant cases of GERD. In this group, endoscopy is mandatory to assessing degree of inflammation and treatment is generally with proton-pump inhibitors, which have made the therapy of GERD relatively easy. Although treatment is effective, problems relating to safety of long-term profound gastric acid suppression, cost and effect on quality of life remain to be resolved.
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