The most useful move at the start of a GERD vignette is to ask what is wrong with the barrier, not how much acid the patient makes. Acid output is usually normal; what fails is the apparatus that keeps acid in the stomach. Hold that frame and the chapter falls into a sequence: barrier anatomy, then grading, then the acid-suppression ladder. The case. A patient with classic heartburn has been on a once-daily PPI taken at bedtime with incomplete relief. Endoscopy shows LA grade B esophagitis. Before escalating the dose, what single change to the regimen is most likely to fix it? Topics coveredThe antireflux barrier: intrinsic LES and crural diaphragm in series, angle of His, intra-abdominal segmentMost GERD patients have a normal resting LES; a hypotensive LES marks severe diseaseTransient LES relaxations (TLESRs) as the dominant reflux mechanismSliding hiatal hernia as the structural amplifier; size cutoffs drive procedure choiceAmerican Foregut Society flap-valve grading in retroflexionLA classification A through D: grading erosive esophagitisLA grade stratifies treatment intensity and Barrett surveillance riskPPI pharmacology: pre-meal dosing, why timing decides efficacyThe acid-suppression ladder: once-daily, twice-daily, and the role of P-CABsWhen endoscopy is confirmatory versus when reflux monitoring is needed Key decisionsPPIs need a meal to work: take 30 to 60 minutes before the first meal, not at bedtime. A mistimed PPI is the commonest reason for apparent failure before any dose escalationA normal resting LES does not exclude GERD: transient LES relaxations carry the reflux, so manometry is not the diagnostic test for refluxLA grade C or D confirms GERD outright and mandates a follow-up scope to assess Barrett after healing; grade A is nonspecific and needs objective reflux testingHiatal hernia size gates the operation: under 2 cm allows TIF, larger hernias need a formal hiatal repairEscalate to twice-daily PPI or a P-CAB before calling reflux truly refractory, but only after confirming timing and adherence For the full chapter with MCQs, tables, and primary-guideline references, visit www.boardpearls.com.Questions or feedback: [email protected]. (00:00) - Opening: GERD is a barrier problem (01:30) - The antireflux barrier anatomy (04:30) - Normal LES and transient relaxations (08:00) - Hiatal hernia and the flap valve (12:00) - LA classification of erosive esophagitis (16:00) - The acid-suppression ladder and PPI timing (22:00) - P-CABs and when to escalate

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“What did the council decide on item 42?” — answered with the speaker and the moment.

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