Reconsidering Gastroesophageal Reflux as a Hydraulic Pressure Phenomenon: A Systemic Theory for Primary Care

The current management of gastroesophageal reflux disease (GERD) in primary care relies heavily on the acid-centric paradigm. However, up to 40% of patients experience refractory symptoms despite standard proton pump inhibitor (PPI) therapy, presenting a persistent challenge for family physicians. This paper proposes the Hydraulic Back-Pressure Model, a novel conceptual framework that redefines GERD not as a primary chemical or localized sphincter disorder, but as a mechanical, pressure-driven phenomenon originating from distal colonic stasis. We hypothesize that GERD is not a primary chemical or localized sphincter disorder, but a mechanical, pressure-driven phenomenon originating from distal colonic stasis, where impaired motility fails to propel soft, moisture-rich fecal matter upward against gravity We hypothesize that impaired motility in the ascending colon causes localized hypertension that forces a paradoxical closure of the ileocecal valve, establishing an upstream static pressure cascade through the small intestine and duodenum. This retrograde force ultimately stalls gastric emptying and forces the lower esophageal sphincter (LES) to serve as an overflow valve. By shifting clinical focus from gastric pH to holistic gastrointestinal mechanics, this theory offers primary care clinicians a pathogenetically targeted, non-pharmacological approach to managing refractory GERD.