Gastroesophageal reflux disease

Gastroesophageal reflux is a normal physiologic phenomenon experienced intermittently by most people, particularly after a meal. Gatroesophageal reflux disease (GERD) or gastro-oesophageal reflux disease (GORD), occurs when the amount of gastric juice that refluxes into the esophagus exceeds the normal limit, causing symptoms with or without associated esophageal mucosal injury or esophagitis .There can be recurrent return of stomach contents back up into the esophagus, frequently causing heartburn, a symptom of irritation of the esophagus by stomach acid. This can lead to scarring and stricture of the esophagus, which can require stretching (dilating).

Pathophysiology

The physiologic and anatomic factors that normally prevent the reflux of gastric juice from the stomach into the esophagus include the following:

  • The lower esophageal sphincter (LES) must have a normal length and pressure and a normal number of episodes of transient relaxation (relaxation in the absence of swallowing).
  • The gastroesophageal junction must be located in the abdomen so that the diaphragmatic crura can assist the action of the LES, thus functioning as an extrinsic sphincter. The presence of a hiatal hernia disrupts this synergistic action and can promote reflux
  • Esophageal clearance must be able to neutralize the acid refluxed through the LES. (Mechanical clearance is achieved with esophageal peristalsis. Chemical clearance is achieved with saliva.)
  • The stomach must empty properly.

Abnormal gastroesophageal reflux might be cause by any factor that interfere with these like

  • A functional (frequent transient LES relaxation) or mechanical (hypotensive LES) problem of the LES is the most common cause of gastroesophageal reflux disease (GERD).
  • Certain foods (eg, coffee, alcohol), medications (eg, calcium channel blockers, nitrates, beta-blockers), or hormones (eg, progesterone) can decrease the pressure of the LES.
  • Obesity is a contributing factor in gastroesophageal reflux disease (GERD), probably because of the increased intra-abdominal pressure.

Risk factors

Conditions that can increase risk of GERD include:

  • Obesity
  • Hiatal hernia
  • Pregnancy
  • Smoking
  • Dry mouth
  • Asthma
  • Diabetes
  • Delayed stomach emptying
  • Connective tissue disorders, such as scleroderma
  • Zollinger-Ellison syndrome

Frequency

Heartburn is a common problem in the United States and in the Western world. Approximately 7% of the population experience symptoms of heartburn daily. An abnormal esophageal exposure to gastric juice is probably present in 20-40% of this population, meaning 20-40% of the people who experience heartburn do indeed have gastroesophageal reflux disease (GERD). In the remaining population, heartburn is probably due to other causes. Because many individuals control symptoms with over-the-counter (OTC) medications and without consulting a medical professional, the condition is likely under reported.

Mortality/Morbidity

In addition to the typical symptoms of gastroesophageal reflux disease (GERD) (eg, heartburn, regurgitation, dysphagia), abnormal reflux can cause atypical symptoms, such as coughing, chest pain, and wheezing. Additional atypical symptoms from abnormal reflux include damage to the lungs (eg, pneumonia, asthma, idiopathic
pulmonary fibrosis), vocal cords (eg, laryngitis, cancer), ear (eg, otitis media), and teeth (eg, enamel decay).Approximately 50% of patients with gastric reflux develop esophagitis.Barrett esophagus is present in 8-15% of patients with gastroesophageal reflux disease (GERD) and may progress to adenocarcinoma.

Race

White males are at a greater risk for Barrett esophagus and adenocarcinoma than other populations.

Sex

No sexual predilection exists. Gastroesophageal reflux disease (GERD) is as common in men as in women.
The male-to-female incidence ratio for esophagitis is 2:1-3:1. The male-to-female incidence ratio for Barrett esophagus is 10:1.

Age

Gastroesophageal reflux disease (GERD) occurs in all age groups.
The prevalence of gastroesophageal reflux disease (GERD) increases in people older than 40 years.

Symptoms

Gastroesophageal reflux disease (GERD) can cause typical (esophageal) symptoms or atypical (extraesophageal) symptoms. However, a diagnosis of gastroesophageal reflux disease (GERD) based on the presence of typical symptoms is correct in only 70% of patients.

Typical (esophageal) symptoms include the following:

  • Heartburn is the most common typical symptom of gastroesophageal reflux disease (GERD). Heartburn is felt as a retrosternal sensation of burning or discomfort that usually occurs after eating or when lying down or bending over.
  • Regurgitation is an effortless return of gastric and/or esophageal contents into the pharynx. Regurgitation can induce respiratory complications if gastric contents spill into the tracheobronchial tree.
  • Dysphagia occurs in approximately one third of patients because of a mechanical stricture or a functional problem (eg, nonobstructive dysphagia secondary to abnormal esophageal peristalsis). Patients with dysphagia experience a sensation that food is stuck, particularly in the retrosternal area.

Atypical (extraesophageal) symptoms include the following:

  • Coughing and/or wheezing are respiratory symptoms resulting from the aspiration of gastric contents into the tracheobronchial tree or from the vagal reflex arc producing bronchoconstriction. Approximately 50% of patients who have GERD-induced asthma do not experience heartburn.
  • Hoarseness results from irritation of the vocal cords by gastric refluxate and is often experienced by patients in the morning.
  • Reflux is the most common cause of noncardiac chest pain, accounting for approximately 50% of cases.

Differential Diagnoses

  • Achalasia
  • Esophagitis
  • Cholelithiasis
  • Chronic gastritis
  • Coronary artery atherosclerosis
  • Irritable bowel syndrome
  • Esophageal cancer
  • Peptic ulcer disease
  • Esophageal spasm

Diagnosis

Laboratory studies

Laboratory tests are seldom useful in establishing a diagnosis of gastroesophageal reflux disease (GERD).

Imaging studies

Barium esophagogram

A barium esophagogram is particularly important for patients with gastroesophageal reflux disease (GERD) who experience dysphagia.It can show the presence and location of a stricture and the presence and shape of a hiatal hernia.

Esophagogastroduodenoscopy (EGD)

EGD also excludes the presence of other diseases (eg, peptic ulcer) that can present similarly to gastroesophageal reflux disease (GERD).Although EGD is frequently performed to help diagnose gastroesophageal reflux disease (GERD), it is not the most cost-effective diagnostic study because esophagitis is present in only 50% of patients with GERD.
EGD identifies the presence and severity of esophagitis and the possible presence of Barrett esophagus

Other studies

Esophageal manometry

Esophageal manometry defines the function of the LES and the esophageal body (peristalsis).Esophageal manometry is essential for correctly positioning the probe for the 24-hour pH monitoring.

Ambulatory 24-hour pH monitoring

Ambulatory 24-hour pH monitoring is the criterion standard in establishing a diagnosis of GERD with a sensitivity of 96% and a specificity of 95%.
Ambulatory 24-hour pH monitoring quantifies the gastroesophageal reflux and allows a correlation between the symptoms of reflux and the episodes of reflux.
Patients with endoscopically confirmed esophagitis do not need pH monitoring to establish a diagnosis of gastroesophageal reflux disease (GERD).

Indications for esophageal manometry and prolonged pH monitoring include the following:

  • Persistence of symptoms while taking adequate antisecretory therapy, such as PPI therapy
  • Recurrence of symptoms after discontinuation of acid-reducing medications
  • Investigation of atypical symptoms, such as chest pain or asthma, in patients without esophagitis
  • Confirmation of the diagnosis in preparation for antireflux surgery

Radionuclide measurement of gastric emptying

Although delayed gastric emptying is present in as many as 60% of patients with gastroesophageal reflux disease (GERD), this emptying is usually a minor factor in the pathogenesis of the disease in most patients (except in patients with advanced diabetes mellitus or connective tissue disorders).Patients with delayed gastric emptying typically experience postprandial bloating and fullness in addition to other symptoms.

Treatment

Medical care

Treatment of gastroesophageal reflux disease (GERD) is a stepwise approach. The goals are to control symptoms, to heal esophagitis, and to prevent recurrent esophagitis or other complications. The treatment is based on lifestyle modification and control of gastric acid secretion.

Lifestyle modifications include the following: 

  • Losing weight (if overweight)
  • Avoiding alcohol, chocolate, citrus juice, and tomato-based products
  • Avoiding large meals especially before bedtime
  • Waiting 3 hours after a meal before lying down
  • Elevating the head of the bed 8 inches

Pharmacologic therapy 

  • Antacids were the standard treatment in the 1970s and are still effective in controlling mild symptoms of gastroesophageal reflux disease (GERD). Antacids should be taken after each meal and at bedtime.
  • Histamine H2-receptor antagonists are the first-line agents for patients with mild to moderate symptoms and grades I-II esophagitis. Histamine H2 receptor antagonists are effective for healing only mild esophagitis in 70-80% of patients with gastroesophageal reflux disease (GERD) and for providing maintenance therapy to prevent relapse.

examples include:Ranitidine,Cemitidine,Nizatidine etc.

  • PPIs are the most powerful medications available for treating this condition. These agents should be used only when gastroesophageal reflux disease (GERD) has been objectively documented. PPIs work by blocking the final step in the H+ ion secretion by the parietal cell. They have few adverse effects and are well tolerated for long-term use.Omeprazole, Lansoprozole are the commonly used ones .
  • Prokinetic agents improve the motility of the esophagus and stomach. These agents are somewhat effective but only in patients with mild symptoms; other patients usually require additional acid-suppressing medications, such as PPIs. Long-term use of prokinetic agents may have serious, even potentially fatal, complications and should be discouraged. Metoclopramide (Reglan) is the only one available for use in USA.

Surgical care

Nissen fundoplication is a surgical procedure to treat gastroesophageal reflux disease (GERD) and hiatus hernia. Fundoplication can be done endoscopically as well

Indications for fundoplication include the following: 

  • Patients with symptoms that are not completely controlled by PPI therapy can be considered for surgery. Surgery can also be considered in patients with well-controlled gastroesophageal reflux disease (GERD), who desire definitive, one-time treatment.
  • The presence of Barrett esophagus is an indication for surgery. Whether acid suppression improves the outcome or prevents the progression of Barrett esophagus remains unknown, but most authorities recommend complete acid suppression in patients with histologically proven Barrett esophagus.
  • The presence of extraesophageal manifestations of gastroesophageal reflux disease (GERD) may indicate the need for surgery. These include the following: (1) respiratory manifestations (eg, cough, wheezing, aspiration); (2) ear, nose, and throat manifestations (eg, hoarseness, sore throat, otitis media); and (3) dental manifestations (eg, enamel erosion).
  • Young patients
  • Poor patient compliance with regard to medications
  • Postmenopausal women with osteoporosis
  • Patients with cardiac conduction defects
  • Cost of medical therapy

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