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gastroesophageal reflux disease (GERD)

Retrograde flow of stomach contents into the esophagus & possibly into the pharynx. Etiology: 1) incompetent lower esophageal sphincter (LES) a) transient relaxation of the LES (not associated with swallowing) is the most common cause of GERD b) smoking may diminish LES pressure c) foods & beverages lowering the LES pressure: - chocolate - alcholic beverages - citrus fruits (& juices) - coffee - onions - peppermint d) pharmaceuticals lowering LES pressure: - nitrates - calcium channel blockers - benzodiazepines - anticholinergics - antidepressants - NSAIDs, aspirin - albuterol [38] - glucagon [38] e) estrogen & progestin might reduce LES pressure by increasing blood levels of nitric oxide f) increased abdominal pressure puts stress on the lower esophageal sphincter (LES) - bending over - exercise - tight fitting clothing [19] g) lying supine shortly after eating (postprandial supination) - eating late at night [19] h) pregnancy [19] 2) delayed gastric emptying time may contribute a) gastroparesis b) fatty foods & fried foods c) large meals d) opiates [19] 3) impaired esophageal clearance may contribute 4) diminished salivary production of bicarbonate [8] 5) associated with hiatal hernia a) 80% of patients with GERD have hiatal hernia b) 50% of patients with hiatal hernia have GERD 6) obesity [19] 7) connective tissue disease [38] 8) age > 50 years Epidemiology: 1) most common cause of non-cardiac chest pain 2) 10-20% of adults have weekly symptoms; 15-40% monthly symptoms 3) more common in elderly than young Pathology: 1) transient, inappropriate LES relaxation 2) loss of crural diaphragm contribution to LES pressure 3) refluxed pepsin, bile & acidity may play roles in esophageal injury 4) diminished esophageal pH may induce bronchospasm -> microaspiration may also induce bronchospasm 5) at any given level of acid exposure, reflux symptoms less severe in elderly [14] Clinical manifestations: 1) heartburn a) radiation towards mouth b) precipitated by meals or recumbent position 2) sour taste 3) regurgitation or vomiting 4) early satiety 5) belching 6) bloating 7) hoarseness [19] 8) up to 1/3 of patients have extra-esophageal manifestations a) non-cardiac chest pain b) chronic cough c) chronic laryngitis d) wheezing, asthma (bronchospasm) e) dyspnea f) globus sensation g) hoarseness 9) psychological factors (especially depression) may play an important role in the perception of symptoms [44] === alarm symptoms === - dysphagia - odynophagia - hematemesis - weight loss - anemia [38] Laboratory: - H pylori testing not routinely indicated [19] Special laboratory: 1) ECG exercise stress test to rule out cardiac etiology [19] - other cardiac stress testing if not eligible 2) upper GI endoscopy a) indications: - dysphagia, odynophagia, chest pain, hematemesis, melena, anemia, weight loss, recurrent vomiting - follow-up after 2 months' therapy with PPI for severe erosive esophagitis to assess healing & rule out Barrett esophagus - routine screening for Barrett esophagus not indicated [19] - continued GERD symptoms after 8 weeks of PPI* - history of esophageal stricture & recurrent dysphagia - men age > 50 years + > 5 years of GERD with additional risk factors [19] - nocturnal reflux, elevated BMI, tobacco use, abdominal fat [19] - only men, not women should be screened for Barrett's esophagus - older men with frequent or chronic heartburn despite PPI [41] b) evaluation of esophagitis, ulceration, stricture c) identification of Barrett's esophagus d) identification of esophageal adenocarcinoma - non-erosive GERD is not a risk factor for esophageal cancer & may not require follow-up upper GI endoscopsy [43] e) endoscopic therapies without long-term benefit [19] 3) 24 hour esophageal impedance - pH monitor (ambulatory) a) definitive diagnostic test (gold standard) b) correlates symptoms with pH above LES < 4 c) GERD refractory to empiric proton pump inhibitor d) if upper GI endoscopy is negative [34,40] e) perform while patient is on proton pump inhibitor [19] 4) Bernstein test (sensitivity & specificity low) [41] . * empirical trial of proton pump inhibitor (PPI) QD for 8 weeks Radiology: 1) upper GI series - detection of ulcerations & strictures 2) esophagram - to rule out cricopharyngeal spasm 3) don't use barium radiographs for diagnosis [22] Differential diagnosis: 1) peptic ulcer disease 2) ischemic heart disease a) GERD & coronary ischemia may coexist b) GERD may aggravate coronary ischemia 3) medication-induced esophagitis 4) scleroderma: refractory GERD, constipation, telangiectasias [19] 5) dyspepsia, including functional dyspepsia* 6) esophageal web * a history of GERD does not guarantee symptoms due to GERD or the diagnosis is correct (case presentation) [19] Complications: 1) erosive esophagitis (50%) -> ulceration (bleeding) 2) esophageal stricture -> dysphagia (8-10%) [7] 3) Barrett's esophagus (12-18%) [7] 4) esophageal cancer 5) increased risk for cancers of the upper aerodigestive tract in older adults [33] - laryngeal cancer* [8,25], pharyngeal carcinoma [33], oral cancer, malignant sinus neoplasm [33] 6) laryngopharygeal reflux 7) pulmonary aspiration 8) dental erosions 9) supraventricular arrhythmias ? [11] 10) complications more frequent in the elderly [8] 11) nocturnal GERD may disturb sleep in the absence of heartburn [17] 12) bronchospasm; exacerbation of asthma [18] * poor correlation between laryngeal lesions & reflux esophagitis on endoscopy [13] Management: 1) phase 1: diet & lifestyle modifications a) weight reduction & smoking cessation routinely recommended b) evidence supporting other recommendations is weak [19] c) dietary modifications - decrease fat intake - high-fat/low-carbohydrate diet of benefit in obese women [31] - avoid high acidity foods - citrus fruits, tomatoes, coffee, - other foods to avoid - onions, chocolate, peppermint - avoid alcohol - rapid eating promotes postprandial reflux [10] d) elevation of the head of the bed lessens supine-only supraesophageal reflux [29] e) avoid late or large evening meals f) discontinue medications that decrease LES pressure - theophylline, anticholinergics, nitrates, Ca+2 channel blockers, benzodiazepines, progesterone, alpha-blockers g) sleeping in left lateral decubitus position lessens esophageal exposure to gastric acid [39] 2) phase 2: proton pump inhibitor (PPI) vs H2-receptor antagonist a) do not test; treat empirically QD for 8 weeks [19,40] b) proton pump inhibitor (PPI) first line, except if CKD4 when H2-receptor antagonist is more appropriate [19] - various PPIs show the same level of efficacy [22] - PPIs superior to H2 receptor antagonists [19] - 8-week course of PPI for healing of erosive esophagitis [22] - efficacy of PPI maximum when taken before meals [34] - if partial response to QD PPI dosing, increase to BID [19] - if partial response NOT specifically mentioned, consider another diagnosis (see dyspepsia) [19] - if symptoms do not respond to 8 week trial of PPI or recur after an 8 week trial of PPI, upper GI endoscopy is indicated to assess for alternative diagnosis (MKSAP19) [19] - trial of another PPI suggested prior to upper GI endoscopy [34] - response to proton pump inhibitors is NOT a good diagnostic test for GERD [9] - trial of deprescribing proton pump inhibitor after a minimum of 4 weeks of therapy with resolution of symptoms - a decrease, discontinuation or change to on-demand acceptable [38] - formerly a trial of discontinuation after 1 year [19] - deprescribing PPI not indicated in patients with Barrett esophagus, severe esophagitis (grade C or D), or history of bleeding GI ulcers [38] c) upper GI endoscopy takes precedence if indicated (see above) [41] 3) other medical therapies a) addition of a QHS dose of H2-receptor antagonist to a proton pump inhibitor for breakthrough acid secretion at night [4]* - addition of a daily H2-receptor antagonist to maximal PPI therapy does not result in meaningful additional acid blockade [42] (MKSAP19) b) baclofen diminishes transient lower esophageal sphincter relaxation c) antacids of uncertain benefit [19] 4) surgery: a) Nissen fundoplication [5] - indications: - may be beneficial for a minority of patients with refractory GERD [36] - refractory symptoms despite optimal medical therapy - adverse effects of PPI [19] - large hiatal hernia - patient not interested in long-term medical therapy - upper GI endoscopy & ambulatory pH monitoring confirm diagnosis of GERD [19] - does not reduce risk of esophageal cancer [6] - uncertain long-term benefit [19] - surgery associated with improved quality of life at 5 years relative to medical management [23] b) LINX Reflux Management System c) esophagectomy - high-grade dysplasia - esophageal cancer 5) patient education: a) GERD is an irreversible lifelong condition b) most patients 85-92% acheive 5 year remission with either proton pump inhibitor or surgery [20] c) diaphragmatic breathing improves excessive GERD-related belching [32] 6) follow-up evaluation for complications of GERD a) esophagitis b) stricture c) Barrett's esophagus (women do not need screening) [19] 7) prevention [37] a) no smoking b) drink < 3 cups of coffee, tea or soda daily c) Mediterranean diet, Dash diet, or vegetarian diet d) at least minutes of moderate-to-vigorous exercise daily e) normal body weight (BMI < 25 kg/m2) [37] * proton pump inhibitors work best by inhibiting acid secretion triggered by meals

Related

ambulatory esophageal pH testing Barrett esophagus Bernstein test esophagitis functional dyspepsia

Specific

gastroesophageal reflux disease (GERD) in the elderly laryngoesophageal reflux (LPR) non-erosive reflux disease (NERD)

General

esophageal disease gastric disease reflux chronic gastrointestinal disease

References

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