Contents
Introduction
Gastro-esophageal reflux disease (GERD) is a condition in which stomach acid flows back into the esophagus.
Condition of troublesome symptoms and complications that result from the reflux of stomach contents into the esophagus
Montreal definition
Aetiology
Risk factors:
- Older age
- Excessive body mass index (BMI), high-fat diet
- Smoking. alcohol consumption
- Anxiety/depression
- Less physical activity at work
Associated conditions:
- Hiatus hernia: Displacement of gastroesophageal junction (GEJ) which normally acts as a barrier to reflux of stomach contents into the esophagus
- Scleroderma: LES muscles replaced by connective tissue
- Zollinger-Ellison syndrome: Gastrinoma results in oversecretion of stomach acids
Pathophysiology
Lower esophageal sphincter (LES) dysfunction:
- Transient lower esophageal sphincter relaxations (TLESRs) (M/C): Brief moments of LES tone inhibition that are independent of a swallow
- Other factors: Reduced LES pressure, hiatal hernias, impaired esophageal clearance, and delayed gastric emptying
Clinical features
Aggravated by food intake, especially those that delay gastric emptying (eg. fats & spicy foods) & lying/stooping.
Classic symptoms:
- Heartburn (M/C symptom): Burning sensation in the chest, radiating toward the mouth (as a result of acid reflux into the esophagus).
- Regurgitation: Associated with sour taste in the back of the mouth
Extraesophageal manifestations:
- Throat clearing and hoarseness (reflux into the larynx)
- Globus sensation: Feeling of fullness/lump in back of throat (due to exposure of hypopharynx to acid leading to increased tonicity of upper esophageal sphincter (UES))
- Bronchospasm (can exacerbate underlying asthma): Cough, dyspnea, and wheezing
- Chronic nausea & vomiting
Complication
- Reflux oesophagitis (vary widely in severity with different sequelae):
- Extensive erosions, ulcerations and oesophageal stricture
- Upper GI bleeding: Present as anemia, hematemesis, coffee-ground emesis, melena, and when especially brisk, hematochezia.
- Barret’s oesophagus: Chronic esophageal inflammation from ongoing acid leading to scarring and development of peptic strictures, usually presenting with the chief complaint of dysphagia
Diagnosis
GERD is usually diagnosed clinically with classic symptoms and response to acid suppression. Heartburn with/without regurgitation is typically sufficient to suspect GERD, particularly when these symptoms are worse postprandially or when recumbent.
Esophagogastroduodenoscopy (EGD): Upper GI endoscopy
Primary benefit is direct visualization of the esophageal mucosa assisting in diagnosis of complications of GERD such as esophagitis, strictures and Barrett’s esophagus.
Los Angeles endoscopic classification:
24-h pH monitoring:
Gold standard diagnostic test of acid reflux allowing for the objective detection of acid reflux events and correlation with symptoms
Differential diagnosis:
- Achalasia
- Dyspepsia: Epigastric discomfort, without heartburn or acid regurgitation, lasting longer than one month
Management
Lifestyle changes:
First-line in management of GERD with a primary goal of symptom reduction and improvement in quality of life
- Head of bed (HOB) elevation (only proven lifestyle modification for GERD): Decrease esophageal acid exposure and esophageal clearance time with subsequent reduction in symptoms in patients with supine GERD
- Risk factors should be minimized/avoided:
- Smoking, heavy alcohol consumption, large evening meals, nighttime snacks, and high dietary fat intake
- Avoid non-steroidal anti-inflammatory drugs (NSAIDs)
Medical management:
Targeted at symptom reduction and minimizing mucosal damage from acid reflux
- Proton pump inhibitors (PPI) (M/effective): Decrease acid secretion from parietal cells into gastric lumen
- H2 blockers: Decrease gastric acid secretion by inhibiting histamine stimulation of the parietal cell
- Cases relapse after the cessation of PPI, therefore lifelong therapy is often required
Nissen fundoplication: Anti-reflux surgery
For persistent GERD despite conservative treatment