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Internal Medicine

Gastroesophageal reflux disease (GERD)

Condition of troublesome symptoms and complications that result from the reflux of stomach contents into the esophagus

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
750px-gerd
A comparison of a healthy condition to GERD | By BruceBlaus – Own work, CC BY-SA 4.0, https://commons.wikimedia.org/w/index.php?curid=44923646

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
gastroesophageal-reflux-disease-gerd-pathogenesis-and-clinical-findings
The Calgary Guide | http://calgaryguide.ucalgary.ca/

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.
Endoscopic view of Los Angeles grade D esophagitis (circumferential esophageal erosions, ulceration, and inflammation). | Clarrett, D. M., & Hachem, C. (2018). Gastroesophageal Reflux Disease (GERD). Missouri medicine, 115(3), 214–218.

Los Angeles endoscopic classification:

Diagnosis and management of gastroesophageal reflux disease – Scientific Figure on ResearchGate. Available from: https://www.researchgate.net/figure/Los-Angeles-endoscopic-classification_tbl2_267652281 [accessed 20 Nov, 2020]

24-h pH monitoring:

Gold standard diagnostic test of acid reflux allowing for the objective detection of acid reflux events and correlation with symptoms
High resolution esophageal impedance and pH tracings. Impedance (measure of electrical conductance) within the lumen of the esophagus is measured simultaneously using multiple probes and the measurements are displayed with the proximal measures at the top progressing distally towards the stomach. The bottom tracing is the pH at the most distal measurement point. Highlighted in yellow are measurements that document liquid reflux from the stomach correlating with a drop in pH indicating reflux of gastric acid. this tracing is a small snapshot of 24 hours of data. | Clarrett, D. M., & Hachem, C. (2018). Gastroesophageal Reflux Disease (GERD). Missouri medicine, 115(3), 214–218.

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

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