Gastroesophageal reflux disease
Gastroesophageal Reflux Disease (or GERD) is the rising (reflux, regurgitation) of acidic gastric contents from the stomach into the esophagus. A mild degree of reflux experienced episodically (say after a large meal) is a normal physiological condition and reflux is only a problem when it causes symptoms or other medical disease. Longstanding reflux can involve a degree of esophagitis (reflux esophagitis) - inflammatory changes in the esophageal mucosa. This in turn may lead to the development of Barrett's esophagus, esophageal strictures, esophageal ulcers and possibly even to esophageal cancer.
Occasional heartburn is common but does not necessarily mean one has GERD. Heartburn that occurs more than twice a week may be considered GERD, and it can eventually lead to more serious health problems.
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2 Diagnosis 3 Pathophysiology 4 Treatment 5 Complications 6 External links |
Symptoms
Adults
The most prominent symptom of GERD is heartburn, the sensation of burning pain in the chest coming upward towards the mouth caused by reflux of acidic contents from the stomach to the esophagus.
Patients with GERD also tend to get waterbrash (or "acid indigestion"), the feeling of a sour taste at the back of their throats due to regurgitation. This can sometimes happen even if the pain of heartburn is absent.
Less common symptoms:
- Chest pain without any of the above
- Dysphagia
- Halitosis
- Regurgitation (vomit-like taste in the mouth)
- Strictures or scarring of oesophagus (especially young children).
- Barrett Oesophagus (sometimes referred to as Barrett's Disease) or dysplasia (a pre-cancerous condition).
GERD in Children
GERD is commonly overlooked in infants and children. It can cause repeated vomiting, coughing, and other respiratory problems.
Diagnosis
A detailed history taking is vital to the diagnosis. Useful investigations may include barium swallow X-rays, esophageal manometry, esophageal pH monitoring and gastroscopy. In general, gastroscopy is not attempted unless there are positive pointers towards diseases of the stomach or esophagus, or the patient carries one or more risk factors (e.g. smoking, longstanding Helicobacter pylori infection).
Gastroscopy (a form of endoscopy) involves the insertion of a thin optical scope through the mouth and throat into the esophagus and stomach (often while the patient is sedated) in order to assess the state of the esaphagus and stomach.
Biopsies can be performed during gastroscopy and these may show:
- Edema and basal hyperplasia (non-specific inflammatory changes)
- Lymphocytic inflammation (non-specific)
- Neutrophilic inflammation (usually either reflux or Helicobacter gastritis)
- Eosinophilic inflammation (usually due to reflux)
- Goblet cell intestinal metaplasia or Barretts oesophagus.
- Dysplasia or pre-cancer.
- Carcinoma.
- Rapid testing assays can quickly detect the presence of Helicobacter pylori in a biopsy sample through urease testing.
Pathophysiology
Having GERD indicates incompetence of the lower esophageal sphincter. Increased acidity or production of gastric acid can contribute to the problem, as can obesity, tight fitting clothes and pregnancy.Factors that can contribute to GERD are:
- Hiatus hernia increases the likelihood of GERD due to mechanical and motility factors.
- Zollinger-Ellison syndrome can present with increased gastric acidity due to gastrin production.
- Hypercalcemia can increase gastrin production, leading to increased acidity.
- Scleroderma and systemic sclerosis can feature esophageal dysmotility.
Treatment
Avoiding aggravating factors
Certain foods and lifestyle tend to promote gastroesophageal reflux. Before attempting medical treatment, the following advice is often dispensed:- Coffee and alcohol are stimulants of gastric acid secretion so avoiding these helps.
- Foods high in fats and smoking reduce lower esophageal sphincter competence so avoiding these tends to help as well.
- Having more but smaller meals also reduces the risk of GERD as it means there is less in the stomach at any one time.
- avoid sodas that contain caffeine
- avoid chocolate and peppermint
- avoid spicy foods like pizza
- avoid acidic foods like oranges and tomatoes
- avoid fried and fatty foods
- avoid food a few hours before bedtime
Drug treatment
A number of drugs is registered for the treatment of GERD, and they are amongst the most often prescribed forms of medication is most Western countries:- Antacids before meals or symptomatically after symptoms begin can reduce gastric acidity.
- Gastric H2 receptor blockers such as ranitidine or famotidine can reduce gastric secretion of acid. These drugs are technically antihistamines.
- Proton pump inhibitors such as omeprazole are even more effective in reducing gastric acid secretion.
Complications
Barrett's Oesophagus has been regarded as a precursor condition to dysplasia which is in turn is a precursor condition for carcinoma. The risk of progression from Barretts to dysplasia is uncertain but is estimated to include 5% - 10% of cases, and has probably been exaggerated in the past.GERD has been linked to laryngitis and asthma, even when not clinically apparent, as well as to ulcers of the vocal cords.
Your doctor may recommend over-the-counter antacids, which you can buy without a prescription, or medications that stop acid production or help the muscles that empty your stomach.
Antacids, such as Alka-Seltzer, Maalox, Mylanta, Pepto-Bismol, Rolaids, and Riopan, are usually the first drugs recommended to relieve heartburn and other mild GERD symptoms. Many brands on the market use different combinations of three basic salts--magnesium, calcium, and aluminum--with hydroxide or bicarbonate ions to neutralize the acid in your stomach. Antacids, however, have side effects. Magnesium salt can lead to diarrhea, and aluminum salts can cause constipation. Aluminum and magnesium salts are often combined in a single product to balance these effects.
Calcium carbonate antacids, such as Tums, Titralac, and Alka-2, can also be a supplemental source of calcium. They can cause constipation as well.
Foaming agents, such as Gaviscon, work by covering your stomach contents with foam to prevent reflux. These drugs may help those who have no damage to the esophagus.
H2 blockers, such as cimetidine (Tagamet HB), famotidine (Pepcid AC), nizatidine (Axid AR), and ranitidine (Zantac 75), impede acid production. They are available in prescription strength and over the counter. These drugs provide short-term relief, but over-the-counter H2 blockers should not be used for more than a few weeks at a time. They are effective for about half of those who have GERD symptoms. Many people benefit from taking H2 blockers at bedtime in combination with a proton pump inhibitor.
Proton pump inhibitors include omeprazole (Prilosec), lansoprazole (Prevacid), pantoprazole (Protonix), rabeprazole (Aciphex), and esomeprazole (Nexium), which are all available by prescription. Proton pump inhibitors are more effective than H2 blockers and can relieve symptoms in almost everyone who has GERD.
Another group of drugs, prokinetics, helps strengthen the sphincter and makes the stomach empty faster. This group includes bethanechol (Urecholine) and metoclopramide (Reglan). Metoclopramide also improves muscle action in the digestive tract, but these drugs have frequent side effects that limit their usefulness.
Because drugs work in different ways, combinations of drugs may help control symptoms. People who get heartburn after eating may take both antacids and H2 blockers. The antacids work first to neutralize the acid in the stomach, while the H2 blockers act on acid production. By the time the antacid stops working, the H2 blocker will have stopped acid production. Your doctor is the best source of information on how to use medications for GERD.
A barium swallow radiograph uses x rays to help spot abnormalities such as a hiatal hernia and severe inflammation of the esophagus. With this test, you drink a solution and then x rays are taken. Mild irritation will not appear on this test, although narrowing of the esophagus--called stricture--ulcers, hiatal hernia, and other problems will.
Upper endoscopy is more accurate than a barium swallow radiograph and may be performed in a hospital or a doctor's office. The doctor will spray your throat to numb it and slide down a thin, flexible plastic tube called an endoscope. A tiny camera in the endoscope allows the doctor to see the surface of the esophagus and to search for abnormalities. If you have had moderate to severe symptoms and this procedure reveals injury to the esophagus, usually no other tests are needed to confirm GERD.
The doctor may use tiny tweezers (forceps) in the endoscope to remove a small piece of tissue for biopsy. A biopsy viewed under a microscope can reveal damage caused by acid reflux and rule out other problems if no infecting organisms or abnormal growths are found.
In an ambulatory pH monitoring examination, the doctor puts a tiny tube into the esophagus that will stay there for 24 hours. While you go about your normal activities, it measures when and how much acid comes up into your esophagus. This test is useful in people with GERD symptoms but no esophageal damage. The procedure is also helpful in detecting whether respiratory symptoms, including wheezing and coughing, are triggered by reflux.
Fundoplication, usually a specific variation called Nissen fundoplication, is the standard surgical treatment for GERD. The upper part of the stomach is wrapped around the LES to strengthen the sphincter and prevent acid reflux and to repair a hiatal hernia.
This fundoplication procedure may be done using a laparoscope and requires only tiny incisions in the abdomen. To perform the fundoplication, surgeons use small instruments that hold a tiny camera. Laparoscopic fundoplication has been used safely and effectively in people of all ages, even babies. When performed by experienced surgeons, the procedure is reported to be as good as standard fundoplication. Furthermore, people can leave the hospital in 1 to 3 days and return to work in 2 to 3 weeks.
In 2000, the U.S. Food and Drug Administration (FDA) approved two endoscopic devices to treat chronic heartburn. The Bard EndoCinch system puts stitches in the LES to create little pleats that help strengthen the muscle. The Stretta system uses electrodes to create tiny cuts on the LES. When the cuts heal, the scar tissue helps toughen the muscle. The long-term effects of these two procedures are unknown.
Also, studies have shown that asthma, chronic cough, and pulmonary fibrosis may be aggravated or even caused by GERD.
For information about Barrett's esophagus, please see the Barrett's Esophagus fact sheet from the National Institute of Diabetes and Digestive and Kidney Diseases.External links
Medications
What if symptoms persist?
If your heartburn does not improve with lifestyle changes or drugs, you may need additional tests.Surgery
Surgery is an option when medicine and lifestyle changes do not work. Surgery may also be a reasonable alternative to a lifetime of drugs and discomfort.Implant
Recently the FDA approved an implant that may help people with GERD who wish to avoid surgery. Enteryx is a solution that becomes spongy and reinforces the LES to keep stomach acid from flowing into the esophagus. It is injected during endoscopy. The implant is approved for people who have GERD and who require and respond to proton pump inhibitors. The long-term effects of the implant are unknown. What are the long-term complications of GERD?
Sometimes GERD can cause serious complications. Inflammation of the esophagus from stomach acid causes bleeding or ulcers. In addition, scars from tissue damage can narrow the esophagus and make swallowing difficult. Some people develop Barrett's esophagus, where cells in the esophageal lining take on an abnormal shape and color, which over time can lead to cancer.