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Gastroesophageal reflux disease

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Gastroesophageal reflux disease
SpecialtyGastroenterology Edit this on Wikidata

Gastroesophageal reflux disease (GERD), gastro-oesophageal reflux disease (GORD), gastric reflux disease, or acid reflux disease is defined as chronic symptoms or mucosal damage produced by the abnormal reflux of stomach acid to the esophagus.[1] A typical symptom is heartburn.

This is commonly due to transient or permanent changes in the barrier between the esophagus and the stomach. This can be due to incompetence of the lower esophageal sphincter, transient lower esophageal sphincter relaxation, impaired expulsion of gastric reflux from the esophagus, or a hiatal hernia.

A different type of acid reflux which produces respiratory and laryngeal manifestations is laryngopharyngeal reflux (LPR), also called extraesophageal reflux disease (EERD). Unlike GERD, LPR is unlikely to produce heartburn, and is thus sometimes called silent reflux.

Signs and symptoms

Adults

The most-common symptoms of GERD are:

Less-common symptoms include:

  • Pain with swallowing (odynophagia)
  • Excessive salivation (this is common during heartburn, as saliva is generally slightly alkaline[2] and is the body's natural response to heartburn, acting similarly to an antacid)
  • Nausea[3]
  • Chest pain

GERD sometimes causes injury of the esophagus. These injuries may include:

Several other atypical symptoms are associated with GERD, but there is good evidence for causation only when they are accompanied by esophageal injury. These symptoms are:

Some people have proposed that symptoms such as pharyngitis, sinusitis, recurrent ear infections, and idiopathic pulmonary fibrosis are due to GERD; however, a causative role has not been established.[3]

Children

GERD may be difficult to detect in infants and children. Symptoms may vary from typical adult symptoms. GERD in children may cause repeated vomiting, effortless spitting up, coughing, and other respiratory problems. Inconsolable crying, failure to gain adequate weight, refusing food, bad breath, and belching or burping are also common. Children may have one symptom or many — no single symptom is universal in all children with GERD.

Common symptoms of Pediatric Reflux

  • Irritability and pain, sometimes screaming suddenly when asleep. Constant or sudden crying or colic-like symptoms. Babies can be inconsolable especially when laid down flat.
  • Poor sleep habits typically with arching their necks and back during or after feeding
  • Excessive possetting or vomiting
  • Frequent burping or frequent hiccups
  • Excessive dribbling or running nose
  • Swallowing problems, gagging and choking
  • Frequent ear infections or sinus congestion
  • Babies are often very gassy and extremely difficult to “burp” after feeds
  • Refusing feeds or frequent feeds for comfort
  • Night time coughing, extreme cases of acid reflux can cause apnoea and respiratory problems such as asthma, bronchitis and pneumonia if stomach contents are inhaled.
  • Bad breath – smelling acidy
  • Rancid/acid smelling diapers with loose stool. Bowel movements can be very frequent or babies can be constipated.

Vomiting feeds

Possetting after a feed is quite normal with most infants. They gain weight, feed well and have no other symptoms, but still this can be upsetting for parents. As the child gets older the lower oesophageal sphincter becomes more competent so the vomiting should begin to show signs of improvement and eventually stop. Some babies suffer more with reflux and about 60% of these babies with persistent reflux may have weight gain issues. It is a very popular misconception though that all babies and children with reflux are underweight. This isn't always the case, some may comfort eat and feed very frequently and not all are sick. Many doctors advise that babies outgrow reflux once they can sit up, or once they stand. Many do, but some will not only fail to outgrow it, but will noticeably worsen with developmental milestones, teething episodes, viral illness and weaning.

Silent Reflux

Some babies with reflux do not vomit at all. This is actually more of a problem because the acidic stomach contents go up the throat and back down again, causing twice the pain and twice the damage.[citation needed] There is no clear relationship between symptoms and the severity of reflux.

It is estimated that of the approximately 4 million babies born in the U.S. each year, up to 35% of them may have difficulties with reflux in the first few months of their life, known as spitting up.[5] Most of those children will outgrow their reflux by their first birthday. However, a small but significant number of them will not outgrow the condition. This is particularly true where there is a family history of GERD present.

Barrett's esophagus

Main article: Barrett's Esophagus

GERD may lead to Barrett's esophagus, a type of metaplasia which is in turn a precursor condition for carcinoma. The risk of progression from Barrett's to dysplasia is uncertain but is estimated at about 20% of cases.[6] Due to the risk of chronic heartburn progressing to Barrett's, EGD every 5 years is recommended for patients with chronic heartburn, or who take drugs for chronic GERD.[citation needed]

Diagnosis

Endoscopic image of peptic stricture, or narrowing of the esophagus near the junction with the stomach. This is a complication of chronic gastroesophageal reflux disease and can be a cause of dysphagia or difficulty swallowing

A detailed historical knowledge is vital for an accurate diagnosis. Useful investigations may include ambulatory Esophageal pH Monitoring, barium swallow X-rays, esophageal manometry, and Esophagogastroduodenoscopy (EGD).

The current gold standard for diagnosis of GERD is esophageal pH monitoring. It is the most objective test to diagnose the reflux disease and it also allows to monitor GERD patients in regards of their response to medical or surgical treatment. One practice for diagnosis of GERD is a short-term treatment with proton pump inhibitors, with improvement in symptoms suggesting a positive diagnosis. According to a systematic review, short-term treatment with proton pump inhibitors may help predict abnormal 24-hr pH monitoring results among patients with symptoms suggestive of GERD. [7] In this study, the positive likelihood ratio of a symptomatic response detecting GERD ranged from 1.63 to 1.87, with sensitivity of 0.78% though specificity was only 0.54%.

In general, an EGD is done when the patient either does not respond well to treatment or has alarm symptoms including dysphagia, anemia, blood in the stool (detected chemically), wheezing, weight loss, or voice changes. Some physicians advocate either once-in-a-lifetime or 5/10-yearly endoscopy for patients with longstanding GERD, to evaluate the possible presence of dysplasia or Barrett's esophagus, a precursor lesion for esophageal adenocarcinoma.[8]

Esophagogastroduodenoscopy (EGD) (a form of endoscopy) involves insertion of a thin scope through the mouth and throat into the esophagus and stomach (often while the patient is sedated) in order to assess the internal surfaces of the esophagus, stomach, and duodenum.

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 due to reflux or Helicobacter gastritis)
  • Eosinophilic inflammation (usually due to reflux)
  • Goblet cell intestinal metaplasia or Barretts esophagus
  • Elongation of the papillae
  • Thinning of the squamous cell layer
  • Dysplasia or pre-cancer
  • Carcinoma

Reflux changes may be non-erosive in nature, leading to the entity "non-erosive reflux disease".

Pathophysiology

GERD is caused by a failure of the cardia. In healthy patients, the "Angle of His"—the angle at which the esophagus enters the stomach—creates a valve that prevents duodenal bile, enzymes, and stomach acid from traveling back into the esophagus where they can cause burning and inflammation of sensitive esophageal tissue.

Factors that can contribute to GERD:

  • Hiatal hernia, which increases the likelihood of GERD due to mechanical and motility factors.[9][10]
  • Obesity: increasing body mass index is associated with more severe GERD.[11]. In a large series of 2000 patients with symptomatic reflux disease, it has been shown that 13 % of changes in esophageal acid exposure is attributable to changes in body mass index.[12]
  • Zollinger-Ellison syndrome, which can be present with increased gastric acidity due to gastrin production
  • Hypercalcemia, which can increase gastrin production, leading to increased acidity
  • Scleroderma and systemic sclerosis, which can feature esophageal dysmotility
  • The use of medicines such as prednisolone
  • Visceroptosis or Glénard syndrome, in which the stomach has sunk in the abdomen upsetting the motility and acid secretion of the stomach.

GERD has been linked to a variety of respiratory and laryngeal complaints such as laryngitis, chronic cough, pulmonary fibrosis, earache, and asthma, even when not clinically apparent. These atypical manifestations of GERD is commonly referred to as laryngopharyngeal reflux or as extraesophageal reflux disease (EERD).


Factors that have been linked with GERD but not conclusively:

In 1999, a review of existing studies found that, on average, 40% of GERD patients also had H. pylori infection.[15] The eradication of H. pylori can lead to an increase in acid secretion,[16] leading to the question of whether H. pylori-infected GERD patients are any different than non-infected GERD patients. A double-blind study, reported in 2004, found no clinically significant difference between these two types of patients with regard to the subjective or objective measures of disease severity.[17]

Prevention

Relief is often found by raising the head of the bed, raising the upper body with pillows, or sleeping sitting up. Avoid pillows that raise the head only, as this does little for heartburn and places continuous strain on the neck. Eating a big meal causes excess stomach acid production, and attacks can be minimized by eating small frequent meals instead of large meals, especially for dinner. To minimize attacks, a sufferer may benefit from avoiding certain foods that stimulate excess acid secretion and/or relax the opening between the stomach and esophagus. Acidic fruit or juice, fatty foods, pretzels, coffee, tea, onions, peppermint, chocolate, or highly spiced foods are to be avoided, especially shortly before bedtime.[18] While there are clearly other health-related benefits associated with dietary interventions, a zealous[specify] recommendation for dietary restrictions is not evidence-based, and there is stronger support for reducing the symptoms of acid reflux found in behavioral changes such as eating less and elevating one's head while sleeping.[19] Tight clothing around the abdomen can also increase the risk of heartburn because it puts pressure on the stomach, which can cause the food and acids in the stomach to reflux to the lower esophageal sphincter.

Treatment

Three types of treatments exist for GERD. These include lifestyle modifications, medications, and surgery.

Lifestyle modifications

Diet

Certain foods and lifestyle are considered to promote gastroesophageal reflux, but a 2006 review suggested that evidence for most dietary interventions is anecdotal; only weight loss and elevating the head of the bed were supported by evidence.[20] A subsequent randomized crossover study showed benefit by avoiding eating two hours before bedtime.[10]

The following may exacerbate the symptoms of GERD:

  • Antacids based on calcium carbonate (but not aluminum hydroxide) were found to actually increase the acidity of the stomach. However, all antacids reduced acidity in the lower esophagus, so the net effect on GERD symptoms may still be positive.[21]
  • Smoking reduces lower esophageal sphincter competence.
Position

Sleeping on the left side has been shown to reduce nighttime reflux episodes in patients.[22]

A meta-analysis suggested that elevating the head of the bed is an effective therapy, although this conclusion was only supported by nonrandomized studies.[20] The head of the bed can be elevated by plastic or wooden bed risers that support bed posts or legs, a therapeutic bed wedge pillow, a wedge or an inflatable mattress lifter that fits in between mattress and box spring or a hospital bed with an elevate feature. The height of the elevation is critical and must be at least 6 to 8 inches (15 to 20 centimetres) to be at least minimally effective to prevent the backflow of gastric fluids. Some innerspring mattresses do not work well when inclined and may cause back pain; some prefer foam mattresses. Some practitioners use higher degrees of incline than provided by the commonly suggested 6 to 8 inches (15 to 20 centimetres) and claim greater success.

Medications

A number of drugs are approved to treat GERD, and are among the most prescribed medication in Western countries.

Clinical trials which compare GERD treatments head-to-head provide physicians with critical information. Unfortunately most pharmaceutical-company sponsored studies are conducted versus placebo and not an active control. However, the DIAMOND has shown rough equivalence of efficacy between a "step-up" approach to therapy (antacids, followed by histamine antagonists, followed by PPIs) and a "step-down" approach (the reverse). The primary endpoint of the study was treatment success after 6 months, and was achieved for 70% of patients in "step-down" versus 72% of patients in "step-up."[25]

Surgery

The standard surgical treatment is the Nissen fundoplication. In this procedure the upper part of the stomach is wrapped around the lower esophageal sphincter (LES) to strengthen the sphincter and prevent acid reflux and to repair a hiatal hernia. The procedure is often done laparoscopically.[26] When compared to medical management laparoscopic fundoplication had better results at 1 year.[27] In addition, laparoscopic fundoplication may reduce SF-36 score (quality of life questionnaire) among patients with gastro-esophageal reflux disease as compared to medical management according to a Cochrane systematic review of randomized controlled trials. [28] There were statistically significant improvements in quality of life at 3 months and 1 year after surgery compared to medical therapy, with an SF-36 general health score mean difference of -5.23 in favor of surgery (95%CI = -6.83 to -6.82).

An obsolete treatment is vagotomy ("highly selective vagotomy"), the surgical removal of vagus nerve branches that innervate the stomach lining. This treatment has been largely replaced by medication.

Another treatment is transoral incisionless fundoplication (TIF) with the use of a device called Esophyx, which allows doctors to rebuild the valve between the stomach and the diaphragm by going through the esophagus.[29]

Other treatments

In 2000 the U.S. Food and Drug Administration (FDA) approved two endoscopic devices to treat chronic heartburn. One system, Endocinch, puts stitches in the LES to create little pleats that help strengthen the muscle. However, long-term results were disappointing, and the device is no longer sold by Bard. Another, the Stretta Procedure, uses electrodes to apply radio frequency energy to the LES. The long-term outcomes of both procedures compared to a Nissen fundoplication are still being determined.

Subsequently the NDO Surgical Plicator was cleared by the FDA for endoscopic GERD treatment. The Plicator creates a plication, or fold, of tissue near the gastroesophageal junction, and fixates the plication with a suture-based implant. The company ceased operations in mid 2008, and the device is no longer on the market.

Another treatment that involved injection of a solution during endoscopy into the lower esophageal wall was available for about one year ending in late 2005. It was marketed under the name Enteryx. It was removed from the market due to several reports of complications from misplaced injections.

Pregnancy

In pregnancy dietary modifications and lifestyle changes may be attempted but often have little effect. Calcium-based antacids are recommended if these changes are not effective. Aluminum- and magnesium antacids are also safe as is ranitidine.[30]

References

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  2. ^ "The saliva PH test and cancer". Healingdaily.com. Retrieved 2009-08-19.
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  4. ^ "Consumer Health Information". Healthlink.mcw.edu. Retrieved 2009-08-19.
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  11. ^ Ayazi S, Crookes P, Peyre C, (2007). "Objective documentation of the link between gastroesophageal reflux disease and obesity". Am. J. Gastroenterol. 102 (S): 138–139.{{cite journal}}: CS1 maint: extra punctuation (link) CS1 maint: multiple names: authors list (link)
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  13. ^ Morse CA, Quan SF, Mays MZ, Green C, Stephen G, Fass R (2004). "Is there a relationship between obstructive sleep apnea and gastroesophageal reflux disease?". Clin. Gastroenterol. Hepatol. 2 (9): 761–8. doi:10.1016/S1542-3565(04)00347-7. PMID 15354276.{{cite journal}}: CS1 maint: multiple names: authors list (link)
  14. ^ Kasasbeh A, Kasasbeh E, Krishnaswamy G (2007). "Potential mechanisms connecting asthma, esophageal reflux, and obesity/sleep apnea complex—a hypothetical review". Sleep Med Rev. 11 (1): 47–58. doi:10.1016/j.smrv.2006.05.001. PMID 17198758.{{cite journal}}: CS1 maint: multiple names: authors list (link)
  15. ^ H.J. O'Connor (1999). "Helicobacter pylori and gastro-oesophageal reflux disease-clinical implications and management". Aliment Pharmacol Ther. 13 (2): 117–27. doi:10.1046/j.1365-2036.1999.00460.x. PMID 10102940. {{cite journal}}: Unknown parameter |month= ignored (help)
  16. ^ El-Omar E, Oien K, Nujuni AE; et al. (1997). "Helicobacter pylori infection and chronic gastric acid hyposecretion". Gastroenterology. 113 (1): 15–24. PMID 9207257. {{cite journal}}: Explicit use of et al. in: |author= (help)CS1 maint: multiple names: authors list (link)
  17. ^ C.A. Fallone, A.N. Barkun, S. Mayrand, G. Wakil, G. Friedman, A. Szilagyi, C. Wheeler & D. Ross (2004). "There is no difference in the disease severity of gastro-oesophageal reflux disease between patients infected and not infected with Helicobacter pylori". Aliment Pharmacol Ther. 20 (7): 761–768. doi:10.1111/j.1365-2036.2004.02171.x. PMID 15379836.{{cite journal}}: CS1 maint: multiple names: authors list (link)
  18. ^ "Lifestyle Changes to Manage Your Heartburn" WebMD
  19. ^ http://www.medscape.com/viewarticle/536343[dead link]
  20. ^ a b Kaltenbach T, Crockett S, Gerson LB (2006). "Are lifestyle measures effective in patients with gastroesophageal reflux disease? An evidence-based approach". Arch. Intern. Med. 166 (9): 965–71. doi:10.1001/archinte.166.9.965. PMID 16682569.{{cite journal}}: CS1 maint: multiple names: authors list (link)
  21. ^ Decktor DL, Robinson M, Maton PN, Lanza FL, Gottlieb S (1995). "Effects of Aluminum/Magnesium Hydroxide and Calcium Carbonate on Esophageal and Gastric pH in Subjects with Heartburn". Am J Ther. 2 (8): 546–552. doi:10.1097/00045391-199508000-00006. PMID 11854825.{{cite journal}}: CS1 maint: multiple names: authors list (link)
  22. ^ Khoury, RM (1999). "Influence of spontaneous sleep positions on nighttime recumbent reflux in patients with gastroesophageal reflux disease". Am. J. Gastroenterol. 94 (8): 2069–73. doi:10.1111/j.1572-0241.1999.01279.x. PMID 10445529. {{cite journal}}: Unknown parameter |coauthors= ignored (|author= suggested) (help)
  23. ^ a b Tran T, Lowry A, El-Serag H (2007). "Meta-analysis: the efficacy of over-the-counter gastro-oesophageal reflux disease drugs". Aliment Pharmacol Ther. 25 (2): 143–53. doi:10.1111/j.1365-2036.2006.03135.x. PMID 17229239.{{cite journal}}: CS1 maint: multiple names: authors list (link)
  24. ^ Cash, B.D. "Role of Serotonergic Agents in Primary Chronic Constipation: Serotonergic Agents and Chronic Constipation". MedScape. p. 4. Retrieved 2009-09-07. {{cite web}}: Unknown parameter |coauthors= ignored (|author= suggested) (help)
  25. ^ van Marrewjik; et al. (2009). "Effect and cost-effectiveness of step-up versus step-down treatment with antacids, H2-receptor antagonists, and proton pump inhibitors in patients with new onset dyspepsia (DIAMOND study): a primary-care-based randomized controlled study". The Lancet. 373: 215–25. doi:10.1016/S0140-6736(09)60070-2. {{cite journal}}: Explicit use of et al. in: |author= (help)
  26. ^ Abbas A, Deschamps C, Cassivi SD; et al. (2004). "The role of laparoscopic fundoplication in Barrett's esophagus". Annals of Thoracic Surgery. 77 (2): 393–396. doi:10.1016/S0003-4975(03)01352-3. PMID 14759403. {{cite journal}}: Explicit use of et al. in: |author= (help)CS1 maint: multiple names: authors list (link)
  27. ^ Grant AM, Wileman SM, Ramsay CR; et al. (2008). "Minimal access surgery compared with medical management for chronic gastro-oesophageal reflux disease: UK collaborative randomised trial". BMJ. 337: a2664. doi:10.1136/bmj.a2664. PMC 2603580. PMID 19074946. {{cite journal}}: Explicit use of et al. in: |author= (help)CS1 maint: multiple names: authors list (link)
  28. ^ Wileman, SM; McCann, S; Grant, AM; Krukowski, ZH; Bruce, J; Wileman, Samantha M (2010). "Medical versus surgical management for gastro-oesophageal reflux disease (GORD) in adults". Cochrane database of systematic reviews (Online). 3: CD003243. doi:10.1002/14651858.CD003243.pub2. PMID 20238321.
  29. ^ "New Surgery For Acid Reflux Sufferers". CBS Interactive Inc. Jan. 16, 2009. Retrieved 2009-09-07. {{cite news}}: Check date values in: |date= (help)
  30. ^ Mahadevan U, Kane S (2006). "American gastroenterological association institute medical position statement on the use of gastrointestinal medications in pregnancy". Gastroenterology. 131 (1): 278–82. doi:10.1053/j.gastro.2006.04.048. PMID 16831610. {{cite journal}}: Unknown parameter |month= ignored (help)
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