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     Gastroesophageal Reflux Disease (GERD)

Study guide:

Definition:

  • Gastroesophageal Reflux Disease (GERD): a chronic digestive disease in which there is regurge of stomach acid or content into the esophagus or mouth.

    • ≥2 heartburn episodes/week that affects the quality of life adversely.

    • Reflux is a normal process that can occur once each hour, GERD occurs when the amount is more than the normal limit and the duration of exposure is longer causing symptom and irritation of the esophagus lining.

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Epidemiology:

  • The prevalence of GERD increases in people older than 40 years.

  • According to Richter and associates: 25-40% of Americans experience symptomatic GERD at some point and 10% of them have daily symptoms.

  • Male-to-female incidence ratio for esophagitis is 2:1-3:1.

  • The male-to-female incidence ratio for Barrett esophagus is 10:1.

  • White males are at a greater risk for Barrett esophagus and adenocarcinoma than other populations.

Etiology:

  • A functional (inappropriate transient LES relaxation) or mechanical (hypotensive LES) problem of the LES is the most common cause of GERD.

  • Acid hypersecretion (rare): Zollinger-Ellison syndrome (gastrin-secreting tumor)

  • Increased intra-gastric pressure.

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Risk Factors:

 

  • Weight gain.

  • Fatty foods or large meal.

  • Delayed gastric emptying.

  • Drinks with caffeine or carbon

  • Chocolate

  • Peppermint

  • Spicy foods

  • Citrus fruit juices

  • Alcohol

  • Smoking

  • Medications: anticholinergics, antihistamines, tricyclic antidepressants, CCB, progesterone, and nitrates.

Pathophysiology:​​​

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  • This loss is usually due to decreased LES resistance with reflux of acidic gastric contents into the esophagus. Causes include:

  • LES is the primary gastroesophegeal barrier, loss of this normal barrier result in reflux.

  1. Structurally defective sphincter.

  2. Transient loss of gastroesophegeal barrier (with structurally normal LES) due to gastric abnormalities like: distention with air/food; delayed gastric emptying and increased intra-abdominal pressure.

  • Long exposure to a low PH from the gastric contents such as acid, pepsin, and duodenal contents; will lead to irritation of the esophageal mucosa and respiratory epithelium and may end up with complications (esophagitis, stricture, Barrett’s esophagus, and risk of aspiration).

Sign & Symptoms:

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  • The most common symptom of GERD is heartburn (pyrosis).

  • Heartburn and acid regurgitation (together are 80% sensitive and specific for reflux).

  • Most commonly these symptoms worsen at night, after large meals and on lying down position.

  • Minimal or transit reflux may cause: asymptomatic esophagitis.

  • Severe reflux may cause: severe esophagitis with laryngitis, aspiration pneumonitis/recurrent pneumonia, idiopathic pulmonary fibrosis, or asthma.

  • RED FLAGS:

    • Dysphagia

    • Odynophagia

    • Chest pain

    • Choking

    • Bleeding

Diagnostic tests:

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  • Usually a clinical diagnosis based on symptom history and relief following a trial of pharmacotherapy (Proton Pump Inhibitors (PPI): symptom relief 80% sensitive for reflux).

  • Endoscopy:

    • Endoscopy is useful for diagnosing the complications of GERD, such as Barrett's esophagus, esophagitis and strictures, but it is not sensitive for diagnosis of GERD itself!

    • Absolute indications:

      • Heartburn accompanied by red flags.

      • Persistent reflux symptoms or prior severe erosive esophagitis after therapeutic trial of 4-8 weeks of PPI 2x daily.

    • History of esophageal stricture with persistent dysphagia.

In people who have symptoms but no evidence of complications, a trial of treatment with lifestyle changes are often recommended, without further testing.

  • 24- hour pH monitoring of the esophagus:  

    • The gold Standard for GERD diagnosis.

    • The Most accurate test, but not required or performed in most cases with endoscopic confirmation.

 

  • Barium study: useful to check for anatomical causes for reflux, like hiatal hernia, it can also reveal pathology resulting from long standing reflux like stricture, or ulcer formation.

 

  • Esophageal manometry: (study of esophageal motility):

    • Diagnose abnormal peristalsis and/or decreased LES tone, but cannot detect presence of reflux.

    • Indicated for people in whom the diagnosis is unclear after other testing or in whom surgery for reflux disease is being considered.

Patient should have a trial of medical therapy for 6-12 weeks before further investigations.

ALWAYS consider doing an ECG for patients with vague chest pain or heartburn, to rule out myocardial infarction.

Treatment:

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Lifestyle modification with pharmacological treatment; only refractory cases will require surgery.

  • Initial treatment involves both:

    • Lifestyle modification:

      • Weight loss.

      • Positioning: Raise the head of the bed six to eight inches.

      • Avoid acid reflux inducing foods: alcohol, coffee, chocolate, etc.

      • Quit smoking.

      • Avoid large and late meals and eating small frequent meal.

      • Avoid tight fitting clothing.

    • Pharmacological treatment:  

      • In mild symptoms:

      • Antacids

      • Histamine antagonist

      • In moderate to severe:

      • PPI.

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  • Surgical treatment:

    • Fundoplication (Nissen’s procedure) is the procedure of choice.

    • Indications:

      • If medications fail and the patient gets complications.  

      • Poor patient compliance with regard to medications

      • Esophageal complications: Barrett esophagus, esophagitis or stricture.

      • Extraesophageal manifestations; like respiratory symptoms.

      • Patients with well-controlled GERD who desire definitive, one-time treatment.

Stages of GERD management:

Complication:

 

  • Esophagitis: According to the Los Angeles classification, it can be classified as:

  • Barrett’s esophagus (BE):

    • Metaplastic columnar epithelium as opposed to the normal epithelium lines distal portion of the esophagus, which is squamous.

    • 30 times greater risk of esophagus adenocarcinoma!

    • Up to 10% of GERD patients will have already developed BE by the time they seek medical attention.

    • Rate of malignant transformation is approximately 1% per yr in patients without dysplasia on initial surveillance biopsies.

    • Rate of malignant transformation in high-grade dysplasia is 32-59% over 5-8 years of surveillance.

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    • Diagnosis:

      • Endoscopy for evaluation and obtaining multiple biopsies.

    • Management:

      • Same as GERD.

      • Endoscopy every 3 years if no dysplasia.

      • High-grade dysplasia: Endoscopy in 6 months + PPI + regular and frequent surveillance with intensive biopsy and endoscopic ablation/resection.

      • Low-grade dysplasia: Endoscopy in 12 months + PPI + both surveillance and endoscopic ablation/resection are satisfactory options.

Treatment of GERD with Barret’s esophagus does not eliminate the risk of metaplasia and malignancy risk!

Other complications of GERD:

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  • Peptic esophageal ulcer.

  • Esophageal stricture.

  • Esophageal adenocarcinoma.

References:

  1. "GERD - Mayo Clinic". Mayoclinic.org. N.p., 2016. Web. 13 May 2016.

  2. "Gastroesophageal Reflux Disease (GERD)". MSD Manual Professional Edition. N.p., 2016. Web. 13 May 2016.

  3. Kaufman, Matthew S, Latha G Stead, and S. Matthew Stead. First Aid For The Surgery Clerkship. 2nd ed. New York: McGraw-Hill Medical, 2009. Print.

  4. Sami, SS and K Ragunath. "The Los Angeles Classification Of Gastroesophageal Reflux Disease". Video Journal and Encyclopedia of GI Endoscopy 1.1 (2013): 103-104. Web. 13 May 2016.

  5. "Gastroesophageal Reflux Disease: Practice Essentials, Background, Anatomy". Emedicine.medscape.com. N.p., 2016. Web. 13 May 2016.

  6. Gastroesophageal Reflux Disease: Diagnosis and Management - American Family Physician [Internet]. Aafp.org. 2016 [cited 28 October 2016]. Available from: http://www.aafp.org/afp/1999/0301/p1161.html

 

Written by: Haneen Al Farhan    

                               

Format editor: Roaa Amer  

 

Reviewed by: Areej Madani

                       Rana Alzahrani

 

Web Publisher: Seba AlMutairi 

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