Gastroesophageal Reflux Disease
Gastroesophageal Reflux Disease (GERD; or GORD when spelling oesophageal, the BE form) is defined as chronic symptoms or mucosal damage produced by the abnormal reflux of gastric contents into the esophagus.
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 (LES), transient LES relaxation, or association with a hiatal hernia.
Heartburn is the major symptom of acid in the esophagus, characterized by a burning discomfort behind the breastbone (sternum). Findings in GERD include esophagitis (reflux esophagitis) – inflammatory changes in the esophageal lining (mucosa) – strictures, difficulty swallowing (dysphagia), and chronic chest pain.
Patients may have only one of those findings. Atypical symptoms of GERD include cough, hoarseness, changes of the voice, chronic ear ache, or sinusitis. Complications of GERD include stricture formation,
Barrett’s esophagus, esophageal ulcers and possibly even lead to esophageal cancer. Occasional heartburn is common but does not necessarily mean one has GERD. Patients that have heartburn symptoms more than once a week are at risk of developing GERD.
A hiatal hernia is usually asymptomatic, but the presence of a hiatal hernia is a risk factor for the development of GERD.
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 and bad breath are also common. Children may have one symptom or many – no single symptom is universally present in all children with GERD.
Babies’ immature digestive systems are usually the cause, and most infants stop having acid reflux by the time they reach their first birthday. Some children don’t outgrow acid reflux, however, and continue to have it into their teen years.
Children that have had heartburn that doesn’t seem to go away, or any other symptoms of GERD for a while, should talk to their parents and visit their doctor.
A detailed history taking is vital to the diagnosis. Useful investigations may include barium swallow X-rays, esophageal manometry, esophageal pH monitoring and Esophagogastroduodenoscopy (EGD).
In general, an EGD is done when the patient does not respond well to treatment, has had symptoms or required medications for a prolonged time (generally 5 years), has dysphagia, anemia, blood in the stool (detected chemically), has weight loss, or has changed in the voice.
Esophagogastroduodenoscopy (EGD) (a form of endoscopy) involves the 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 surface 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 either reflux or Helicobacter gastritis)
- Eosinophilic inflammation (usually due to reflux)
- Goblet cell intestinal metaplasia or Barrett’s esophagus.
- Dysplasia or pre-cancer.
- Rapid testing assays can quickly detect the presence of Helicobacter pylori in a biopsy sample through urease testing.
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. It is also thought that yeast infections of the digestive tract can cause GERD-like symptoms.
Another paradoxical cause of GERD-like symptoms is not enough stomach acid (hypochlorhydria). The valve that empties the stomach into the intestines is triggered by acidity. If there is not enough acid, this valve does not open and the stomach contents are churned up into the esophagus. There is still enough acidity to cause irritation to the esophagus.
Factors that can contribute to GERD are:
- Hiatus hernia, which increases the likelihood of GERD due to mechanical and motility factors
- 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 rubric “lifestyle modifications” is the term physicians use when recommending non-pharmaceutical treatments for GERD. A 2006 review suggested that evidence for most dietary interventions is anecdotal; only weight loss and elevating the head of the bed were found to be supported by evidence
Certain foods and lifestyle are considered to promote gastroesophageal reflux:
- Coffee, alcohol, calcium supplements, and excessive amounts of Vitamin C supplements are stimulants of gastric acid secretion. Taking these before bedtime especially can promote evening reflux. Calcium-containing antacids are in this group
- Foods high in fats and smoking reduce lower esophageal sphincter competence, so avoiding these tends to help, as well. Fat also delays emptying of the stomach.
- Having more but smaller meals also reduce the risk of GERD, as it means there is less food in the stomach at any one time.
- avoid eating for 2 hours before bedtime
- elevates the head of the bed on 6-inch blocks. (Pillows under the head and shoulders have been shown to be ineffective.)
- avoid soft drinks that contain caffeine
- avoid chocolate and peppermint
- avoid spicy foods
- avoid acidic foods like oranges and tomatoes(okay when fresh.)
- avoid cruciferous vegetables: onions, cabbage, cauliflower, broccoli, Brussels sprouts, milk, and milk-based products contain calcium and fat, so should be avoided before bedtime.
- Avoiding food for 2 hours before bedtime and not lying down after a meal are frequently recommended lifestyle modifications.
Elevating the head of the bed
Elevation to the head of the bed is the next-easiest to implement. If one implements pharmacologic therapy in combination with food avoidance before bedtime and elevation of the head of the bed over 95% of patients will have complete relief.
Additional conservative measures can be considered if there is incomplete relief. Another approach is to advise all conservative measures to maximize response.
Elevating the head of the bed can be accomplished by using blocks as noted above (“cinderblocks” commonly available at hardware stores in the United States are the lowest cost solution) or with other items: plastic or wooden bed risers which support bed posts or legs, vehicle jack stands, a bed wedge pillow, or an inflatable mattress lifter that fits in between mattress and box spring.
The height of the elevation is critical and must be within the range of 6 to 8 inches in order to be as effective as possible in hindering the backflow of gastric fluids. Elevating the bed is also known as “positional therapy”.
A number of drugs are registered for the treatment of GERD, and they are among the most-often-prescribed forms of medication in most Western countries. They can be used in combination with other drugs, although some antacids can impede the function of other medications:
Antacids before meals or symptomatically after symptoms begin can reduce gastric acidity (increase the pH). Alginic acid may coat the mucosa as well as increase the pH and decrease reflux.
Gastric H2 receptor blockers such as ranitidine or famotidine can reduce the gastric secretion of acid. These drugs are technically antihistamines. They relieve complaints in about 50% of all GERD patients.
Proton pump inhibitors such as omeprazole are the most effective in reducing gastric acid secretion, as they stop the secretion of acid at the source of acid production, i.e. the proton pump. To maximize the effectiveness of this medication the drug should be taken a half hour before meals.
Prokinetics strengthen the LES and speed up gastric emptying. Cisapride, a member of this class, was withdrawn from the market for causing Long QT syndrome.
The standard surgical treatment, sometimes preferred over longtime use of medication, is the Nissen fundoplication. 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.
The procedure is often done laparoscopically. An obsolete treatment is a vagotomy (“highly selective vagotomy”), the surgical removal of vagus nerve branches that innervate the stomach lining. This treatment has been largely replaced by medication.
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.
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.
Another treatment which involved an injection of a solution that is injected during endoscopy into the lower esophageal wall was available for approximately 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. Some people have found success using dietary change to treat their own acid reflux.
Barrett’s esophagus, a type of dysplasia, is a precursor high-grade dysplasia, which is, in turn, a precursor condition for carcinoma. The risk of progression from Barrett’s to dysplasia is uncertain but is estimated to include 0.1% to 0.5% of cases, and has probably been exaggerated in the past.
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 medication for GERD chronically.
GERD has been linked to laryngitis, chronic cough, pulmonary fibrosis, earache, and asthma, even when not clinically apparent, as well as to ulcers of the vocal cords.