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ACIDITY / GERD
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Gastroesophageal Reflux Disease

Introduction

Background

Gastroesophageal reflux is a normal physiologic phenomenon experienced intermittently by most people, particularly after a meal.Gastroesophageal reflux disease (GERD) occurs when the amount of gastric juice that refluxes into the esophagus exceeds the normal limit, causing symptoms with or without associated esophageal mucosal injury (ie, esophagitis).

For excellent patient education resources, visit eMedicine'sHeartburn/GERD/Reflux Center and Esophagus, Stomach, and Intestine Center. Also, see eMedicine's patient education articles Gastroesophageal Reflux Disease (GERD),Heartburn, and Heartburn/GERD Medications.

 

Pathophysiology

The physiologic and anatomic factors that prevent the reflux of gastric juice from the stomach into the esophagus include the following:

  • The lower esophageal sphincter (LES) must have a normal length and pressure and a normal number of episodes of transient relaxation (relaxation in the absence of swallowing).
  • The gastroesophageal junction must be located in the abdomen so that the diaphragmatic crura can assist the action of the LES, thus functioning as an extrinsic sphincter. The presence of a hiatal hernia disrupts this synergistic action and can promote reflux (see Image 3 or below).
    Barium swallow indicating hiatal hernia.

    Barium swallow indicating hiatal hernia.

  • Esophageal clearance must be able to neutralize the acid refluxed through the LES. (Mechanical clearance is achieved with esophageal peristalsis. Chemical clearance is achieved with saliva.)
  • The stomach must empty properly.

Abnormal gastroesophageal reflux is caused by the abnormalities of one or more of the following protective mechanisms:

  • A functional (frequent transient LES relaxation) or mechanical (hypotensive LES) problem of the LES is the most common cause of gastroesophageal reflux disease (GERD).
  • Certain foods (eg, coffee, alcohol), medications (eg, calcium channel blockers, nitrates, beta-blockers), or hormones (eg, progesterone) can decrease the pressure of the LES.
  • Obesity is a contributing factor in gastroesophageal reflux disease (GERD), probably because of the increased intra-abdominal pressure.

From a therapeutic point of view, informing patients that gastric refluxate is made up not only of acid but also of duodenal contents (eg, bile, pancreatic secretions) is important.

 

Frequency

United States

Heartburn is a common problem in the United States and in the Western world. Approximately 7% of the population experience symptoms of heartburn daily. An abnormal esophageal exposure to gastric juice is probably present in 20-40% of this population, meaning 20-40% of the people who experience heartburn do indeed have gastroesophageal reflux disease (GERD). In the remaining population, heartburn is probably due to other causes. Because many individuals control symptoms with over-the-counter (OTC) medications and without consulting a medical professional, the condition is likely underreported.

Mortality/Morbidity

  • In addition to the typical symptoms of gastroesophageal reflux disease (GERD) (eg, heartburn, regurgitation, dysphagia), abnormal reflux can cause atypical symptoms, such as coughing, chest pain, and wheezing. Additional atypical symptoms from abnormal reflux include damage to the lungs (eg, pneumonia, asthma, idiopathic pulmonary fibrosis), vocal cords (eg, laryngitis, cancer), ear (eg, otitis media), and teeth (eg, enamel decay).
  • Approximately 50% of patients with gastric reflux develop esophagitis (see Image 6 or below).
    Peptic esophagitis. A rapid urease test (RUT) is ...

    Peptic esophagitis. A rapid urease test (RUT) is performed on the esophageal biopsy sample. The result is positive for esophagitis.


    {{mediacaption:1674250_0}}Esophagitis is classified into the following 4 grades based on its severity:
    • Grade I – Erythema
    • Grade II – Linear nonconfluent erosions
    • Grade III – Circular confluent erosions
    • Grade IV – Stricture or Barrett esophagus. Barrett esophagus is thought to be caused by the chronic reflux of gastric juice into the esophagus. Barrett esophagus occurs when the squamous epithelium of the esophagus is replaced by the intestinal columnar epithelium (see Image 1 or below).
      Esophagogastroduodenoscopy indicating Barrett eso...

      Esophagogastroduodenoscopy indicating Barrett esophagus.


      {{mediacaption:176678_1}}Barrett esophagus is present in 8-15% of patients with gastroesophageal reflux disease (GERD) and may progress to adenocarcinoma (see Images 2 and 7 or below).
      Gastroesophageal reflux disease (GERD)/Barrett es...

      Gastroesophageal reflux disease (GERD)/Barrett esophagus/adenocarcinoma sequence.


      Endoscopy demonstrating intraluminal esophageal c...

      Endoscopy demonstrating intraluminal esophageal cancer.


      {{mediacaption:1674255_3}}See Esophageal Cancer.

Race

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

Sex

  • No sexual predilection exists. Gastroesophageal reflux disease (GERD) is as common in men as in women.
  • The male-to-female incidence ratio for esophagitis is 2:1-3:1. The male-to-female incidence ratio for Barrett esophagus is 10:1.

Age

  • Gastroesophageal reflux disease (GERD) occurs in all age groups.
  • The prevalence of gastroesophageal reflux disease (GERD) increases in people older than 40 years.

Clinical

History

Gastroesophageal reflux disease (GERD) can cause typical (esophageal) symptoms or atypical (extraesophageal) symptoms. However, a diagnosis of gastroesophageal reflux disease (GERD) based on the presence of typical symptoms is correct in only 70% of patients.

  • Typical (esophageal) symptoms include the following:
    • Heartburn is the most common typical symptom of gastroesophageal reflux disease (GERD). Heartburn is felt as a retrosternal sensation of burning or discomfort that usually occurs after eating or when lying down or bending over.
    • Regurgitation is an effortless return of gastric and/or esophageal contents into the pharynx. Regurgitation can induce respiratory complications if gastric contents spill into the tracheobronchial tree.
    • Dysphagia occurs in approximately one third of patients because of a mechanical stricture or a functional problem (eg, nonobstructive dysphagia secondary to abnormal esophageal peristalsis). Patients with dysphagia experience a sensation that food is stuck, particularly in the retrosternal area.
  • Atypical (extraesophageal) symptoms include the following:
    • Coughing and/or wheezing are respiratory symptoms resulting from the aspiration of gastric contents into the tracheobronchial tree or from the vagal reflex arc producing bronchoconstriction. Approximately 50% of patients who have GERD-induced asthma do not experience heartburn.
    • Hoarseness results from irritation of the vocal cords by gastric refluxate and is often experienced by patients in the morning.
    • Reflux is the most common cause of noncardiac chest pain, accounting for approximately 50% of cases. Patients can present to the emergency department with pain resembling a myocardial infarction. Reflux should be ruled out (using esophageal manometry and 24-h pH testing if necessary) once a cardiac cause for the chest pain has been excluded. Alternatively, a therapeutic trial of a high-dose proton pump inhibitor (PPI) can be tried.
      Ambulatory pH monitoring indicating episodes of r...

      Ambulatory pH monitoring indicating episodes of reflux correlating with the heartburn experienced by the patient.

 

Physical

The physical examination is noncontributory.

Differential Diagnoses

Achalasia
Esophagitis
Cholelithiasis
Gastritis, Chronic
Coronary Artery Atherosclerosis
Irritable Bowel Syndrome
Esophageal Cancer
Peptic Ulcer Disease
Esophageal Spasm
 

Other Problems to Be Considered

Some studies have shown that gastroesophageal reflux disease (GERD) is highly prevalent in patients who are morbidly obese and that a high body mass index (BMI) is a risk factor for the development of this condition.1,2,3,4,5,6 

The mechanism by which a high BMI increases esophageal acid exposure is not completely understood. Increased intragastric pressure and gastroesophageal pressure gradient, incompetence of the LES, and increased frequency of transient LES relaxations may all play a role in the pathophysiology of gastroesophageal reflux disease (GERD) in patients who are morbidly obese.

To further support the hypothesis that obesity increases esophageal acid exposure is the documentation of a dose-response relationship between increased BMI and increased prevalence of gastroesophageal reflux disease (GERD) and its complications. Therefore, the pathophysiology of GERD in patients who are morbidly obese might differ from that of patients who are not obese. The therapeutic implication of such a premise is that the correction of reflux in patients who are morbidly obese might be better achieved with a procedure that first controls obesity.

Workup

Laboratory Studies

  • Laboratory tests are seldom useful in establishing a diagnosis of gastroesophageal reflux disease (GERD).

Imaging Studies

  • Barium esophagogram
    • A barium esophagogram is particularly important for patients with gastroesophageal reflux disease (GERD) who experience dysphagia.
    • A barium esophagogram can show the presence and location of a stricture and the presence and shape of a hiatal hernia.
  • Esophagogastroduodenoscopy (EGD)
    • EGD identifies the presence and severity of esophagitis and the possible presence of Barrett esophagus (see Image 1 or below).
      Esophagogastroduodenoscopy indicating Barrett eso...

      Esophagogastroduodenoscopy indicating Barrett esophagus.

    • EGD also excludes the presence of other diseases (eg, peptic ulcer) that can present similarly to gastroesophageal reflux disease (GERD).
    • Although EGD is frequently performed to help diagnose gastroesophageal reflux disease (GERD), it is not the most cost-effective diagnostic study because esophagitis is present in only 50% of patients with GERD.

Other Tests

  • Esophageal manometry
    • Esophageal manometry defines the function of the LES and the esophageal body (peristalsis).
    • Esophageal manometry is essential for correctly positioning the probe for the 24-hour pH monitoring.
  • Ambulatory 24-hour pH monitoring
    • Ambulatory 24-hour pH monitoring is the criterion standard in establishing a diagnosis of GERD with a sensitivity of 96% and a specificity of 95%.
    • Ambulatory 24-hour pH monitoring quantifies the gastroesophageal reflux and allows a correlation between the symptoms of reflux and the episodes of reflux.
    • Patients with endoscopically confirmed esophagitis do not need pH monitoring to establish a diagnosis of gastroesophageal reflux disease (GERD).
  • Indications for esophageal manometry and prolonged pH monitoring include the following:
    • Persistence of symptoms while taking adequate antisecretory therapy, such as PPI therapy
    • Recurrence of symptoms after discontinuation of acid-reducing medications
    • Investigation of atypical symptoms, such as chest pain or asthma, in patients without esophagitis
    • Confirmation of the diagnosis in preparation for antireflux surgery
  • Radionuclide measurement of gastric emptying
    • Although delayed gastric emptying is present in as many as 60% of patients with gastroesophageal reflux disease (GERD), this emptying is usually a minor factor in the pathogenesis of the disease in most patients (except in patients with advanced diabetes mellitus or connective tissue disorders).
    • Patients with delayed gastric emptying typically experience postprandial bloating and fullness in addition to other symptoms.
  • Medical Care

    Treatment of gastroesophageal reflux disease (GERD) is a stepwise approach. The goals are to control symptoms, to heal esophagitis, and to prevent recurrent esophagitis or other complications. The treatment is based on lifestyle modification and control of gastric acid secretion.

    • Lifestyle modifications include the following:  
      • Losing weight (if overweight)
      • Avoiding alcohol, chocolate, citrus juice, and tomato-based products
      • Avoiding large meals
      • Waiting 3 hours after a meal before lying down
      • Elevating the head of the bed 8 inches
 
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