Gastroesophageal Reflux Disease

BASICS

DESCRIPTION

Reflux of gastroduodenal contents into the esophagus with or without esophageal inflammation

System(s) affected: Gastrointestinal
Genetics: N/A
Incidence/Prevalence in USA: 65% of adults have suffered heartburn; 24% have had symptoms for > 10 years. 17% of adults use indigestion aids at least once weekly, only 24% of sufferers have consulted a physician. Children affected 1/300-1000. 30-80% of pregnant women report heartburn.
Predominant age: All ages
Predominant sex: Male = Female

SIGNS AND SYMPTOMS

Heartburn (pyrosis) 70-85%
Regurgitation 60%
Dysphagia (possible stricture) 15-20%
Angina-like chest pain 33%
Bronchospasm (asthma) 15-20%
Laryngitis (dysphonia)
Chronic cough
Globus sensation
Loss of dental enamel
In infants: Recurrent emesis, failure to thrive, apnea syndrome

CAUSES

Inappropriate relaxation of lower esophageal sphincter (LES) (idiopathic, food- or drug-related)
Familial clustering of GERD has been described suggesting a possible genetic basis
Pregnancy (progestational hormones cause decreased LES pressure)
Scleroderma (reduced esophageal motility and incompetent LES)
Chalasia of infancy
Delayed gastric emptying (impaired acid clearance)
Acid hypersecretion (e.g., Zollinger-Ellison syndrome)
Heller's myotomy for achalasia

RISK FACTORS

Foods that lower LES pressure (high-fat content, yellow onions, chocolate, peppermint)
Foods that irritate esophageal mucosa (citrus fruits, spicy tomato drinks)
Hiatal hernia - acid trapping
Cigarette smoking; excessive alcohol; coffee
Medications that lower LES pressure (e.g., theophylline, anticholinergics, progesterone, calcium channel blockers [nifedipine, verapamil], alpha adrenergic agents, diazepam, meperidine)
Indwelling nasogastric tube
Chest trauma
In children: Down syndrome, mental retardation, cerebral palsy, repaired tracheoesophageal fistula
Eradication of H. pylori infection (resulting in increased acid production, loss of acid buffering, etc.) - remains controversial

DIAGNOSIS

LABORATORY

N/A

Drugs that may alter lab results: N/A
Disorders that may alter lab results: N/A

PATHOLOGICAL FINDINGS

Acute inflammation (especially eosinophils)
Hyperplasia (thickening) of the basal zone of the epithelium seen in 85%
Lengthening of vascular channels within vascular papillae so that they approach the luminal surface
Barrett's epithelial change - gastric columnar epithelium (intestinal metaplasia) migrates upward into the distal esophagus; may be associated with strictures and peptic ulceration; dysplasia and malignant transformation

SPECIAL TESTS

Esophageal pH monitoring (antacids, H2 blockers, proton pump inhibitors and other antisecretory agents can give false negative pH monitoring)
Esophageal manometry (anticholinergics, theophylline, calcium channel blockers, meperidine, diazepam may give falsely low LES pressure on manometry)
Acid perfusion (Bernstein) test
Gastric analysis (exclude gastric hypersecretion)

IMAGING

Barium swallow: Presence of a sliding hiatal hernia appears to be a predictor of reflux esophagitis; mucosal irregularity due to inflammation and edema; prominent longitudinal folds, erosions, ulcers; smoothly tapered strictures; pseudodiverticula
Radionuclide scintigraphy

DIAGNOSTIC PROCEDURES

"Once in a lifetime" endoscopy in chronic GERD patients to exclude Barrett's, etc. is becoming an accepted practice

Endoscopy:

Grade	Finding	% Patients with grade
0	Normal	20-40
I	Erythema, friability	20-30
II	Isolated round or linear erosions	20-30
III	Confluent erosions, exudate	5-10
IV	Deep ulceration, stricture/stenosis	5

Barrett's change suspected when salmon colored mucosa extends > 2 cm above normal squamocolumnar junction (in up to 10%).
Mucosal biopsy
Cytology for Barrett's dysplasia (flow cytometry useful adjunct when available)
Metoclopramide or cisapride may give falsely negative gastric emptying results
Empiric trial of proton pump inhibitor compares well to pH monitoring as a diagnostic tool in reflux-induced symptoms

TREATMENT

APPROPRIATE HEALTH CARE

Outpatient diagnosis (typical heartburn history has a positive predictive value of > 80% and warrants empiric therapy in absence of alarm symptoms)
Inpatient if surgery indicated

GENERAL MEASURES

Elevate head of bed, avoid lying down directly after meals; avoid stooping, bending, tight-fitting garments
Avoid drugs causing decreased LES pressure
Weight loss
Avoid voluntary eructation
Stepped therapy
- Phase I: lifestyle and diet modifications plus antacids or OTC H2 blockers
- Phase II: H2 blockers in prescription doses; proton pump inhibitors increasingly used as initial therapy of uncomplicated heartburn
- Phase III: (1) high-dose H2 blocker or proton pump inhibitor (e.g., omeprazole or lansoprazole) or (2) H2 blockers or proton pump inhibitor plus cisapride
- Phase IV: surgery

SURGICAL MEASURES

Phase IV of stepped therapy (see General Measures)

ACTIVITY

Full activity

DIET

Avoid chocolate, peppermint, onions, high-fat foods, alcohol, tobacco, coffee, citrus juices

PATIENT EDUCATION

Digestive Diseases Clearinghouse, Suite 600, 1555 Wilson Blvd., Rosslyn, VA 22209, (212)685-3440

FOLLOW UP

PREVENTION/AVOIDANCE

Long-term maintenance therapy with H2 blockers or proton pump inhibitors along with lifestyle and diet modifications to prevent symptomatic relapse
Peptic strictures may require periodic dilatation (although frequency of dilatation is reduced by PPI maintenance)
Omeprazole 20 mg daily, lansoprazole 15 mg daily and rabeprazole 20 mg daily are effective (approved for chronic maintenance in severe GERD)
Antireflux surgery should be considered for patients with severe disease in lieu of chronic drug therapy (laparoscopic approach increasingly being used)
Every other year endoscopy, biopsy and cytology to detect dysplasia in Barrett's epithelium (more frequently if dysplasia present)

POSSIBLE COMPLICATIONS

Peptic stricture (10-15%)
Hemorrhage (3%)
Barrett's esophagus (10%)
Pulmonary or ear, nose, throat complications (5-10%)
Noncardiac chest pain
Adenocarcinoma from Barrett's epithelium

EXPECTED COURSE AND PROGNOSIS

Majority of patients respond well to antisecretory or prokinetic therapy. Overall healing rate at ≤ 12 weeks for PPIs = 84% vs H2 blockers 52%. Speed of healing is 12% per week for PPI vs 6% per week for H2 blockers. Complete freedom from heartburn is 77% for PPI vs 48% for H2 blockers.
Symptoms and esophageal inflammation often return promptly when treatment withdrawn
Relapse prevention therapy with H2 blockers/proton pump inhibitor often requires the full healing dose be maintained
Antireflux surgery (e.g., fundoplication) for complications or "refractory" disease; excellent short-term results but long-term follow-up is relatively limited
Regression of Barrett's epithelium does not routinely occur despite aggressive medical or surgical therapy
Cost effectiveness of long-term maintenance therapy has been shown for PPIs and H2 blockers (PPI more cost effective than high dose H2 blockers)

MISCELLANEOUS

ASSOCIATED CONDITIONS

Extraesophageal reflux
Reflux-induced asthma
Pulmonary aspiration
Chronic cough/throat clearing
Loss of dental enamel
Halitosis
Laryngitis, laryngeal carcinoma
Globus sensation
Vocal cord granulomas

AGE-RELATED FACTORS

Pediatric:

Reflux symptoms usually resolve by 18 mo
Vomiting, weight loss, failure to thrive more common than heartburn
Positional treatment = use of infant seat for 2-3 hours after meals; thickened feedings
Drug treatment = antacids or liquid H2 blockers (e.g., Zantac syrup)
Surgery for severe symptoms (apnea, choking, persistent vomiting) successful in 85-95%

Geriatric: Complications more likely
Others: N/A

PREGNANCY

Heartburn (when first experienced): 52% 1st trimester, 24% 2nd trimester, 9% 3rd trimester
Tends to recur in subsequent pregnancies
Symptomatic therapy includes multiple small meals, avoid lying down for 2-3 hours after meals, elevating the head of the bed at night
Antacids or H2 blockers are probably safe in the 2nd trimester

OTHER NOTES

Alkaline (bile) reflux accounts for up to 15% of Barrett's esophagus and severe esophagitis; promotility agent or surgery may be required in this setting

ABBREVIATIONS

LES = lower esophageal sphincter
GER = gastroesophageal reflux
GERD = gastroesophageal reflux disease
PPI = proton pump inhibitor

Clinical Investigations

ROLE OF HOMOEOPATHY

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