Gastroesophageal reflux disease

Definition

Gastroesophageal reflux is a normal physiological phenomenon experienced intermittently by most people, particularly after a meal. Gastroesophageal reflux disease (GERD) or Acid Reflux Disease 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 (esophagitis).

Epidemiology

The prevalence of Gastroesophageal reflux disease in Asia is increasing. also, there appear to be racial differences in the clinical manifestations as well as the natural history of GERD between East and West countries. Helicobacter pylori infection, genetic factors, dietary differences, disparities in parietal cell mass and gastric acid secretion are possible factors that accounted for these racial differences.

Risk factors for progressive disease in these patients were increased age, female sex, the presence of symptoms at initial diagnosis by endoscopy, hiatus hernia, the absence of atrophic gastritis, and the absence of H. pylori infection. Evidence suggesting that genetics play a role in GERD is gradually accumulating.

Etiology

The etiology of GERD can be attributed to such factors as transient lower esophageal sphincter (LES) relaxations, decreased LES resting tone, delayed stomach emptying, ineffective esophageal clearance, and diminished salivation. Other contributing factors include the potency of the refluxed material, and the inability of the esophageal tissue to resist injury and repair itself.

Factors that may exacerbate the symptoms of GERD in some patients include smoking, caffeine, chocolate, fatty foods, overeating with gastric distention, tight clothing, the presence of a hiatal hernia, and certain medications. A careful history will often show what factors are important for individual patients. While avoidance of exacerbating factors may be helpful, there is relatively little data supporting the efficacy of lifestyle modification alone for the treatment of GERD. Patients should discuss these and other risk factors with their physicians, who can evaluate their condition and advise them on an appropriate treatment plan. It is important that patients follow the treatment plan advised by their physicians.

Clinical Manifestations

Heartburn, a burning sensation or discomfort behind the breastbone or sternum, is the most common symptom of GERD. It may be accompanied by regurgitation of gastric contents into the mouth or the lungs. In patients with significant GERD, dysphagia is common and may be a sign of the formation of a stricture in the esophagus. Pulmonary manifestations such as asthma, coughing, or intermittent wheezing and vocal cord inflammation with hoarseness occur in some patients.

Most episodes of GERD occur during the day, usually after eating; some sufferers also experience reflux during sleep. Nocturnal reflux is commonly associated with a higher risk and a higher degree of esophagitis: acid remains in the esophagus for prolonged periods because there is less swallowing and less saliva produced to neutralize the acid. The symptoms and degree of esophageal mucosal damage are primarily determined by the pH concentration of the refluxate and the duration of esophageal acid exposure. The development of esophagitis requires the presence of acid in the refluxate, with rare exceptions.

Factors that may exacerbate the symptoms of GERD in some patients include smoking, caffeine, chocolate, fatty foods, overeating with gastric distention, tight clothing, the presence of a hiatal hernia, and certain medications. A careful history will often show what factors are important for individual patients. While avoidance of exacerbating factors may be helpful, there is relatively little data supporting the efficacy of lifestyle modification alone for the treatment of GERD. Patients should discuss these and other risk factors with their physicians, who can evaluate their condition and advise them on an appropriate treatment plan. It is important that patients follow the treatment plan advised by their physicians.

Diagnosis

A detailed anamnesis is vital to the diagnosis. Clinical investigations may include barium swallow X-rays, esophageal manometry, 24 hour esophageal pH monitoring and Esophagogastroduodenoscopy (EGD). Usually, an EGD is done when the patient does not respond well to treatment, or has alarm symptoms including: dysphagia, anemia, blood in the stool (detected chemically), wheezing, weight loss, or changes in the voice. Some physicians advocate once-in-a-lifetime endoscopy for patients with longstanding GERD, to evaluate for the presence of Barrett's esophagus, a precursor lesion for esophageal adenocarcinoma.

Endoscopy may confirm the diagnosis if the doctor finds that the patient has esophagitis or Barrett's esophagus. Endoscopy also helps to exclude the presence of esophageal cancer.

Complications

Complications of GERD include esophageal erosion, esophageal ulcer, and esophageal stricture; replacement of normal esophageal epithelium with abnormal (Barrett's) epithelium; and pulmonary aspiration. The majority of patients with GERD will have a normal esophagus upon endoscopy. A physician can diagnose and evaluate the severity of GERD.

Treatment