Gastroesophageal reflux disease Totally Explained

Everything about Gastroesophageal Reflux totally explained

Gastroesophageal reflux disease (American English and Canadian English) or Gastro-oesophageal reflux disease (British English, Hiberno-English, Australian English, New Zealand English, South African English) and abbreviated to either GERD or GORD is defined as chronic symptoms or mucosal damage produced by the abnormal reflux in 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 cardia, transient cardia relaxation, impaired expulsion of gastric reflux from the esophagus, or a hiatus hernia.
If the reflux reaches the throat, it's called laryngopharyngeal reflux disease.

Symptoms

Adults

Heartburn is the major symptom of acid in the esophagus, characterized by 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 symptoms. Typical GERD symptoms include cough, hoarseness, voice changes, chronic ear ache, burning chest pains, nausea or sinusitis. GERD complications include stricture formation, Barrett's esophagus, esophageal spasms, esophageal ulcers, and possibly even lead to esophageal cancer, especially in adults over 60 years old.
Occasional heartburn is common but doesn't necessarily mean one has GERD. Patients with 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 developing GERD.

Children

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, bad breath, and belching or burping are also common. Children may have one symptom or many — no single symptom is universal in all children with GERD.
It is estimated that of the approximately 4 million babies born in the U.S. each year, up to 35% of them may have difficulties with reflux in the first few months of their life. Most of those children will outgrow their reflux by their first birthday. However, a small but significant number of them won't outgrow the condition.
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 who have had heartburn that doesn't seem to go away, or any other GERD symptoms for a while, should talk to their parents and visit their doctor.

Diagnosis

A detailed history taking is vital to the diagnosis. Useful investigations may include barium swallow X-rays, esophageal manometry, 24-hour esophageal pH monitoring and Esophagogastroduodenoscopy (EGD). In general, an EGD is done when the patient doesn't respond well to treatment, or has alarm symptoms including: dysphagia, anemia, blood in the stool (detected chemically), wheezing, weight loss, or voice changes. Some physicians advocate once-in-a-lifetime endoscopy for patients with longstanding GERD, to evaluate the possible presence of Barrett's esophagus, a precursor lesion for esophageal adenocarcinoma. Esophagogastroduodenoscopy (EGD) (a form of endoscopy) involves 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 surfaces 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 due to reflux or Helicobacter gastritis)
Eosinophilic inflammation (usually due to reflux)
Goblet cell intestinal metaplasia or Barretts esophagus.
Elongation of the papillae
Thinning of the squamous cell layer
Dysplasia or pre-cancer.
Carcinoma.

Reflux changes may be non-erosive in nature, leading to the entity non-erosive reflux disease.

Pathophysiology

GERD is caused by a failure of the cardia. In healthy patients the "Angle of His," the angle at which the esophagus enters the stomach, is in fact creating a valve that prevents duodenal bile, enzymes, and stomach acid from traveling back into the esophagus where they can cause burning and inflammation of sensitive esophageal tissue.
Another paradoxical cause of GERD-like symptoms isn't enough stomach acid (hypochlorhydria). The valve that empties the stomach into the intestines is triggered by acidity. If there isn't enough acid this valve doesn't open, and the stomach contents are churned up into the esophagus. However, there's still enough acidity to irritate the esophagus.
Factors that can contribute to GERD:

Hiatus hernia, which increases the likelihood of GERD due to mechanical and motility factors

Obesity: increasing body mass index is associated with more severe GERD

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 GERD has been linked to laryngitis, chronic cough, pulmonary fibrosis, earache, and asthma, even when not clinically apparent, as well as to laryngopharyngeal reflux and ulcers of the vocal cords.
Factors that have been linked with GERD but not conclusively:

Obstructive sleep apnea

Gallstones which can impede the flow of bile into the Duodenum which can affect the ability to neutralize gastric acid

Treatment

Physicians recommend lifestyle modifications when not recommending drugs to treat GERD. A 2006 review suggested that evidence for most dietary interventions is anecdotal; only weight loss and elevating the head of the bed were supported by evidence. A subsequent randomized crossover study showed benefit by avoiding eating two hours before bed.

Foods

Certain foods and lifestyle are considered to promote gastroesophageal reflux:

Coffee, alcohol, and excessive amounts of Vitamin C supplements stimulate gastric acid secretion. Taking these before bedtime especially can cause evening reflux. (Although a study published in 2006 by Stanford University researchers indicates there's no published evidence of dietary changes benefiting those with GERD..

Foods high in fats and smoking reduce lower esophageal sphincter competence, so avoiding these tends to help. Fat also delays stomach emptying.

Eating within 2-3 hours before bedtime.

Large meals. Having more but smaller meals reduces GERD risk, as it means there's less food in the stomach at any one time.

Carbonated soft drinks with or without sugar.

Chocolate and peppermint.

Acidic foods, such as oranges and tomatoes.

Cruciferous vegetables: onions, cabbage, cauliflower, broccoli, spinach, brussels sprouts.

Milk and milk-based products containing calcium and fat, within 2 hours of bedtime.

Positional therapy

Sleeping on the left side has been shown to drastically reduce nighttime reflux episodes in patients..
Elevating the head of the bed is also effective. Additional conservative measures may be considered if there's incomplete relief. Another approach is to apply all conservative measures for maximum response. A meta-analysis suggested that elevating the head of bed is an effective therapy, although this conclusion was only supported by nonrandomized studies .

Gastric H₂ receptor blockers such as ranitidine or famotidine can reduce gastric secretion of acid. These drugs are technically antihistamines. They relieve complaints in about 50% of all GERD patients. Compared to placebo (which also is associated with symptom improvement), they've a number needed to treat of eight (8) .

Prokinetics strengthen the lower esophageal sphincter (LES) and speed up gastric emptying. Cisapride, a member of this class, was withdrawn from the market for causing Long QT syndrome.

Sucralfate (Carafate) is also useful as an adjunct in helping to heal and prevent esophageal damage caused by GERD, however it must be taken several times daily and at least two (2) hours apart from meals and medications.

Posture and GERD

In adults, a slouched posture is an important factor contributing to GERD. With a slouched posture there's no straight path between the stomach and esophagus; muscles around the esophagus go into a spasm. Gas and acidity get blocked in the spasm, causing coughing and other asthma-like symptoms. A meta-analysis suggested that elevating the head of the bed is an effective therapy, although this conclusion was only supported by nonrandomized studies.
An obsolete treatment is vagotomy ("highly selective vagotomy"), the surgical removal of vagus nerve branches that innervate the stomach lining. This treatment has been largely replaced by medication.

Other treatments

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.
Subsequently the NDO Surgical Plicator was cleared by the FDA for endoscopic GERD treatment. The Plicator creates a plication, or fold, of tissue near the gastroesophageal junction, and fixates the plication with a suture-based implant. The Plicator is currently marketed by NDO Surgical, Inc. (External Link

) Another treatment that involved injection of a solution during endoscopy into the lower esophageal wall was available for about 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.

Barrett's esophagus

GERD may lead to Barrett's esophagus, a type of metaplasia 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 drugs for chronic GERD.

Further Information

Get more info on 'Gastroesophageal Reflux'.

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