Gastroesophageal Reflux Disease

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Contents 1 More Specific Terms 2 Introduction 3 Etiology 4 Epidemiology 5 Pathology 6 Clinical-manifestations 7 Diagnostic-procedures 8 Radiology 9 Complications 10 Differential-diagnosis 11 Management 12 More General Terms 13 Additional Terms 14 References

More Specific Terms

• gastroesophageal reflux disease (GERD) in the elderly
• laryngoesophageal reflux (LPR)

Introduction

• Retrograde flow of stomach contents into the esophagus & possibly into the pharynx.

Etiology

• incompetent lower esophageal sphincter ( LES)

• transient relaxation of the LES (not associated with swallowing) is the most common cause of GERD
• foods & medications may diminish LES pressure (see LES)
• see lower esophageal sphincter

• delayed gastric emptying time may contribute
• impaired esophageal clearance may contribute
• diminished salivary production of bicarbonate [8]
• associated with hiatal hernia

• 80% of patients with GERD have hiatal hernia
• 50% of patients with hiatal hernia have GERD

Epidemiology

• most common cause of non- cardiac chest pain
• 10-20% of adults have weekly symptoms; 15-40% monthly symptoms
• more common in elderly than young

Pathology

• transient, inappropriate LES relaxation
• loss of crural diaphragm contribution to LES pressure
• refluxed pepsin, bile & acidity may play roles in esophageal injury
• diminished esophageal pH may induce bronchospasm

• microaspiration may also induce bronchospasm

• at any given level of acid exposure, reflux symptoms less severe in elderly [14]

Clinical-manifestations

• heartburn

• radiation towards mouth
• precipitated by meals or recumbent position

• sour taste
• regurgitation or vomiting
• early satiety
• belching
• bloating
• hoarseness [19]
• up to 1/3 of patients have extra- esophageal manifestations

• non- cardiac chest pain
• chronic cough
• laryngitis
• wheezing, asthma ( bronchospasm)

Diagnostic-procedures

• upper GI endoscopy

• indications:

• dysphagia, odynophagia, chest pain
• age > 50 years + > 5 years of GERD [19]

• evaluation of esophagitis, ulceration, stricture
• identification of Barrett's esophagus
• identification of adenocarcinoma

• Bernstein test
• 24 hour esophageal pH monitor ( ambulatory)

• definitive diagnostic test ( gold standard)
• correlates symptoms with pH above LES < 4
• GERD refractory to empiric proton pump inhibitor
• perform while patient is on proton pump inhibitor [19]

Radiology

• upper GI series - detection of ulcerations & strictures
• esophagram - to rule out cricopharyngeal spasm

Complications

• erosive esophagitis (50%) -> ulceration ( bleeding)
• esophageal stricture -> dysphagia (8-10%) [7]
• Barrett's esophagus (12-18%) [7]
• esophageal cancer
• laryngeal cancer* [8]
• pulmonary aspiration
• dental erosions
• supraventricular arrhythmias ? [11]
• complications more frequent in the elderly [8]
• nocturnal GERD may disturb sleep in the absence of heartburn [17]
• bronchospasm; exacerbation of asthma [18]

• * poor correlation between laryngeal lesions & reflux esophagitis on endoscopy [13]

Differential-diagnosis

• peptic ulcer disease
• ischemic heart disease

• GERD & coronary ischemia may coexist
• GERD may aggravate coronary ischemia

• medication-induced esophagitis
• scleroderma: refractory GERD, constipation, telangiectasias [19]

Management

• do not test; treat empirically [19]

• ref [19] suggests start with proton pump inhibitor

• phase 1

• dietary modifications

• lose weight if indicated
• decrease fat intake
• avoid high acidity foods

• citrus fruits, tomatoes, coffee,

• other foods to avoid

• onions, chocolate, peppermint

• avoid alcohol
• rapid eating promotes postprandial reflux [10]

• smoking cessation
• elevation of head of bed
• avoid late or large evening meals
• discontinue medications that decrease LES pressure

• theophylline, anticholinergics, nitrates, Ca+2 channel blockers, benzodiazepines, progesterone, alpha-blockers

• antacids

• phase 2

• H2-receptor antagonists

• cimetidine ( Tagamet) 400 mg BID or 800 mg QHS
• famotidine ( Pepcid) 20 mg BID or 40 mg QHS
• nizatidine ( Axid) 150 mg BID or 300 mg QHS
• ranitidine ( Zantac) 150 mg BID or 300 mg QHS

• prokinetic agents

• cisapride ( Propulsid) 10-20 mg QID (removed from US market 7/14/2000)
• metoclopramide ( Reglan) 10-20 mg QID

• uncertain benefit [19]

• phase 3

• proton pump inhibitors ( PPI)

• omeprazole ( Prilosec) 20-40 mg QD
• lansoprazole ( Prevacid) 15-30 mg QD
• addition of a QHS dose of H2-receptor antagonist to a proton pump inhibitor for breakthrough acid secretion at night [4]*
• response to proton pump inhibitors is NOT a good diagnostic test for GERD [9]
• addition of H2-receptor antagonist may be synergistic (see proton pump inhibitor)

• baclofen diminishes transient lower esophageal sphincter relaxation
• surgery: Nissen fundoplication [5]

• indications:

• good response to PPI [19]
• patient not interested in long-term medical therpy

• does not reduce risk of esophageal cancer [6]
• uncertain long-term benefit [19]

• LINX Reflux Management System
• esophagectomy

• high-grade dysplasia
• esophageal cancer

• patient education:

• GERD is an irreversible lifelong condition
• most patients 85-92% acheive 5 year remission with either proton pump inhibitor or surgery [20]

• follow-up evaluation for complications of GERD

• esophagitis
• stricture
• Barrett's esophagus

• * proton pump inhibitors work best by inhibiting acid secretion triggered by meals

More General Terms

• esophageal disease
• gastric disease
• reflux
• chronic gastrointestinal disease

Additional Terms

• ambulatory esophageal pH testing
• Barrett esophagus
• Bernstein test
• esophagitis

References

1. Saunders Manual of Medical Practice, Rakel (ed), WB Saunders, Philadelphia, 1996, pg 325-26
2. Manual of Medical Therapeutics, 28th ed, Ewald & McKenzie (eds), Little, Brown & Co, Boston, 1995, pg 339-340
3. Kaiser Permanente Clinical Practice Guidelines
4. Prescriber's Letter 14(3): 2007 What You Should Know About Proton Pump Inhibitors Detail-Document#: [1] (subscription needed) [2]
5. Journal Watch 21(13):103, 2001 Spechler et al JAMA 285:2331, 2001 Kabrilas JAMA 285:2376, 2001
6. Journal Watch 22(1):3, 2002 Ye et al Gastroenterology 121:1286, 2001
7. Geriatrics Review Syllabus, American Geriatrics Society, 5th edition, 2002-2004
8. Chait M, Clinical Geriatrics 12(4): 39, 2004
9. Journal Watch 24(10):79, 2004 Numans ME, Lau J, de Wit NJ, Bonis PA. Short-term treatment with proton-pump inhibitors as a test for gastroesophageal reflux disease: a meta-analysis of diagnostic test characteristics. Ann Intern Med. 2004 Apr 6;140(7):518-27. PMID: [3]
10. Journal Watch 24(21):161, 2004 Wildi SM, Tutuian R, Castell DO. The influence of rapid food intake on postprandial reflux: studies in healthy volunteers. Am J Gastroenterol. 2004 Sep;99(9):1645-51. PMID: [4]
11. Cuomo R, De Giorgi F, Adinolfi L, Sarnelli G, Loffredo F, Efficie E, Verde C, Savarese MF, Usai P, Budillon G. Oesophageal acid exposure and altered neurocardiac function in patients with GERD and idiopathic cardiac dysrhythmias. Aliment Pharmacol Ther. 2006 Jul 15;24(2):361-70. PMID: [5]
12. Omari TI et al, Effect of baclofen on esophagogastric motility and gastroesophageal reflux in children with gastroesophageal reflux disease. A randomized controlled trial. J Pediatr 2006, 149:468 PMID: [6]
    - Di Lorenzo C Gastroesophageal reflux. Not a time to relax. J Pediatr 2006, 149:436 PMID: [7]
13. Vavricka SR, Storck CA, Wildi SM, Tutuian R, Wiegand N, Rousson V, Fruehauf H, Mullhaupt B, Fried M. Limited diagnostic value of laryngopharyngeal lesions in patients with gastroesophageal reflux during routine upper gastrointestinal endoscopy. Am J Gastroenterol. 2007 Apr;102(4):716-22. PMID: [8]
    - Vaezi MF. Are there specific laryngeal signs for gastroesophageal reflux disease? Am J Gastroenterol. 2007 Apr;102(4):723-4. No abstract available. PMID: [9]
14. Lee J et al, Effects of age on the gastroesophageal junction, eosphageal motility, and reflux disease. Clin Gastroenterol Hepatol 2007, 5:1132 PMID: [10]
15. Prescriber's Letter 15(5): 2008 Treatment of Gastroesophageal Reflux in Children Detail-Document#: [11] (subscription needed) [12]
16. Prescriber's Letter 15(8): 2008 Treatment of Gastroesophageal Reflux in Infants Detail-Document#: [13] (subscription needed) [14]
17. Orr WC et al. Occurrence of nighttime gastroesophageal reflux in disturbed and normal sleepers. Clin Gastroenterol Hepatol 2008 Oct; 6:1099. PMID: [15]
18. Mastronarde JG et al, for the American Lung Association Asthma Clinical Research Centers Efficacy of esomeprazole for treatment of poorly controlled asthma. N Engl J Med 2009 Apr 9; 360:1487 PMID: [16]
19. Medical Knowledge Self Assessment Program (MKSAP) 14, 15, American College of Physicians, Philadelphia 2006, 2009
20. Galmiche JP et al Laparoscopic Antireflux Surgery vs Esomeprazole Treatment for Chronic GERD JAMA. 2011;305(19):1969-1977 <PubMed> PMID: [17] <Internet> [18]
21. Gastroesophageal Reflux/Hiatal Hernia: NIH Institute and Center Resources [19]
22. National Guideline Clearinghouse VHA/DoD clinical practice guideline for the management of adults with gastroesophageal reflux disease in primary care practice. ngc-guideline: [20]
    - Initial management of dyspepsia and GERD (Institute for Clinical Systems Improvement) ngc-guideline: [21]
    - Gastroesophageal reflux disease (GERD). University of Michigan Health System ngc-guideline: [22]
    - American Gastroenterological Association medical position statement on the management of gastroesophageal reflux disease. ngc-guideline: [23]
    - Guidelines for surgical treatment of gastroesophageal reflux disease. Society of American Gastrointestinal and Endoscopic Surgeons (SAGES). ngc-guideline: [24]
    - Pediatric gastroesophageal reflux clinical practice guidelines: joint recommendations of the North American Society for Pediatric Gastroenterology, Hepatology, and Nutrition (NASPGHAN) and the European Society for Pediatric Gastroenterology, Hepatology, and Nutrition (ESPGHAN). ngc-guideline: [25]
    - National Guideline Clearinghouse Guideline syntheses Diagnosis and Treatment of Gastroesophageal Reflux Disease (GERD) ngc-guideline-synthesis: 16427

gastroesophageal reflux disease (GERD)