GASTROESOPHAGEAL REFLUX DISEASE (GERD)

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Gastroesophageal reflux disease is a clinical scenario where the gastric or duodenal contents reflux back up into the esophagus. Reflux esophagitis, however, is a painful syndrome caused by the irritation or erosions of the lining of the esophagus caused by these irritants. Reflux disease is a very common phenomenon in the United States and may present in many different forms. It may be physiologic, a normal occurrence, or pathologic, causing clinical problems. There are many causes of gastroesophageal reflux disease but a hiatal hernia and lower esophageal sphincter dysfunction are the two most common causes.

Gastroesophageal reflux disease was thought to be caused by a hiatal hernia, a sliding of the stomach into the esophagus through the diaphragm, but recent studies indicate that it is more of a dysfunction of the lower esophageal sphincter (physiologic valve between the esophagus and the stomach). The lower esophageal sphincter generally has a high pressure and is closed, preventing regurgitation of the stomach contents; but in certain reflux scenarios, the pressure is reduced or the valve functions are abnormal allowing gastric or duodenal contents to reflux back into the esophagus.

Gastroesophageal reflux disease can have many symptoms. Heartburn is a classic symptom but associated symptoms include trouble swallowing, painful swallowing, regurgitation, water-brash breath, and belching. Classic heartburn is usually described as a burning behind the chest bone but may radiate into the chest and can occasionally be made worse by the ingestion of certain foods.

People with gastroesophaqeal reflux disease may or may not have esophagitis. Although heartburn is a classic presentation of reflux esophaqitis, there are many other clinical scenarios associated with gastroesophageal reflux disease. These include noncardiac chest pain, chronic hoarseness, chronic cough or sore throat, and laryngitis. Also certain pulmonary conditions such as asthma, recurrent bronchitis, bronchiectasis, aspiration pneumonia, and pulmonary fibrosis are thought possibly to be caused by reflux disease. Some patient's with gastroesophaqeal reflux disease may have no symptoms at all.

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Long-standing gastroesophageal reflux disease can either have a very benign clinical outcome or can be more serious in certain persons. There is an association with esophageal ulcer and bleeding, peptic esophageal strictures, and Barrett's esophagitis. Gastroesophageal reflux disease is not thought to lead to cancer; but in a small population, 10 percent to 15 percent, there is an association of Barrett's epithelium with gastroesophageal reflux disease. It is thought that Barrett's disease is a precursor to the cancer and surveillance is done in this population of patient's to look for these dysplastic changes.

Diagnosis of gastroesophageal reflux disease can be made by a number of different clinical tests. The most common one is the history. The patient will have classic symptoms of reflux disease and will often respond to lifestyle modifications and/or to medications, resolving their symptoms. An x-ray of the esophagus called a barium esophagram will show the ulcerative changes in people who have rather significant esophagitis but this test is not good for milder degrees of inflammation or for a diagnosis of Barrett's esophagitis. Upper gastrointestinal endoscopy, a test where a patient swallows a tube with a light on it, is very sensitive and specific for the diagnosis of esophagitis and for evaluating the Barrett's cell changes. Twenty-four hour pH monitoring is also helpful, particularly in atypical presentations of reflux disease involving the nose, throat, larynx, and lungs.

Once gastroesophageal reflux disease has been diagnosed, treatment is very straightforward and is successful most of the time.

Lifestyle modifications are probably the cornerstone of treatment. certain activities, maneuvers, foods, and drugs tend to reduce the lower esophageal sphincter to promote reflux disease. Usually adjustment of diet and activities will improve the esophageal acid clearance time and increase the lower esophageal sphincter tone.

Recommendations include the following:

1.Elevate the head of the bed six to eight inches on bed blocks or bricks to improve esophageal clearance

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2. Avoid eating a meal within two hours of reclining. 3. Avoid large volumes of food at a single time, particularly those high in fat.

4. Avoid coffee, tea, alcohol, tobacco, chocolates, and peppermint

5. Avoid foods with garlic and onion.

6. Be aware that certain medications facilitate reflux. These include theophylline derivatives, progesterone, anti-depressants, nitrates, calcium channel blockers, slow release potassium combinations, nonsteriodal anti-flammatory compounds, and tetracycline derivative

drugs.

Once lifestyle modifications have been tried and failed, then one goes to pharmacologic therapy. The first step is the use of antacids. It is best to take antacids one hour and three hours after a meal and at bedtime.

H2 antagonist drugs are the next drugs of choice for treatment of gastroesophageal reflux disease. These are drugs such as Tagamet, Axid, Pepcid and Zantac.

When these fail, proton pump inhibitor drugs are used such as Prilosec, Prevacid, Aciphex, and Protonix. The advantage of these is that they can be given as a single daily dose and often are very effective. They can be used as a first-line drug, not only as a treatment but as a diagnosis, particularly in people with low risk of complications. All of the above are safe for long-term use.

When lifestyle modifications and drug therapy have failed, the only other choice is surgery. A Nissen fundoplication is a surgical procedure where the lower esophageal sphincter tone is corrected by making a wraparound valve. This prevents reflux from occurring. It is now most commonly done using a laparoscope which improves the perioperative morbility.

Gastroesophageal reflux disease is a very common disease and often thought by many to be just a normal situation for them. However, there are certain warning signs that would

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should be evaluated very aggressively to make sure they have reflux disease improvement. Also, it is very important to be aware of the associated Barrett’s disease with adenocarcinoma of the esophagus and a search should be done at some point in a patient with gastroesophageal reflux disease whether or not there is Barrett’s epithelium present and arrange appropriate surveillance.

Otherwise, with lifestyle modifications, drugs and surgical procedures which are currently available, gastroesophageal reflux disease can be controlled, improving one's quality of life.

J. V. Jones, Jr., M.D., practices Internal Medicine at the Green Clinic in Ruston, Louisiana. He has an avid interest in gastroesophageal reflux disease and has participated in many national studies.

He is a member of the American College of Physicians and the American College of Gastroenterology.

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