Gastroesophageal Reflux Disease


Article Author:
Catiele Antunes


Article Editor:
Sean Curtis


Editors In Chief:
James Beauchamp
Mark Pellegrini
Nicole Hale-Crutch


Managing Editors:
Orawan Chaigasame
Carrie Smith
Abdul Waheed
Frank Smeeks
Kristina Soman-Faulkner
Benjamin Eovaldi
Radia Jamil
Sobhan Daneshfar
Pritesh Sheth
Hassam Zulfiqar
Steve Bhimji
John Shell
Matthew Varacallo
Ahmad Malik
Mark Pellegrini
James Hughes
Beata Beatty
Richard Ciresi
Hajira Basit
Phillip Hynes
Kavin Sugumar


Updated:
5/5/2019 10:04:55 PM

Introduction

Gastroesophageal reflux disease (GERD) is a condition that develops when there is a retrograde flow of stomach contents causing symptoms or complications. GERD can present as Non-erosive reflux disease (NERD) when typical symptoms of GERD occur in the absence of visible mucosal injury during endoscopy, or as erosive esophagitis (EE) when patients have histopathological changes in esophageal mucosa. The latter is also called reflux esophagitis.

The typical symptom is heartburn. This most often occurs 30 min to 60 min after meals and upon reclining. Patients often report relief from antacids or baking soda. When patients present with this description of symptoms, the diagnosis can be established with a high degree of confidence.

Epidemiology

GERD is extremely common, with a prevalence of approximately 20% of adults in the western culture. Most adults with GERD have mild disease, but esophageal mucosa damage (reflux esophagitis) can develop in up to a third of the patients. Symptoms occur daily in approximately 7% of patients, weekly in 14% and monthly in 15% to 40% of all patients.

There is no significant difference in prevalence among males and females, but males seem to have a higher rate of complications. The rate of esophagitis is 2:1 and the rate of Barrett's is 0:1 in males compared to females.

GERD incidence increases with age, particularly after age 40.

Obesity also seems to increase the risk of GERD. A meta-analysis published in the Annals of Internal Medicine in 2005 concluded that obesity was associated with a statistically significant increase in the risk of GERD symptoms, erosive esophagitis, and esophageal carcinoma. The ProGERD study published in 2005 evaluated the predictive factors for erosive reflux disease in more than six thousand patients with reflux disease. They found the odds ratio for erosive disease increased with the body mass index (BMI), with patients with a BMI greater than 30 Kg/m2 to 40 Kg/m2 having an odds ratio of 1.97 (95% confidence level 1.32 to 2.92).

Pathophysiology

There are few components of the pathophysiology of GERD.

  1. Impaired Lower Esophageal Sphincter (LES) Function: the LES functions as an anti-reflux barrier at the gastroesophageal junction, preventing acid from the stomach from entering the esophagus. In healthy individuals, a certain amount of physiologic gastroesophageal reflux occurs by means of transient relaxation of the LES, which increases after a meal to permit gas to be vented from the stomach. In patients with GERD, there may be an increased transient relaxation of the LES associated with a reduction in the pressures of the sphincter. The mechanisms of increased transient relaxation are unknown. However, there are several known risk factors for decreased LES pressures: pregnancy, diabetes, scleroderma, obesity, and medications such as calcium channel blockers, cholinergic antagonists, glucagon, nicotine from cigarette smoking and oral contraceptives.
  2. A hiatal hernia: hiatal hernias are common and usually do not cause symptoms. In patients with GERD, however, they are associated with higher amounts of acid reflux and delayed esophageal acid clearance. Large hiatal hernias seem to contribute to decreasing LES tone. Hiatal hernias are found in a fourth of patients with non-erosive GERD, in three-fourths of patients with erosive GERD, and in over 90% of patients with Barrett Disease.
  3. Irritant effects of Refluxate: the gastric acid fluid (pH less than 4) is extremely caustic. Prolonged contact of gastric contents with esophageal mucosa leads to damage (esophagitis). In some patients, reflux of bile or alkaline pancreatic secretions can also lead to damage.
  4. Abnormal esophageal clearance: the acid that reaches the esophagus is normally cleared and neutralized by esophageal peristalsis and salivary bicarbonate. During sleep, peristalsis is infrequent, prolonging acid exposure to the esophageal mucosa. Alcohol and sedatives also seem to decrease peristalsis. Researchers estimate that 50% of patients with GERD have some degree of decrease peristalsis. Also, conditions such as Sjogrën disease that affect the quality or quantity of the saliva, anticholinergic medications, and oral radiation can further worsen the natural protective mechanisms and lead to higher exposure of the esophageal mucosa to damage.

History and Physical

The typical manifestation of GERD is heartburn, regurgitation, and dysphagia. Other symptoms include a globus (lump in the throat) sensation, odynophagia, and nausea. Heartburn is defined as a retrosternal burning discomfort, located in the epigastric area that may radiate up towards and neck and typically occurs in the postprandial period. Patients often report that postural changes, such as bending forward, can worsen the symptoms. Symptoms are usually also aggravated by ingestion of certain foods or beverages such as tomato sauce, chocolate, coffee, teas, and alcohol.

Atypical presentation refers to symptoms that are extraesophageal, including pulmonary, ear, nose and throat manifestations, as well as non-cardiac chest pain.

Evaluation

Initial diagnostic tests are not warranted for patients with typical GERD symptoms. Practitioners should further investigate patients with "alarm features" such as troublesome dysphagia, odynophagia, weight loss, iron deficiency anemia, and in patients with troublesome symptoms that persist despite appropriate empiric proton pump inhibitor therapy. It must be remembered that diabetic patients may present with dyspeptic symptoms during a myocardial infarction. Thus, a high index of suspicion should be maintained in these patients in the acute setting.

Radiographic studies are of limited use in the management of GERD due to poor sensitivity in milder forms of GERD, but they can detect moderate to severe esophagitis, strictures, hiatal hernia, and tumors. The studies most commonly used are the barium swallow, which only examines the esophagus, and the upper gastrointestinal series, which examines the esophagus, stomach, and small intestines.

In addition to excluding the presence of other diseases such as tumors and peptic ulcers, an upper endoscopy can detect and grade the severity of GERD-induced esophagitis. Upper endoscopy is highly specific for GERD (90% to 95%) but has a limited sensitivity (approximately 50%). The Los Angeles (LA) Classification grades reflux esophagitis on a scale of A (one or more isolated mucosal breaks less than 5 mm that do not extend between the tops of two mucosal folds) to D (one or more mucosal breaks that involve at least 75% of the esophageal circumference).

Esophageal pH or combined esophageal impedance testing is usually unnecessary in most patients but may be indicated in patients who have atypical or extraesophageal symptoms or who are being considered for antireflux surgery. Impedance testing detects changes in the resistance of electrical current on a catheter placed within the esophagus. In addition to recording the esophageal pH, it can differentiate both antegrade and retrograde transit of liquid and gas. The test is helpful in patients who have suspected GERD but negative pH tests. Doctors only recommend this test after standard testing has failed to demonstrate significant GERD in patients with typical or atypical symptoms and patients with refractory GERD. 

Treatment / Management

The goals of treating GERD are to resolve symptoms, heal esophagitis, and prevent complications. Treatment options include lifestyle modifications, medical management with antacids and antisecretory agents, and mechanical therapies.

  • Lifestyle modifications are a cornerstone in the treatment of GERD. Medical practitioners should provide counseling about weight loss, head elevation, tobacco and alcohol cessation, avoidance of late meals, and cessation of foods that can potentially aggravate symptoms.
  • Medical treatments include antacid and antisecretory agents. Antacids are inexpensive, readily available, and effective. Histamine-2 (H2)-receptor antagonists, inhibit the secretion of gastric acid by competitively blocking the H2-receptors located in the gastric parietal cells. H2-blockers have an excellent safety profile and are available over the counter. These drugs are approximately 75% effective in patients with mild to moderate degrees of esophagitis. Proton pump inhibitors (PPIs) act by blocking the hydrogen-potassium ATPase on the apical surface of the parietal cells. PPIs are more effective than H2-blockers because they act on the common pathway of acid secretion. Practitioners use these as initial therapy in patients with moderate to severe GERD and patients with complications of GERD. These complications include bleeding and strictures. Studies comparing H2-blockers and PPIs have demonstrated that the latter has superior healing rates and decreased relapse rates.
  • Antireflux procedures include laparoscopic fundoplication and bariatric surgery in obese patients. Fundoplication offers excellent relief of symptoms and healing of esophagitis in over 85% of properly selected patients. Outcomes in patients who have extraesophageal symptoms and have had fundoplication surgery have been less encouraging.

Pearls and Other Issues

Barrett's esophagus is the only complication of GERD with malignant potential. Patients are typically middle-aged white males. In patient's with Barrett's esophagus, surveillance for dysplasia is warranted.

Enhancing Healthcare Team Outcomes

GERD is usually managed by the primary care provider, nurse practitioner, internist, and the gastroenterologist. While the treatment is simple, these patients need long term follow up. For those who comply with medications, symptom relief is immediate.

However, the key to prevention is educating the patient on making changes in lifestyle. Lifestyle modifications are a cornerstone in the treatment of GERD. Medical practitioners should provide counseling about weight loss, head elevation, tobacco and alcohol cessation, avoidance of late meals, and cessation of foods that can potentially aggravate symptoms.

Unfortunately, compliance with lifestyle changes are poor and most patients continue to have recurrent symptoms. Some patients may develop Barrett's esophagus and require further endoscopic workup and laparoscopic surgery. [1][2][3][1]


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Gastroesophageal Reflux Disease - Questions

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Which of the following lifestyle modifications has had the most significant benefit on gastroesophageal reflux disease?



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A female presents with complaints of chest pain. She has been experiencing this "burning" in the mid sternum for the past few weeks. The pain occurs in the evening. It usually lasts 15-20 minutes and makes her nauseated. Which test is used to confirm the diagnosis?



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For a shortened esophagus, what is the procedure of choice?



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An 11-month-old has symptoms of reflux. What findings on biopsy would confirm the diagnosis?



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A patient has severe gastroesophageal reflux disease. He receives a prescription for ranitidine. What will be the action of this drug?



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Which of the following lifestyle modifications offers the strongest supporting data for improvement of gastroesophageal reflux disease?



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Which of the following is the best test to investigate gastroesophageal reflux disease (GERD)?



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Which of the following is an acceptable treatment option for patients suspected to have symptoms due to acid reflux into the supraesophageal structures?



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Biopsy is performed of the lower esophagus in a patient with reflux. Which of the following will most likely be seen in a stained specimen?



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What is the most common gastrointestinal (GI) disorder in pediatric patients?



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What is the best test to make a diagnosis of gastroesophageal reflux (GERD)?



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Which of the following foods can decrease the lower esophageal sphincter pressure in gastroesophageal reflux disease?



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A 36-year-old female with no significant medical history presents complaining of a 2-month history of chest discomfort she describes as substernal, worsened by meals, and sometimes nocturnal but denies weight loss or odynophagia and is found to have a normal physical exam. What should be the initial treatment?



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When doing a manometric procedure for gastroesophageal reflux, where should the pH electrode be placed?



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A 50-year-old patient presents with a 10 year history of gastroesophageal reflux disease (GERD) partially controlled by omeprazole. Which of the following is the next best management decision?



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A 38-year-old female with no significant medical history presents with three months of chest discomfort which she describes as substernal, worsened by meals, and sometimes nocturnal. She denies weight loss or odynophagia and has a normal physical exam. What is the next best step?



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A young infant is diagnosed with gastroesophageal reflux disease (GERD). Which of the following is the best recommendation?



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Which of the following is the most common noncardiac cause of chest pain?



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Which of the following is the best approach for uncomplicated gastroesophageal reflux in an infant?



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Which of the following is the most common cause of gastroesophageal reflux disease (GERD) in infants?



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What is the best feeding position in a child with gastroesophageal reflux disease (GERD)?



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Gastroesophageal reflux disease (GERD) is suspected in a patient complaining of heartburn, a dry cough, and belching. The patient denies dysphagia, weight loss, and dark stools. What is the appropriate next step?



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Which condition is a common cause of a persistent cough in vaccinated nonsmokers that is resistant to treatment with antibiotics and bronchodilators. Also, it is worsened by the recumbent position, alcohol, and caffeine?



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An infant presents with uncomplicated gastroesophageal reflux (GERD). Which of the following would be most appropriate?



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What is the most common symptom in infants of gastroesophageal reflux disease (GERD)?



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What is the most common diagnosis of non bilious vomiting in a healthy infant?



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Which of the following is the initial best method of diagnosing pediatric gastroesophageal reflux?



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A 45-year-old man presents to the clinic with mid-epigastric pain that is exacerbated by spicy food. He is diagnosed with gastroesophageal reflux disease (GERD). What substance is causing his symptoms?



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Which of the following is implicated in the pathogenesis of gastroesophageal reflux disease?



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What is a lifestyle modification utilized in the treatment of gastroesophageal reflux disease?



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A patient has developed gastroesophageal reflux disease (GERD) secondary to daily strenuous swimming. When lying down to sleep, which position would minimize reflux?



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In a vomiting neonate, which statement is true?



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A 14-month-old toddler is brought in with persistent spitting up after meals for most of his life. He is at the 75th percentile for weight and has no respiratory symptoms. The exam is normal. Select the most probable diagnosis.



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A 6-month-old male regurgitates most of each feeding. pH monitoring shows low readings over extended periods. The infant is at the 50th percentile for height and weight. There is no other medical history or findings. Select the most appropriate management.



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A 32-year-old male complains of an 18-month history of chest pain. The discomfort is intermittent with tightness and mild shortness of breath. It does not radiate. It initially would occur at night but now occurs during the day. It rarely is associated with activity. There is rare heartburn that responds to antacids or H2 blockers. He denies hematemesis, dysphagia, hematochezia, or melena. The patient does not drink alcohol, smoke, or have a family history of heart disease. The physical exam is normal. An ECG and a routine stress test are normal. Select the appropriate next step.



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A patient complains of intermittent heartburn, mostly at night following a large meal. Select the true statement.



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A 4-year-old child with cerebral palsy and cognitive development of a 9-month-old is brought in with a fever and a cough. According to the parents, she drools all the time, has chronic hoarseness, and has had three episodes of pneumonia. The child recovers after treatment of radiographically proven pneumonia. What test should be done?



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Which phases of food are used to perform an esophageal reflux study using a nuclear scan?



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A patient notes "heartburn", especially when lying down. What is is the most likely cause?



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A 17-year-old female presents complaining of burning epigastric pain after meals. She states that there is a sour taste in her mouth. She denies a history of smoking, NSAID use, or being awakened at night by her pain. Antacids help minimally. What is the most likely diagnosis?



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A 6-month-old previously healthy female is being evaluated. The mother describes an episode where she put the infant to bed following being breastfed. She went to check on the infant about an hour later to find the infant arching her back while making choking sounds. The infant appeared to conscious, but the episode did not resolve until she had violent spit up and started to cry. The patient was consolable. She is afebrile, 95% percentile for weight and developmentally appropriate. What treatment is most appropriate?



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A registered nurse is providing discharge teaching to a patient with a diagnosis of gastroesophageal reflux disease (GERD). The client asks the nurse about diet and lifestyle modifications that are suggested to decrease the chance of reoccurrence of symptoms. How should the nurse respond to the query? Select all that apply.



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In a client with gastroesophageal reflux disease (GERD), which of the following are appropriate recommendations? Select all that apply.



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A 57-year-old obese male comes to the emergency department with a complaint of acute chest pain. He describes the pain as a 7/10 substernal, burning sensation that does not radiate anywhere. He states he often gets this pain at night, and that he’s tried taking ibuprofen which has never helped. He has a history significant for hypertension. Vitals: BP 145/94 mmHg, T 98.7 F, RR 20/min, HR 76 bpm, and SpO2 98% on room air. On physical exam, there is a soft systolic murmur at the left sternal border. Lungs are clear to auscultation bilaterally. EKG shows evidence of left ventricular hypertrophy. CBC and basic metabolic profile are within normal limits. CK(MB) and troponin are negative on three successive draws. What is a likely mechanism behind this man’s presentation?



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Gastroesophageal Reflux Disease - References

References

Miwa H,Igarashi A,Teng L,Uda A,Deguchi H,Tango T, Systematic review with network meta-analysis: indirect comparison of the efficacy of vonoprazan and proton-pump inhibitors for maintenance treatment of gastroesophageal reflux disease. Journal of gastroenterology. 2019 Mar 27;     [PubMed]
Park A,Weltz AS,Sanford Z,Addo A,Zahiri HR, Laparoscopic antireflux surgery (LARS) is highly effective in the treatment of select patients with chronic cough. Surgery. 2019 Apr 4;     [PubMed]
GASTROESOPHAGEAL REFLUX DISEASE. Gastroenterology nursing : the official journal of the Society of Gastroenterology Nurses and Associates. 2019 Mar/Apr;     [PubMed]

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