Gastroesophageal Reflux Disease (GERD): Causes, Symptoms & Treatment

Gastroesophageal Reflux Disease (GERD): Causes, Symptoms & Treatment

Question. Write a short note on gastroesophageal reflux disease.

Answer. A chronic condition in which the lower esophageal sphincter allows gastric acids to reflux into the esophagus, causing heartburn, acid indigestion, and possible injury to the esophageal lining.

Mechanism

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Etiology of gastroesophageal reflux disease

• Relaxed or hypotonic sphincter: It is due to diabetes mellitus, hiatus hernia, and fatty meal.
• Decreased lower esophageal sphincter pressure: This is due to prolonged gastric tube intubation, scleroderma, and the use of certain drugs such as calcium channel blockers, and nitrates.
• Raised intra-abdominal pressure: It is due to ascites, obesity, and pregnancy.
• Impaired esophageal mucosal function: It is due to the usage of alcohol and smoking.
• Delayed gastric emptying: This is due to pyloric obstruction, fatty foods, and gastroparesis.
• Increased gastric contents: It is due to large meals and Zollinger­Ellison syndrome.
• Sliding hiatus hernia: Where the esophagogastric junction slides up through the diaphragm resulting in:

• • Loss of the obliquity of entry of the esophagus into the stomach.
  • Loss of the reinforcing effect of intra­abdominal pressure on the lower oesophageal sphincter.

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These two above-mentioned factors of hiatus hernia facilitate gastroesophageal reflux but do not directly cause it.

• Cardiomyotomy and vagotomy: They decrease the efficiency of the lower esophageal sphincter.
  Increased intra-abdominal pressure: Pregnancy, obesity, ascites, weight­lifting, and straining increase intra-abdominal pressure.
• Reduced tone of lower esophageal sphincter: Cigarette smoking, alcohol, fatty foods, and caffeine act by reducing the lower oesophageal sphincter tone.
• Impaired gastric emptying: Impaired gastric emptying due to obstruction of gastric outlet or use of anticholinergic drugs, fatty foods, and large-volume meals acts by increasing the gastric content available for reflux.
• Systemic sclerosis.
• Drugs that reduce the lower esophageal sphincter tone, e.g. aminophylline, beta­agonists, nitrates, calcium channel blockers, etc.

Clinical Features of gastroesophageal reflux

• Typical symptoms: Heartburn and acid regurgitation
• Atypical symptoms: Dysphagia, Globus sensation, noncardiac chest pain, dyspepsia, or abdominal pain.
• Extra-esophageal symptoms: Hoarseness, sore throat, sinusitis, otitis media, chronic cough, laryngitis, dental erosion, and recurrent aspiration.
• Malignancy: Head and neck cancer, esophageal adenocarcinoma

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Complications of gastroesophageal reflex

• Esophagitis
• Esophageal strictures
• Esophageal ulcers
• Aspiration pneumonia
• Iron deficiency anemia
• Barretts esophagus
• Carcinoma of esophagus

Investigations of gastroesophageal reflex

• Endoscopy: Enables visualization of esophagitis, strictures, and Barrett’s mucosa which all can be confirmed by biopsy.
• Barium meal can reveal a hiatus hernia.
• Bernstein test is done in patients with high clinical suspicion but with negative endoscopy.
• Resting ECG and stress ECG to rule out ischemic heart disease.
• Esophageal motility studies.

Management of gastroesophageal reflux 

1. Conservative measures:

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• Abstain from eating within 2 hrs of bedtime
• Elevate the head of the bed by 6 inches
• Sleep in the left lateral decubitus position
• Avoid: Caffeine, nicotine, alcohol, chocolate, mints, carbonated beverages, high­fat foods, tomato or citrus-based products
• Avoid if possible medications that can worsen GERD anti­cholinergic, theophylline, prostaglandin, calcium channel blockers, alendronate
• Weight loss if obese
• Rabeprazole and esomeprazole provide superior gastric acid suppression.

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2. Medical treatment of  gastroesophageal reflux

• In mild cases liquid antacid is used, i.e. 10 to 15 mL, one to three hours after the meal which provides relief from heartburn.
• In moderate cases, H 2 receptor antagonist, i.e. ranitidine 150 mg BD or QID with meals and before bedtime for 6 weeks.
• In severe cases, proton pump inhibitors are given, i.e. omeprazole 20 to 40 mg/day, pantoprazole 40mg/day, and rabeprazole 10 to 20 mg/day is given.
  These should be given for 6 to 8 weeks.
  For maintenance therapy treatment should be given for 6 to 8 months.
• Metoclopramide or domperidone 10 mg TID increases lower esophageal sphincter tone and promotes gastric emptying.
• Repeated dilatations are used to treat esophageal strictures.
• In anemics oral iron or blood transfusion is given.

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3. Surgical treatment of gastroesophageal reflux

• Surgical resection of strictures should be carried out.
• Surgical return of lower esophageal sphincter to the abdomen in a patient with sliding hiatus hernia, construction of an additional valve mechanism is done.