Gastroesophageal Reflux Disease

Commonly known as heartburn, gastroesophageal reflux disease (GERD) is the backflow of gastric or duodenal contents, or both, into the esophagus and past the lower esophageal sphincter (LES), without associated belching or vomiting. Reflux may cause symptoms or pathologic changes. Persistent reflux can cause reflux esophagitis, an inflammation of the esophageal mucosa. The prognosis varies with the underlying cause.

Causes

The esophagus is the passageway ("food pipe") that carries swallowed food to the stomach. GERD occurs when the muscular valve between the esophagus and the stomach does not function properly, causing acid to back up into the esophagus. The acid can then cause inflammation of the esophagus. GERD can cause: internal bleeding, esophageal ulcers .

Signs and Symptoms

• Heartburn
• Belching
• Regurgitation of food
• Nausea and vomiting
• Vomiting blood
• Hoarseness or change in voice
• Sore throat
• Difficulty swallowing
• Cough or wheezing

Diagnostic tests

A careful history and physical examination are essential to the diagnosis. Several tests help to confirm it:

• The esophageal acidity test, a standard test for acid reflux, is the most sensitive and accurate measure of gastroesophageal reflux. Gastroesophageal scintillation testing may also detect reflux.
• Esophageal manometry is used to evaluate the resting pressure of the LES and determine sphincter competence.
• An acid perfusion test confirms esophagitis.
• Esophagoscopy and biopsy allow visualization and tissue sampling of the esophagus. These tests are used to evaluate the extent of the disease and confirm pathologic changes in the mucosa.
• Barium swallow with fluoroscopy reveals normal findings except in patients with advanced disease. In children, barium esophagography under fluoroscopic control may show reflux.

Treatment

Effective management relieves symptoms by reducing reflux through gravity, strengthening the LES with drug therapy, neutralizing gastric contents, and reducing intra-abdominal pressure. Treatment should also include reviewing how the patient's lifestyle or dietary habits may affect his LES pressure and reflux symptoms.

In mild cases, diet therapy may reduce symptoms sufficiently so that no other treatment is required. Positional therapy, which relieves symptoms by reducing intra-abdominal pressure, is especially useful in infants and children with uncomplicated cases.

For intermittent reflux, antacids given 1 hour before and 3 hours after meals and at bedtime may be effective. Drug therapy may also include cholinergic drugs, such as bethanechol, to increase LES pressure, and histamine-2 receptor antagonists, such as famotidine and ranitidine, to reduce gastric acidity. A 4 week course of lansoprazole is useful in acute cases. Metoclopramide and sucralfate have also been used with beneficial results.

Surgery is usually reserved for patients with refractory symptoms or serious complications. Indications for surgery include pulmonary aspiration, hemorrhage, esophageal obstruction or perforation, intractable pain, incompetent LES, or associated hiatal hernia. Surgical procedures reduce reflux by creating an artificial closure at the gastroesophageal junction. Several surgical approaches involve wrapping the gastric fundus around the esophagus. Other surgical procedures include a vagotomy or pyloroplasty (which may be combined with an antireflux regimen) to modify gastric contents.

Prevention

Avoid foods and activities that worsen symptoms. Maintain a healthy weight.

• Sit up for 2-3 hours after eating.
• Avoid wearing clothing or belts that are too tight.
• Do not smoke.
• Avoid drinking beverages that contain alcohol or caffeine.
• Modify diet to avoid foods that increase heartburn.