Gastroesophageal reflux disease

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Gastroesophageal Reflux Disease (GERD; or GORD when spelling œsophageal, the BrE form) is defined as chronic symptoms or mucosal damage produced by the abnormal reflux of gastric contents into the esophagus^[1].

This is commonly due to transient or permanent changes in the barrier between the esophagus and the stomach. This can be due to incompetence of the lower esophageal sphincter (LES), transient LES relaxation, impaired expulsion of gastric reflux from the esophagus, or association with a hiatal hernia.

[edit] Symptoms

[edit] Adults

Heartburn is the major symptom of acid in the esophagus, characterized by a burning discomfort behind the breastbone (sternum). Findings in GERD include esophagitis (reflux esophagitis) — inflammatory changes in the esophageal lining (mucosa) — strictures, difficulty swallowing (dysphagia), and chronic chest pain. Patients may have only one of those findings. Typical symptoms of GERD include cough, hoarseness, changes of the voice, chronic ear ache, acute sharp chest pains, nausea or sinusitis. Complicatons of GERD include stricture formation, Barrett's esophagus, esophageal ulcers and possibly even lead to esophageal cancer, especially in adults over 60 years old.

Occasional heartburn is common but does not necessarily mean one has GERD. Patients that have heartburn symptoms more than once a week are at risk of developing GERD. A hiatal hernia is usually asymptomatic, but the presence of a hiatal hernia is a risk factor for development of GERD.

[edit] Children

GERD may be difficult to detect in infants and children. Symptoms may vary from typical adult symptoms. GERD in children may cause repeated vomiting, effortless spitting up, coughing, and other respiratory problems. Inconsolable crying, failure to gain adequate weight, refusing food and bad breath and belching or burping are also common. Children may have one symptom or many — no single symptom is universally present in all children with GERD.

It is estimated that of the approximately 8 million babies born in the U.S. each year, upwards of 35% of them may have difficulties with reflux in the first few months of their life. A majority of those children will outgrow their reflux by their first birthday, however, a small but significant number of them will not outgrow the condition.

Babies' immature digestive systems are usually the cause, and most infants stop having acid reflux by the time they reach their first birthday. Some children do not outgrow acid reflux, however, and continue to have it into their teen years. Children that have had heartburn that does not seem to go away, or any other symptoms of GERD for a while, should talk to their parents and visit their doctor.

[edit] Diagnosis

Endoscopic image of peptic stricture, or narrowing of the esophagus near the junction with the stomach. This is a complication of chronic gastroesophageal reflux disease, and can be a cause of dysphagia, or difficulty swallowing

A detailed history taking is vital to the diagnosis. Useful investigations may include barium swallow X-rays, esophageal manometry, 24 hour esophageal pH monitoring and Esophagogastroduodenoscopy (EGD). In general, an EGD is done when the patient does not respond well to treatment, or has alarm symptoms including: dysphagia, anemia, blood in the stool (detected chemically), wheezing, weight loss, or changes in the voice. Some physicians advocate once-in-a-lifetime endoscopy for patients with longstanding GERD, to evaluate for the presence of Barrett's esophagus, a precursor lesion for esophageal adenocarcinoma.

Esophagogastroduodenoscopy (EGD) (a form of endoscopy) involves the insertion of a thin scope through the mouth and throat into the esophagus and stomach (often while the patient is sedated) in order to assess the internal surface of the esophagus, stomach and duodenum.

Biopsies can be performed during gastroscopy and these may show:

• Edema and basal hyperplasia (non-specific inflammatory changes)
• Lymphocytic inflammation (non-specific)
• Neutrophilic inflammation (usually due to reflux or Helicobacter gastritis)
• Eosinophilic inflammation (usually due to reflux)
• Goblet cell intestinal metaplasia or Barretts esophagus.
• Elongation of the papillae
• Thinning of the squamous cell layer
• Dysplasia or pre-cancer.
• Carcinoma.

[edit] Pathophysiology

GERD is caused by a failure of the Anti-Reflux Barrier (ARB) and its primary component, the GastroEsophageal valve (GEV). The understanding of the GEV has continued to progress in recent years, and more focus is currently being placed on the GEV, rather than the Lower Esophageal Sphincter (LES) as the largest contributor to the ARB. Researchers have demonstrated the robust nature of the GEV and have shown that the intact GEV alone is highly competent to stop reflux. For example, in cadavers, where no muscle tone or LES pressure is present, the stomach ruptured when filled with water before reflux would occur. This displays the power of the GEV to stop reflux even in the absence of any LES pressure.

In healthy patients, the Angle of His, the angle at which the esophagus enters the stomach, is intact creating a valve that prevents duodenal bile, enzymes, and stomach acid from traveling back into the esophagus where it can cause burning and inflammation of the sensitive esophageal tissue.

Another paradoxical cause of GERD-like symptoms is not enough stomach acid (hypochlorhydria). The valve that empties the stomach into the intestines is triggered by acidity. If there is not enough acid, this valve does not open and the stomach contents are churned up into the esophagus. There is still enough acidity to cause irritation to the esophagus.

Factors that can contribute to GERD are:

• Hiatus hernia, which increases the likelihood of GERD due to mechanical and motility factors
• Zollinger-Ellison syndrome, which can be present with increased gastric acidity due to gastrin production
• Hypercalcemia, which can increase gastrin production, leading to increased acidity
• Scleroderma and systemic sclerosis, which can feature esophageal dysmotility
• Gallstones which can impede the flow of bile into the Duodenum which can affect the ability to neutralize gastric acid

GERD has been linked to laryngitis, chronic cough, pulmonary fibrosis, earache, and asthma, even when not clinically apparent, as well as to laryngopharyngeal reflux and ulcers of the vocal cords.

[edit] Treatment

The rubric "lifestyle modifications" is the term physicians use when recommending non-pharmaceutical treatments for GERD. A 2006 review suggested that evidence for most dietary interventions is anecdotal; only weight loss and elevating the head of the bed were found to be supported by evidence^[2].

[edit] Foods

Certain foods and lifestyle are considered to promote gastroesophageal reflux:

• Coffee, alcohol, and excessive amounts of Vitamin C supplements are stimulants of gastric acid secretion. Taking these before bedtime especially can promote evening reflux. Calcium containing antacids are in this group^[3]. (Although a study published in 2006 by Stanford University researchers disputes the effect of coffee, acidic, spicy foods etc. as a myth.^[4])
• Foods high in fats and smoking reduce lower esophageal sphincter competence, so avoiding these tends to help, as well. Fat also delays emptying of the stomach.
• Having more but smaller meals also reduces the risk of GERD, as it means there is less food in the stomach at any one time.
• Eating shortly before bedtime (For clinical purposes, this usually means 2-3 hours before going to bed).
• Large meals
• chocolate and peppermint
• spicy foods
• acidic foods like oranges and tomatoes (However, they are okay when fresh.)
• cruciferous vegetables: onions, cabbage, cauliflower, broccoli, spinach, brussel sprouts
• milk and milk-based products contain calcium and fat, so should be avoided before bedtime.

However, following this list of foods directly is not 100% accurate for some have a more serious case of GERD than others. Thus, it is up to an individual to decide which foods bother them and which ones do not. But practical advice offered by many sources is to avoid food for a minimum of 2 hours before bedtime and, also, not lying down after a meal.

[edit] Positional therapy

Elevation to the head of the bed is the next-easiest to implement. If one implements pharmacologic therapy in combination with food avoidance before bedtime and elevation of the head of the bed over 95% of patients will have complete relief. Additional conservative measures can be considered if there is incomplete relief. Another approach is to advise all conservative measures to maximize response.

Elevating the head of the bed can be accomplished by using blocks as noted above or with other items: plastic or wooden bed risers which support bed posts or legs, a bed wedge pillow, or an inflatable mattress lifter that fits in between mattress and box spring. The height of the elevation is critical and must be at a minimum of 6 to 8 inches (15 to 20 cm) in order to be at least minimally effective in hindering the backflow of gastric fluids. It should be noted that some innerspring mattresses do not work well when inclined and tend to cause back pain thus foam based mattresses are to be preferred. Moreover, some use higher degrees of incline than provided by the commonly suggested 6 to 8 inches (15 to 20 cm) and claim greater success. Elevating the head of the bed is also known as "positional therapy".

[edit] Drug treatment

A number of drugs are registered for the treatment of GERD, and they are among the most-often-prescribed forms of medication in most Western countries. They can be used in combination with other drugs, although some antacids can impede the function of other medications:

• Proton pump inhibitors are the most effective in reducing gastric acid secretion. These drugs stop the secretion of acid at the source of acid production, i.e. the proton pump.
• Antacids before meals or symptomatically after symptoms begin can reduce gastric acidity (increase the pH).
• Alginic acid (Gaviscon) may coat the mucosa as well as increase the pH and decrease reflux. A meta-analysis of randomized controlled trials suggests alginic acid may be the most effective of non-prescription treatments with a number needed to treat of 4 ^[5].
• Gastric H₂ receptor blockers such as ranitidine or famotidine can reduce gastric secretion of acid. These drugs are technically antihistamines. They relieve complaints in about 50% of all GERD patients. Compared to placebo (which also is associated with improvement in symptoms), they have a number needed to treat of 8 ^[5].
• Prokinetics strengthen the LES and speed up gastric emptying. Cisapride, a member of this class, was withdrawn from the market for causing Long QT syndrome.
• Sucralfate (Carafate®) is also useful as an adjunct in helping to heal and prevent esophageal damage caused by GERD, however it must be taken several times daily and at least 2 hours apart from meals and medications.

[edit] Posture and GERD

In adults, a slouched posture is one of the important contributory factors to GERD. Muscles around the esophagus go in a spasm and there is no straight path between the stomach and esophagus with a slouched posture. Coughing, gas and acidity get blocked in the spasm, thus causing asthma kind symptoms. In short, the pathway between the stomach and esophagus gets blocked by the spasms and shortening of the muscles in and around the area, which is caused by a slouched posture. A meta-analysis suggested that elevating the head of bed at night is an effective therapy, although this conclusion was only supported by nonrandomized studies ^[6].

[edit] Surgical treatment

The standard surgical treatment, sometimes preferred over longtime use of medication, is the Nissen fundoplication. The upper part of the stomach is wrapped around the LES to strengthen the sphincter and prevent acid reflux and to repair a hiatal hernia. The procedure is often done laparoscopically.

An obsolete treatment is vagotomy ("highly selective vagotomy"), the surgical removal of vagus nerve branches that innervate the stomach lining. This treatment has been largely replaced by medication.

[edit] Endoluminal Fundoplication

In June 2006 EndoGastric Solutions introduced EsophyX ELF in the Europe Union as an alternative to surgical and pharmaceutical approaches for the treatment of GERD. EsophyX ELF is intended to deliver similar benefits as the time-proven laparoscopic fundoplication procedures, by reducing hiatal hernia, recreating the Angle of His, and creating a GastroEsophageal Valve (GEV). The key differences are that EsophyX ELF is an endoscopic non-invasive procedure that is performed transorally (through the mouth), does not require incisions, and does not dissect any part of the natural anatomy.

Previous endoluminal treatments focused predominantly on the LES. However, failure to effectively treat reflux long-term with endoluminal therapies which focused only on the Lower Esophageal Sphincter (LES) combined with the fact that surgical approaches like Nissen fundoplication recreate the GEV and have excellent long-term efficacy, has led to an awareness that the GEV is probably the most powerful component of the Anti-Reflux Barrier. The device has been designed to deploy multiple tissue fasteners to create a robust and durable valve and is intended to restore the geometry of the GastroEsophageal Junction and recreate the natural, unidirectional valve mechanism necessary to prevent GERD. EsophyX ELF has not been cleared by the US FDA and is not yet available in the US.

[edit] Other treatments

In 2000, the U.S. Food and Drug Administration (FDA) approved two endoscopic devices to treat chronic heartburn. One system, Endocinch, puts stitches in the LES to create little pleats that help strengthen the muscle. Another, the Stretta Procedure, uses electrodes to apply radio frequency energy to the LES. The long term outcomes of both procedures compared to a Nissen fundoplication are still being determined.

Subsequently the NDO Surgical Plicator was FDA cleared for the endoscopic treatment of GERD. The Plicator creates a plication, or fold, of tissue near the gastroesophageal junction, and fixates the plication with a suture-based implant. The Plicator is currently marketed by NDO Surgical, Inc. [1].

Another treatment which involved injection of a solution that is injected during endoscopy into the lower esophageal wall was available for approximately one year ending in late 2005. It was marketed under the name Enteryx. It was removed from the market due to several reports of complications from misplaced injections.

[edit] Barrett's esophagus

Barrett's esophagus, a type of dysplasia, is a precursor high-grade dysplasia, which is in turn a precursor condition for carcinoma. The risk of progression from Barrett's to dysplasia is uncertain but is estimated to include 0.1% to 0.5% of cases, and has probably been exaggerated in the past. Due to the risk of chronic heartburn progressing to Barrett's, EGD every 5 years is recommended for patients with chronic heartburn, or who take medication for GERD chronically.

[edit] References

1. ^ DeVault KR, Castell DO. Updated guidelines for the diagnosis and treatment of gastroesophageal reflux disease. The Practice Parameters Committee of the American College of Gastroenterology. Am J Gastroenterol 1999;94:1434-42. PMID 10364004.
2. ^ Kaltenbach T, Crockett S, Gerson LB. Are lifestyle measures effective in patients with gastroesophageal reflux disease? An evidence-based approach. Arch Intern Med 2006;166:965-71. PMID 16682569.
3. ^ Decktor DL, Robinson M, Maton PN, Lanza FL, Gottlieb S. Effects of Aluminum/Magnesium Hydroxide and Calcium Carbonate on Esophageal and Gastric pH in Subjects with Heartburn. Am J Ther 1995;2:546-552. PMID 11854825.
4. ^ Kaltenbach T, Crockett S, Gerson LB. Are lifestyle measures effective in patients with gastroesophageal reflux disease? An evidence-based approach. Arch Intern Med 2006;166:965-71. PMID 16682569.
5. ^ ^{a b} Tran T, Lowry A, El-Serag H (2007). "Meta-analysis: the efficacy of over-the-counter gastro-oesophageal reflux disease therapies". Aliment Pharmacol Ther 25 (2): 143-53. DOI:10.1111/j.1365-2036.2006.03135.x. PMID 17229239. 
6. ^ Kaltenbach T, Crockett S, Gerson L (2006). "Are lifestyle measures effective in patients with gastroesophageal reflux disease? An evidence-based approach". Arch Intern Med 166 (9): 965-71. PMID 16682569. 

[edit] External links

• NIH GERD patient information page
• Esophagitis Candida (yeast) infections
• KidsHealth GERD Information for Kids
• Cleveland Clinic
• GERD baby/child information page