Gastroesophageal Reflux Disorder
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Introduction
Gastroesophageal Reflux Disorder (GERD) is the most common problem of the esophagus. causing occasional heartburn in nearly half the population and daily symptoms of almost 15% of people.
GERD occurs when the esophageal is exposed to acid-containing gastric secretions.
The Case of...
Causes and Risk Factors
In adults, risk factors include:
- eating close to bedtime
- fatty or spicy foods
- cigarettes
- alcohol
- obesity
Hiatal hernias can contribute to GERD, but they can occur independently of each other.
In infants, risk factors include:
- improper feeding
- cow's milk protein allergy
Pathophysiology
several mechanisms can contribute to GERD symptoms:
- decreased saliva production
- transient lower esophageal sphincter (LES) relaxations: normal
- hiatus hernia
- mucosal hypersensitivity
- decreased resting LES tone (obesity, scleroderma)
- decreased LES tone (caffeine, alcohol, peppermint); decreased gastric emptying (high fat diet), large meals
Signs and Symptoms
- history
- physical exam
History
Heartburn/reflux is the cardinal feature of GERD. Other symptoms can include
- chronic cough, asthma, hoarseness, chronic sore throat, and globus sensation
non-cardiac chest pain
waterbrash - flush of saliva
dyspepsia
nausea
frank regurgitation
Red Flags
weight loss, bleeding (anemia), dysphagia, melena, hematemesis, progressive symptoms
Physical Exam
Investigations
- lab investigations
- diagnostic imaging
Lab Investigations
Diagnostic Imaging
Differential Diagnosis
Treatments
Lifestyle
- diet: avoid fatty foods, chocolate, peppermint, and alcohol
- position: avoid eating before bed; sleep with the head of the bed up a bit
- reduce caffeine and nicotine
- wear loose clothes and lose weight to reduce pressure on stomach
medications
H2 receptor blockers (ranitidine, cimetidine)
proton pump inhibitors (omeprazole, lansoprazole). PPIs do not prevent reflux, but rather reduce acid secretion
misoprostol, in combination with NSAIDs
sulcrate
Screen for dysplasia every 2-3 years
Surgery
Nissen fundiplication is used for the vast majority of patients for whom surgery is indicated:
- documented reflux with esophagitis and Barrett's esophagus
- failed medical management
Success rates are 90% at 10 years.
Pediatrics
Consider feeding techniques, including positioning.
Thickened feeds or specialty bottles can help.
Cow's milk protein intolerance will lead to a better responsed with whey-predominant or hydrolyzed formulas.
Consequences and Course
Complications can include pain, bleeding, strictures, or Barrett's esophagus or carcinoma.
Sore throat, cough, laryngitis, asthma can be common.
reactive atypia has no malignant potential and is due to inflammation.
Resources and References
Topic Development
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