Acid reflux/Gastroesophageal Reflux Disease G.E.R.D.
Gastroesophageal Reflux Disease (GERD,
or GORD when -oesophageal, the BE form, is substituted) is injury to the
esophagus that develops from chronic exposure of the esophagus to acid coming up
from the stomach (reflux). In contrast, heartburn is the 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. Atypical symptoms of GERD include cough, hoarseness, changes of
the voice, and sinusitis. Complicatons of GERD include stricture formation,
Barrett's esophagus, esophageal ulcers and possibly even to esophageal cancer.
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
Symptoms
Adults
The most prominent symptom of GERD is heartburn, the sensation of burning pain
in the chest coming upward towards the mouth caused by reflux of acidic contents
from the stomach to the esophagus.
Patients with GERD also tend to get the feeling of a sour or salty taste at the
back of their throats due to regurgitation. This can sometimes happen even if
the pain of heartburn is absent.
Less common symptoms:
- Chest pain without any of the above
- Dysphagia (difficulty swallowing)
- Halitosis (bad breath)
- Regurgitation (vomit-like taste in the mouth)
- Repeated throat clearing
- Water brash (the sensation of a large amount of non-acid
liquid due to sudden hypersecretion of saliva)
Complications:
- Strictures or scarring of esophagus (especially young
children).
- Barrett's esophagus (sometimes referred to as Barrett's
Disease)
Esophageal cancer
- Important Warning symptoms:
- Trouble swallowing Dysphagia requires immediate medical
attention
- Vomiting blood or partially digested blood (looks like
coffee grounds) requires immediate medical attention as does digested blood in
the stools.
GERD in Children
GERD is commonly overlooked 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 are also common.
Children may have one symptom or many - no single symptom is universally present
in all children with GERD.
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
don't outgrow acid reflux, however, and continue to have it into their teen
years. Children that have had heartburn that doesn't seem to go away, or any
other symptoms of GERD for a while, should talk to their parents and visit their
doctor.
Diagnosis
A detailed history taking is vital to the diagnosis. Useful investigations may
include barium swallow X-rays, esophageal manometry, esophageal pH monitoring
and Esophagogastroduodenoscopy (EGD). In general, an EGD is done when the
patient does not respond well to treatment, has had symptoms or required
medications for a prolonged time (generally 5 years), has dysphagia, anemia,
blood in the stool (detected chemically), has weight loss, or has changes in the
voice.
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 either reflux or
Helicobacter gastritis)
- Eosinophilic inflammation (usually due to reflux)
- Goblet cell intestinal metaplasia or Barretts esophagus.
- Dysplasia or pre-cancer.
- Carcinoma.
- Rapid testing assays can quickly detect the presence of
Helicobacter pylori in a biopsy sample through urease testing.
- athophysiology
Having GERD indicates incompetence of the lower esophageal sphincter.
Increased acidity or production of gastric acid can contribute to the problem,
as can obesity, tight fitting clothes and pregnancy. It is also thought that
yeast infections of the digestive tract can cause GERD-like symptoms.
Factors that can contribute to GERD are:
Hiatus hernia increases the likelihood of GERD due to mechanical and motility
factors.
Zollinger-Ellison syndrome can present with increased gastric acidity due to
gastrin production.
Hypercalcemia can increase gastrin production, leading to increased acidity.
Scleroderma and systemic sclerosis can feature esophageal dysmotility.
Treatment
Avoiding aggravating factors
Certain foods and lifestyle tend to promote gastroesophageal reflux:
-
Coffee, alcohol,
calcium supplements, and excessive amounts of Vitamin C supplements are
stimulants of gastric acid secretion so avoiding these helps.
-
Foods high in fats
and smoking reduce lower esophageal sphincter competence so avoiding these
tends to help as well.
-
Having more but
smaller meals also reduces the risk of GERD as it means there is less in the
stomach at any one time.
Advice generally given:
- avoid eating for 2 hours before bedtime
- avoid sodas that contain caffeine
- avoid chocolate and peppermint
- avoid spicy foods like pizza
- avoid acidic foods like oranges and tomatoes
- avoid fried and fatty foods
- avoid milk and heavily milk based products
Drug treatment
A number of drugs is registered for the treatment of GERD, and they are
amongst the most often prescribed forms of medication is most Western
countries. They can be used in combination, although some antacids can impede
the function of other medications:
- Antacids before meals or symptomatically after symptoms
begin can reduce gastric acidity (increase the pH).
- 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.
- Proton pump inhibitors such as omeprazole are even more
effective in reducing gastric acid secretion.
- Prokinetics strengthen the LES and speed up gastric
emptying. Cisapride, a member of this class, was withdrawn for causing Long QT
syndrome.
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.
Other treatments
In 2000, the U.S. Food and Drug Administration (FDA) approved two endoscopic
devices to treat chronic heartburn. One system puts stitches in the LES to
create little pleats that help strengthen the muscle. Another uses electrodes to
create tiny cuts on the LES. When the cuts heal, the scar tissue helps toughen
the muscle. The long-term effects of these two procedures are unknown.
Recently, the FDA approved an implant that may help people with GERD who wish to
avoid surgery. It is a solution that is injected during endoscopy and becomes
spongy, reinforcing the LES to keep stomach acid from flowing into the
esophagus. The implant is approved for people who have GERD and who require and
respond to proton pump inhibitors. The long-term effects of the implant are
unknown.
Barrett's esophagus
Barrett's esophagus, a type of dysplasia, is a precursor high grade dysplasia,
which is in turn is a precursor condition for carcinoma. The risk of progression
from Barretts 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.
GERD has been linked to laryngitis, chronic cough, pulmonary fibrosis and
asthma, even when not clinically apparent, as well as to ulcers of the vocal
cords.
Links to other useful web-sites |
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