Gastroesophageal Reflux Disease (GERD)-Causes–Mechanism-Diagnosis, Treatment and Complicatons

Gastroesophageal Reflux Disease, Causes, Mechanism, Diagnosis, Treatment and Complications

Definition:

According to the American College of Gastroenterology (ACG) GERD is defined as;
“Symptoms OR mucosal damage produced by the abnormal reflux of gastric contents into the oesophagus”. Often this condition is chronic and relapsing. You may see complications of GERD in patients who lack typical symptoms.

Mechanism:

The primary barrier to gastroesophageal reflux is the lower oesophagal sphincter (LES)
LES normally works in conjunction with the diaphragm
If barrier disrupted, acid goes from stomach to oesophagus and causes mucosal damage and symptoms of GERD.

Clinical Manifestations:

Most common symptoms are;
1. Heartburn—retrosternal burning discomfort (behind the sternum)
2. Regurgitation—effortless return of gastric contents into the pharynx without nausea, retching, or abdominal contractions
3. Dysphagia—difficulty swallowing
Other symptoms include:
1. Chest pain, water brash, globus sensation, odynophagia, nausea
Extraesophageal manifestations, for instance,
3. Asthma, laryngitis, chronic cough

Diagnostic Evaluation:

* If classic symptoms of heartburn and regurgitation exist in the absence of “alarm symptoms” the diagnosis of GERD can be made clinically and treatment can be initiated

Alarm Signs/Symptoms

Dysphagia
Early satiety
GI bleeding
Odynophagia ( painful swallowing in the mouth or oesophagus)
Vomiting
Weight loss
Iron deficiency anemia

Oesophagogastrodeudeno-endoscopy:

Endoscopy (with biopsy if needed)
In patients with alarm signs/symptoms
Those who fail a medication trial
Those who require long-term treatment
Lacks sensitivity for identifying pathologic reflux
Absence of endoscopic features does not exclude a GERD diagnosis
Allows for detection, stratification, and management of oesophagal manifestations or complications of GERD

24-hour pH monitoring

The accepted standard for establishing or excluding the presence of GERD for those patients who do not have mucosal changes
Trans-nasal catheter or wireless, capsule shaped device is used for this purpose

Distinguish from Dyspepsia

Ulcer-like symptoms-burning, epigastric pain
Dysmotility-like symptoms-nausea, bloating, early satiety, anorexia
In addition to anti-secretory meds and an EGD need to consider an evaluation for Helicobacter pylori

Treatment

Goals of therapy
*Symptomatic relief
*Heal esophagitis
*Avoid complications

Better Living:

1. Avoid acidic foods (citrus/tomato), alcohol, caffeine, chocolate, onions, garlic, peppermint
2. Decrease fat intake
3. Avoid lying down within 3-4 hours after a meal
4. Elevate the head of bed 4-8 inches
5. Avoid meds that may potentiate GERD (CCB, alpha agonists, theophylline, nitrates, sedatives, NSAIDS)
6. Avoid clothing that is tight around the waist
7. Lose weight
8. Stop smoking
9. Avoid Large Meals

Antacids

1. Over the counter, acid suppressants and antacids appropriate initial therapy
2. Approximately  1/3 of patients with heartburn-related symptoms use at least twice weekly
3. More effective than placebo in relieving GERD symptoms

Histamine H2-Receptor Antagonists

More effective than placebo and antacids for relieving heartburn in patients with GERD
Faster healing of erosive esophagitis when compared with placebo
Can use regularly or on-demand

Agent	Equivalent	Dosage / Dosages
Cimetidine ( Tagamet )	400mg twice daily	400-800 mg twice daily
Famotidine ( Pepcid )	20mg twice daily	20-40 mg twice daily
Nizatidine ( Axid )	150mg twice daily	150 mg twice daily
Ranitidine ( Zantac )	150mg twice daily	150 mg twice daily

Proton Pump Inhibitors

Better control of symptoms with PPIs vs H2RAs(histamine H2 receptor antagonists)  and better remission rates
Faster healing of erosive esophagitis with PPIs vs H2RAs

Agent	Equivalent	Dosage / Dosages
Esomeprazole or omeprazole	40 mg daily	20 – 40 mg daily
Lansoprazole	30 mg daily	10 – 15 mg daily
Pantoprazole	40 mg daily	40 mg daily
Rabeprazole	20 mg daily	20 mg daily

lH2RAs vs PPIs

12 weeks of freedom from symptoms
48% vs 77%
12 weeks healing rate
52% vs 84%
Speed of healing
6%/wk vs 12%/wk
Hence, PPIs are better

Complications

1. Erosive esophagitis

Responsible for 40-60% of GERD symptoms
The severity of symptoms often fail to match the severity of erosive esophagitis

2. Oesophagal Stricture

Result of healing of erosive esophagitis
May need dilation

3. Barrett’s Esophagus

Columnar metaplasia of the oesophagus ( see Barrett's oesophagus)
Associated with the development of adenocarcinoma

Management of Barrett’s Esophagus

1. Manage in the same manner as GERD
2. EGD every 3 years in patient’s without dysplasia