Esophagus

Gastroesophageal Reflux

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Gastroesophageal Reflux, Esophageal Relux, Reflux Esophagitis, Heartburn, Acid Reflux, Acid Regurgitation, Water Brash, Pyrosis, GERD

  • Epidemiology
  1. Incidence: 36% in U.S.
  2. Most take OTC medications and do not seek medical help
  3. GERD patients wait 1-3 years before seeing a doctor
  • Risk Factors
  • Reduced LES pressure
  1. Smooth muscle relaxants
    1. Aminophylline
    2. Nitrates
    3. Calcium Channel Blockers
    4. Caffeine
    5. Inhaled Albuterol
      1. Crowell (2001) Chest 120:1184-9 [PubMed]
  2. Tobacco abuse
  3. Pregnancy
    1. Progesterone-mediated relaxation of the lower esophageal sphincter
  4. Scleroderma
  5. Diabetes Mellitus (esp. longer standing disease)
    1. Esophageal Dysmotility, decreased lower esophageal sphincter tone, prolonged transit time
  • Complications
  • Symptoms
  • Classic
  1. Heartburn (Initial GERD symptom)
    1. Location: Epigastric and retrosternal Chest Pain
    2. Characteristic: Caustic or stinging
    3. No radiation to the back
  2. Acid Regurgitation (Water Brash or Pyrosis)
    1. Suggests progressing GERD
    2. Provoked by lying supine or leaning forward
    3. Regurgitation of digested food or clear burning fluid
    4. Undigested food suggests alternative diagnosis
      1. Achalasia
      2. Esophageal Diverticulum
  3. Difficult swallowing (Dysphagia)
    1. See Dysphagia from Esophageal Cause
    2. Mechanical obstruction of solid foods
      1. Suggests peptic stricture
    3. Liquid obstruction suggests alternative diagnosis
      1. Neuromuscular disorder
      2. Neoplasm
      3. Esophageal diverticulum
  • Symptoms
  • Atypical
  1. Abdominal Pain (29%)
  2. Chronic Cough (27%)
    1. GERD is responsible for a non-smoker with 3 weeks of Chronic Cough in 40% of cases
    2. Consider empiric Proton Pump Inhibitor
    3. Palombini (1999) Chest 116(2): 279-84 [PubMed]
  3. Hoarseness (21%)
  4. Belching (15%)
  5. Bloating (15%)
  6. Aspiration (14%)
  7. Wheezing (7%)
  8. Globus Hystericus (4%)
  9. Recurrent Pharyngitis
  10. Halitosis
  • Signs
  • Orofacial effects of chronic Acid Reflux
  1. Dental Erosions (yellow discoloration)
  2. Masticatory Mucosa inflammation
  3. Chronic Sinusitis
  • Red Flags
  • Symptoms Indicating Evaluation (e.g. Endoscopy)
  1. Dysphagia
    1. Immediately assess for Barrett's Esophagus
  2. Odynophagia
    1. Assess for Esophageal Ulcer
  3. Weight Loss (Suggests Dysphagia or Odynophagia)
  4. Early satiety or Vomiting
  5. Aspiration
  6. Wheezing or cough
  7. Gastrointestinal Bleeding
  8. Unexplained Iron Deficiency Anemia
    1. Suggests esophageal ulcer
  9. High risk patients
    1. Male over 45 years old with longstanding GERD symptoms
    2. History of severe Erosive Gastritis
    3. Tobacco abuse with weekly GERD symptoms in the last year (OR 51.4)
    4. Obesity (BMI >30 kg/m^2) with weekly GERD symptoms in the last year (OR 34.4)
    5. Elderly with reflux (use high level of suspicion)
      1. Even serious pathology may present as mild GERD
      2. Johnson (2004) Gastroenterology 126:660-4 [PubMed]
  • Pathophysiology
  1. Transient relaxation of lower esophageal sphincter
  • Diagnosis
  • Typical cases
  1. See GerdQ Questionnaire
  2. Symptoms and signs are sufficient for diagnosis for uncomplicated cases
  3. Empiric management is the recommended strategy for uncomplicated cases
  • Diagnosis
  • Complicated or refractory cases
  1. Upper endoscopy
    1. Indicated for red flag symptoms (see above)
    2. Test Sensitivity and Specificity are low for GERD diagnosis
    3. Standard for evaluating GERD complications (e.g. Barrett Esophagus)
  2. pH probe (24 hour pH monitoring)
    1. Indicated prior to Anti-Reflux Surgery (Nissen Fundoplication)
    2. Test Sensitivity: 70 to 96%
    3. Test Specificity: 70 to 96%
  • Management
  • General Measures
  1. Drink 8 glasses (8 ounces) non-caffeinated fluid daily
  2. Decrease provocative foods
    1. Decrease or eliminate Caffeine
    2. Avoid spicy foods
    3. Avoid milk products toward end of day
    4. Avoid chocolate
    5. Avoid fatty foods
  3. Tobacco Cessation
  4. No eating food 2-3 hours before bedtime
  5. Elevate head of bed to 30 degrees
    1. Place 6-8 inch blocks under legs at head of bed
    2. Place Styrofoam wedge under mattress
  6. Symptomatic therapy for mild intermittent symptoms
    1. OTC Antacid medications (e.g. Maalox, Tums, Rolaids)
      1. More effective than Placebo for GERD symptoms
      2. Chatfield (1999) Curr Med Res Opin 15:152-9 [PubMed]
    2. Antacid chewing gum (Surpass by Wrigley)
  • Management
  • Medications
  1. Institute general measures above
  2. Proton Pump Inhibitor
    1. All Proton Pump Inhibitors equivalent in GERD
      1. Klok (2003) Aliment Pharmacol Ther 17:1237-45 [PubMed]
    2. Initial treatment for 6 to 12 weeks
      1. Dose 30-60 minutes prior to meal
      2. Use high dose (twice daily) for severe or refractory symptoms
    3. Taper to lower dose for 4 to 8 weeks
    4. Trial off Proton Pump Inhibitor
  3. Consider H2 Blocker maintenance therapy
    1. Consider concurrent with first week of Proton Pump Inhibitor use (until complete pump blockade)
    2. H2 Blockers are inferior to PPI for control of GERD symptoms
      1. Starting with Proton Pump Inhibitor (instead of stepping up from H2 Blocker) is more cost effective
      2. Sigterman (2013) Cochrane Database Syst Rev 5:CD002095 [PubMed]
      3. Habu (2005) J Gastroenterol 40(11): 1029-35 [PubMed]
  4. Medications not found to be beneficial
    1. Sucralfate (Carafate) offers minimal benefit in GERD
  1. Restart Proton Pump Inhibitor (e.g. Omeprazole)
  2. Consider Endoscopy (EGD)
    1. Evaluate for Barrett's Esophagus
  3. Consider evaluation for Anti-Reflux Surgery (Nissen Fundoplication)
    1. Upper Endoscopy (evaluate for Barrett's Esophagus)
    2. Upper Gastrointestinal Series (defines anatomy)
    3. Manometry
    4. 24-Hour pH Monitoring
  4. Consider other Esophageal Dysmotility
    1. Esophageal Achalasia
    2. Esophageal Spasm
  • Management
  • Follow-up
  1. Normal upper endoscopy (EGD)
    1. No repeat EGD for 10 years unless symptoms progress
    2. Schnell (2001) Gastroenterology 120:1607-19 [PubMed]