Gastroesophageal Reflux

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Chapter 25 Gastroesophageal Reflux

INTRODUCTION

Description: The reflux of gastric acid to the sensitive esophagus causes heartburn, the cardinal manifestation of gastroesophageal reflux disease (GERD).
Prevalence: Common.
Predominant Age: Generally reproductive and beyond.
Genetics: No genetic pattern.

ETIOLOGY AND PATHOGENESIS

Causes: The most common cause is decreased tone of the lower esophageal sphincter (LES). This is complicated in pregnant patients by the reduced gastric emptying and reduced esophageal sphincter tone that occur during pregnancy.
Risk Factors: Cigarette smoking, alcohol abuse, some medications or foods, pregnancy, scleroderma, sliding hiatal hernia.

CLINICAL CHARACTERISTICS

Signs and Symptoms

• Upper abdominal pain, nausea, vomiting, dyspepsia, heartburn, chest pain, and “gas” (70% to 85%; symptoms most common after large meals, consuming certain foods, and on assuming the recumbent position)
• Dysphagia (15% to 20%, suggests stricture)
• Bronchospasm/asthma (15% to 20%)

DIAGNOSTIC APPROACH

Differential Diagnosis

• Ulcer disease (gastric or duodenal)
• Chemical or infectious esophagitis
• Crohn’s disease of the esophagus
• Angina pectoris
• Achalasia
• Esophageal cancer

Associated Conditions: Dysphagia. Nocturnal aspiration may occur and be mistaken for asthma.

Workup and Evaluation

Laboratory: No evaluation indicated.
Imaging: Barium swallow may demonstrate hiatal hernia or esophageal narrowing. For patients who are pregnant, this should be reserved for after completion of the pregnancy.
Special Tests: Upper gastrointestinal endoscopy eliminates other potential causes of gastroesophageal reflux disease that include esophageal motility disorders, erosive esophagitis, and peptic ulcer disease (gastric or duodenal).
Diagnostic Procedures: History (>80% accurate), physical examination, endoscopy, barium swallow.

Pathologic Findings

Acute inflammatory changes and hyperplasia of the basal layers of epithelium (85%). Squamous metaplasia of the lower esophagus may occur with chronic exposure to reflux acid (Barrett’s syndrome), which may undergo dysplasia or malignant change.

MANAGEMENT AND THERAPY

Nonpharmacologic

General Measures: Dietary changes, elevation of the head of the bed, smoking cessation, alcohol in moderation only, weight loss, antacids. (Antacids that coat [liquids], and those that tend to float on the surface of the stomach contents, such as Gaviscon, give better heartburn relief than other agents.).
Specific Measures: Eliminate medications that contribute to reduced esophageal pressure, such as diazepam and calcium channel blockers, or that may damage the esophagus (nonsteroidal anti-inflammatory drugs [NSAIDs]). Use acid-blocking therapy.
Diet: Avoid eating spicy or acidic meals, chocolate, onions, garlic, peppermint, and large meals before bedtime.
Activity: No restriction.
Patient Education: Reassurance, diet counseling, behavior modification.

Drug(s) of Choice

Antacids.
Histamine H2-antagonists (cimetidine 800 mg two times daily, ranitidine 400 mg four times daily, famotidine 20 mg two times daily, or nizatidine 150 mg two times daily).
Hydrogen potassium pump blocker (omeprazole 20 to 40 mg daily for 4 to 8 weeks, esomeprazole 20 to 40 mg daily for 4 to 8 weeks, or pantoprazole 40 mg daily for 8 weeks).
Cisapride (10 to 20 mg four times daily, before meals, and every night.
Misoprostol (Cytotec, 100 to 200 micrograms PO four times daily) if mucosal injury is documented or suspected.
Contraindications: Known or suspected hypersensitivity. Misoprostol is contraindicated during pregnancy and lactation.
Precautions: Because of a lack of long-term follow-up, hydrogen pump inhibitors may be taken only for 8 to 12 weeks.
Interactions: Multiple drug interactions are possible with agents such as cimetidine; check full prescribing information.

Alternative Drugs

Bethanechol, antiemetics, phenobarbital if necessary.

FOLLOW-UP

Patient Monitoring: Normal health maintenance
Prevention/Avoidance: Reduction of modifiable risk factors (e.g., smoking, weight loss, diet).
Possible Complications: Esophageal stricture, bleeding. Prolonged exposure of acid to the esophagus may lead to stricture formation and dysphagia. Epithelial changes induced in the lower esophagus are also associated with an increased risk of esophageal cancer.

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Expected Outcome: Generally good symptomatic relief, but long-term therapy is often required.

MISCELLANEOUS

Pregnancy Considerations: No effect on pregnancy, although may worsen during pregnancy because of reduced esophageal tone and increased intra-abdominal pressure caused by the expanding uterus.
ICD-9-CM Codes: 530.11.

REFERENCES

Level II

Chang AB, Lasserson TJ, Kiljander TO, et al. Systematic review and meta-analysis of randomised controlled trials of gastro-oesophageal reflux interventions for chronic cough associated with gastro-oesophageal reflux. BMJ. 2006;332(7532):11. Epub 2005 Dec 5

Qadeer MA, Phillips CO, Lopez AR, et al. Proton pump inhibitor therapy for suspected GERD-related chronic laryngitis: a meta-analysis of randomized controlled trials. Am J Gastroenterol. 2006;101:2646. Epub 2006 Oct 13

Ulualp SO, Roland PS, Toohill RJ, Shaker R. Prevalence of gastroesophagopharyngeal acid reflux events: an evidence-based systematic review. Am J Otolaryngol. 2005;26:239.

Level III

DeVault KR, Castell DO. Guidelines for the diagnosis and treatment of gastroesophageal reflux disease. Arch Intern Med. 1995;155:2165.

Feldman M, Burton ME. Drug therapy: histamine2-receptor antagonists-standard therapy for acid-peptic disease. N Engl J Med. 1990;323:1672. 1749.

Fennerty MB, Sampliner RE, Garewall HS. Barrett’s oesophagus—cancer risk, biology and therapeutic management. Aliment Pharmacol Ther. 1993;7:339.

Kahrilas PJ. Gastroesophageal reflux disease. JAMA. 1996;276:983.

Kahrilas PJ, Lee TJ. Pathophysiology of gastroesophageal reflux disease. Thorac Surg Clin. 2005;15:323.

Locke GR3rd. Current medical management of gastroesophageal reflux disease. Thorac Surg Clin. 2005;15:369.

Moayyedi P, Talley NJ. Gastro-oesophageal reflux disease. Lancet. 2006;367(9528):2086.

Nava-Ocampo AA, Velazquez-Armenta EY, Han JY, Koren G. Use of proton pump inhibitors during pregnancy and breastfeeding. Can Fam Physician. 2006;52:853.

Rapkin AJ, Mayer EA. Gastroenterologic causes of chronic pelvic pain. Obstet Gynecol Clin North Am. 1993;20:663.

Turcotte S, Duranceau A. Gastroesophageal reflux and cancer. Thorac Surg Clin. 2005;15:341.

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