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SOURCE

Source: May D, Thiman M, Rao SCS. Gastroesophageal reflux disease. In: DiPiro JT, Talbert RL, Yee GC, Matzke GR, Wells BG, Posey LM, eds. Pharmacotherapy: A Pathophysiologic Approach. 10th ed. New York, NY: McGraw-Hill; 2017. http://accesspharmacy.mhmedical.com/content.aspx?bookid=1861&sectionid=135145538. Accessed March 27, 2017.

CONDITION/DISORDER SYNONYMS

  • Heartburn.

  • Acid reflux disease.

  • GERD

DEFINITION

  • Retrograde movement of stomach contents into esophagus causing troublesome symptoms and/or complications.

ETIOLOGY

  • Defective lower esophageal sphincter (LES) pressure or function.

  • Abnormal esophageal anatomy.

  • Improper esophageal clearance of gastric fluids.

  • Reduced mucosal resistance to acid.

  • Delayed or ineffective gastric emptying.

  • Reduced salivary buffering of acid.

PATHOPHYSIOLOGY

  • Decreased LES pressure may result from spontaneous transient LES relaxations, transient increases in intraabdominal pressure, atonic LES, or ingestion of certain foods and medications.

  • Substances that promote esophageal damage upon reflux include gastric acid, pepsin, bile acids, and pancreatic enzymes.

  • Composition and volume of refluxate and duration of exposure are most important factors in determining clinical consequences.

  • Complications from long-term acid exposure include esophagitis, esophageal strictures, Barrett esophagus, and esophageal adenocarcinoma.

EPIDEMIOLOGY

  • Most common in persons older than 40 years.

  • 20% of adults in Western countries suffer from GERD symptoms on weekly basis.

  • Prevalence of GERD highest in Western countries.

  • No difference in incidence between men and women, except for higher incidence during pregnancy.

RISK FACTORS

  • Obesity.

  • Smoking.

  • Alcohol consumption.

  • Certain medications and foods.

CLINICAL PRESENTATION

SIGNS AND SYMPTOMS

  • Heartburn (substernal sensation of warmth or burning rising up from abdomen that may radiate to neck), water brash (hypersalivation), belching, regurgitation.

  • Pain may wax and wane and be aggravated by activities that worsen reflux (eg, recumbent position, bending over, or high-fat meals).

  • Extraesophageal symptoms may include chronic cough, laryngitis, asthma, and dental enamel erosion.

  • Alarm symptoms include dysphagia, odynophagia, and unexplained weight loss.

  • Tissue injury-based GERD (with or without symptoms) may present with esophagitis, esophageal strictures, Barrett esophagus, or esophageal carcinoma.

DIAGNOSIS

MEANS OF CONFIRMATION AND DIAGNOSIS

  • Clinical history, including symptoms and risk factors.

  • Patients with mild, typical symptoms do not usually require invasive evaluation.

  • Clinical diagnosis can be assumed in patients who respond to appropriate therapy.

  • Perform diagnostic tests in patients who do not respond to therapy or who present with alarm symptoms.

IMAGING

  • Barium radiography not routinely used—lacks sensitivity and specificity, and cannot identify Barrett esophagus.

DIAGNOSTIC PROCEDURES

  • Endoscopy preferred for assessing mucosa for esophagitis, identifying Barrett esophagus, and diagnosing complications.

  • Camera-containing capsule swallowed by patient can visualize esophageal mucosa.

  • Ambulatory pH monitoring helps correlate symptoms with abnormal esophageal acid exposure.

  • Combined impedance–pH monitoring measures both acid ...

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