Gastroesophageal Reflux Disease

Source: William DB, Schade RR. Gastroesophageal Reflux Disease. In: DiPiro JT, Talbert RL, Yee GC, Matzke GR, Wells BG, Posey LM, eds. Pharmacotherapy: A Pathophysiologic Approach. 8th ed. http://accesspharmacy.com/content.aspx?aid=7977509. Accessed June 12, 2012.

• Heartburn
• Acid reflux disease
• GERD

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

• 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

• 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.

• Most common in persons older than 40 years.
• 10–20% 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.

• Obesity
• Smoking
• Alcohol consumption
• Certain medications and foods

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 (e.g., 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.

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 and nonacid reflux.
• Esophageal manometry used to evaluate esophageal peristalsis and motility prior to antireflux surgery.

Differential Diagnosis

• Angina pectoris
• Peptic ulcer disease
• Gastritis
• Infectious esophagitis (Candida, herpes simplex virus, cytomegalovirus)
• Pill-induced esophagitis
• Esophageal motility disorders (e.g., achalasia, esophageal spasm, scleroderma)
• Zollinger-Ellison syndrome

• Reduce or eliminate symptoms.
• Decrease frequency and duration of reflux.
• Promote healing of injured mucosa.
• Prevent development of complications.

• Treatment strategies can:
  • Decrease acidity of refluxate
  • Reduce gastric volume
  • Improve ...