GERD

• Gastroesophageal reflux disease (GERD) is symptoms or complications resulting from refluxed stomach contents into the esophagus, oral cavity, or lungs
• Episodic heartburn that is not frequent or painful enough to be bothersome is not included in the definition
• Reflux in some cases is associated with defective lower esophageal sphincter (LES) pressure or function
• Patients may have decreased LES pressure from spontaneous transient LES relaxations, transient increases in intraabdominal pressure, or an atonic LES
• Problems with other normal mucosal defense mechanisms may contribute to the development of GERD
• Abnormal esophageal anatomy-Congenital GERD
• Improper esophageal clearance of gastric fluids
• Reduced mucosal resistance to acid
• Delayed or ineffective gastric emptying
• Inadequate production of epidermal growth factor
• Reduced salivary buffering of acid
• Esophagitis occurs when the esophagus is repeatedly exposed to refluxed gastric contents for prolonged periods
• Substances that promote esophageal damage upon reflux into the esophagus include gastric acid, pepsin, bile acids, and pancreatic enzymes
• An "acid pocket" is thought to be an area of unbuffered acid in the proximal stomach that accumulates after a meal and may contribute to GERD symptoms postprandially
• GERD patients are predisposed to upward migration of acid from the acid pocket, which may also be positioned above the diaphragm in patients with hiatal hernia, increasing the risk for acid reflux
• Reflux and heartburn are common in pregnancy due to hormonal effects on LES tone and increased intraabdominal pressure from an enlarging uterus
• Obesity is a risk factor for GERD due to increased intra-abdominal pressure
• Complications from long-term acid reflux include esophagitis, esophageal strictures, Barrett esophagus, and esophageal adenocarcinoma
• An esophageal stricture refers to the abnormal narrowing of the esophageal lumen, often presenting as dysphagia
• Barrett's esophagus is a condition where tissue similar to the lining of the intestine replaces the tissue lining the esophagus, increasing the risk of esophageal adenocarcinoma
• Symptom-based GERD typically presents with heartburn, water brash, belching, and regurgitation
• Alarm symptoms indicating complications include dysphagia, odynophagia, bleeding, and weight loss
• Nonerosive reflux disease (NERD) refers to the absence of tissue injury or erosions in GERD
• Tissue injury-based GERD may present with esophagitis, esophageal strictures, Barrett esophagus, or esophageal carcinoma
• Extraesophageal symptoms may include chronic cough, laryngitis, and asthma
• Diagnostic tests may be necessary for patients who do not respond to therapy or present with alarm symptoms, with endoscopy preferred for assessing mucosal injury and complications
• Therapy aims to decrease acidity of the refluxate, improve gastric emptying, increase LES pressure, enhance esophageal acid clearance, and protect the esophageal mucosa
• Lifestyle changes, antacids, H2 receptor antagonists, proton pump inhibitors, and antireflux surgery are treatment options based on disease severity
• Pharmacologic therapy includes antacids, proton pump inhibitors, and histamine 2-receptor antagonists
• Promotility agents and mucosal protectants may be adjuncts to acid-suppression therapy in some cases
• Omeprazole, lansoprazole, esomeprazole, pantoprazole, and rabeprazole are proton pump inhibitors with profound and long-lasting antisecretory effects
• Histamine 2-receptor antagonists like cimetidine, ranitidine, famotidine, and nizatidine are effective for treating mild to moderate GERD
• Promotility agents like metoclopramide and bethanechol may be useful adjuncts in patients with motility defects
• Sucralfate is a mucosal protectant with limited value for GERD treatment but may be useful for other conditions like radiation esophagitis and bile reflux GERD
• Nonpharmacologic therapy includes weight reduction, dietary changes, and lifestyle modifications to manage GERD symptoms