Disorder characterized by frequent passage of gastric contents from the stomach back into the esophagus. Symptoms of GERD may include heartburn, coughing, frequent clearing of the throat, and difficulty in swallowing. It can be caused by relaxation of the muscle that connects the esophagus and the stomach, delayed emptying of the esophagus or stomach, hiatal hernia, obesity, or pregnancy. Treatment is with antacids or acid-inhibiting medications and lifestyle changes such as not eating before bedtime, avoiding acidic or fatty foods or beverages, cessation of smoking, and weight loss. Surgery may be necessary in severe cases.
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This is commonly due to transient or permanent changes in the barrier between the esophagus and the stomach. This can be due to incompetence of the cardia, transient cardia relaxation, impaired expulsion of gastric reflux from the esophagus, or a hiatus hernia.
If the reflux reaches the throat, it is called laryngopharyngeal reflux disease.
Occasional heartburn is common but does not necessarily mean one has GERD. Patients with heartburn symptoms more than once a week are at risk of developing GERD. A hiatal hernia is usually asymptomatic, but the presence of a hiatal hernia is a risk factor for developing GERD.
GERD is commonly treated with Proton Pump Inhibitor PPI medications which inhibit acid production in the stomach but do not reduce frequency of reflux episodes. Approximately 30% of GERD patients experience inadequate symptom relief while on PPI therapy.
GERD may be difficult to detect in infants and children. Symptoms may vary from typical adult symptoms. GERD in children may cause repeated vomiting, effortless spitting up, coughing, and other respiratory problems. Inconsolable crying, failure to gain adequate weight, refusing food, bad breath, and belching or burping are also common. Children may have one symptom or many — no single symptom is universal in all children with GERD.
It is estimated that of the approximately 4 million babies born in the U.S. each year, up to 35% of them may have difficulties with reflux in the first few months of their life, known as spitting up. Most of those children will outgrow their reflux by their first birthday. However, a small but significant number of them will not outgrow the condition.
Babies' immature digestive systems are usually the cause, and most infants stop having acid reflux by the time they reach their first birthday. Some children do not outgrow acid reflux, however, and continue to have it into their teen years. Children who have had heartburn that does not seem to go away, or any other GERD symptoms for a while, should talk to their parents and visit their doctor.
A detailed history taking is vital to the diagnosis. Useful investigations may include barium swallow X-rays, esophageal manometry, 24-hour esophageal pH monitoring and Esophagogastroduodenoscopy (EGD). In general, an EGD is done when the patient does not respond well to treatment, or has alarm symptoms including: dysphagia, anemia, blood in the stool (detected chemically), wheezing, weight loss, or voice changes. Some physicians advocate once-in-a-lifetime endoscopy for patients with longstanding GERD, to evaluate the possible presence of Barrett's esophagus, a precursor lesion for esophageal adenocarcinoma.
Esophagogastroduodenoscopy (EGD) (a form of endoscopy) involves insertion of a thin scope through the mouth and throat into the esophagus and stomach (often while the patient is sedated) in order to assess the internal surfaces of the esophagus, stomach, and duodenum.
Biopsies can be performed during gastroscopy and these may show:
Reflux changes may be non-erosive in nature, leading to the entity non-erosive reflux disease.
Patients with ongoing symptoms while on PPI therapy are commonly diagnosed with impedance-pH monitoring while continuing their medications. The impedance-pH monitoring diagnostic test determines the frequency of reflux episodes and the time relationship of reflux episodes and symptoms. The impedance-pH monitoring test determines if the patient's symptoms are related to acid reflux, related to nonacid reflux or not related to reflux or any type. A positive GERD diagnosis is made if acid or nonacid reflux preceeds symptoms in a statistically meaningful manner. Patients with a positive impedance-pH monitoring test may benefit from acid reduction therapy such as fundoplication surgery or endoscopic fundoplication techniques.
Another paradoxical cause of GERD-like symptoms is not enough stomach acid (hypochlorhydria). The valve that empties the stomach into the intestines is triggered by acidity. If there is not enough acid this valve does not open, and the stomach contents are churned up into the esophagus. However, there is still enough acidity to irritate the esophagus.
Factors that can contribute to GERD:
Factors that have been linked with GERD but not conclusively:
Elevating the head of the bed is also effective. Additional conservative measures may be considered if there is incomplete relief. Another approach is to apply all conservative measures for maximum response. A meta-analysis suggested that elevating the head of bed is an effective therapy, although this conclusion was only supported by nonrandomized studies .
The head of the bed can be elevated by plastic or wooden bed risers that support bed posts or legs, a bed wedge pillow, or a wedge or an inflatable mattress lifter that fits in between mattress and box spring. The height of the elevation is critical and must be at least 6 to 8 inches (15 to 20 cm) to be at least minimally effective to prevent the backflow of gastric fluids. It should be noted that some innerspring mattresses do not work well when inclined and tend to cause back pain, thus foam mattresses are to be preferred. Some practitioners use higher degrees of incline than provided by the commonly suggested 6 to 8 inches (15 to 20 cm) and claim greater success.
In adults, a slouched posture is an important factor contributing to GERD. With a slouched posture there is no straight path between the stomach and esophagus; muscles around the esophagus go into a spasm. Gas and acidity get blocked in the spasm, causing coughing and other asthma-like symptoms.
An obsolete treatment is vagotomy ("highly selective vagotomy"), the surgical removal of vagus nerve branches that innervate the stomach lining. This treatment has been largely replaced by medication.
Subsequently the NDO Surgical Plicator was cleared by the FDA for endoscopic GERD treatment. The Plicator creates a plication, or fold, of tissue near the gastroesophageal junction, and fixates the plication with a suture-based implant. The company ceased operations in mid 2008, and the device is no longer on the market.
Another treatment that involved injection of a solution during endoscopy into the lower esophageal wall was available for about one year ending in late 2005. It was marketed under the name Enteryx. It was removed from the market due to several reports of complications from misplaced injections.
Management of gastroesophageal reflux disease.(CME Topic)(medical research)(includes related article "Key Points" and statistical tables)
Jul 01, 2006; Abstract: Gastroesophageal reflux disease is the most common and expensive digestive disease with complex and multi-factorial...