Gastroesophageal reflux disease

Gastroesophageal reflux disease
Synonyms Gastro-oesophageal reflux disease (GORD), gastric reflux disease, acid reflux disease, reflux, gastroesophageal reflux
X-ray showing radiocontrast from the stomach entering the esophagus due to severe reflux
Pronunciation
  • /gæstroʊɪˌsɑfəˈdʒiəl/ /ˈriflʌks/[1][2][3]
Specialty Gastroenterology
Symptoms Taste of acid, heartburn, bad breath, chest pain, breathing problems[4]
Complications Esophagitis, esophageal strictures, Barrett's esophagus[4]
Duration Long term[4][5]
Causes Poor closure of the lower esophageal sphincter[4]
Risk factors Obesity, pregnancy, smoking, hiatus hernia, taking certain medicines[4]
Diagnostic method Gastroscopy, upper GI series, esophageal pH monitoring, esophageal manometry[4]
Similar conditions Peptic ulcer disease, esophageal cancer, esophageal spasm, angina[6]
Treatment Lifestyle changes, medications, surgery[4]
Medication Antacids, H2 receptor blockers, proton pump inhibitors, prokinetics[4][7]
Frequency ~15% (Western populations)[7]

Gastroesophageal reflux disease (GERD), also known as acid reflux, is a long-term condition where stomach contents come back up into the esophagus resulting in either symptoms or complications.[4][5] Symptoms include the taste of acid in the back of the mouth, heartburn, bad breath, chest pain, vomiting, breathing problems, and wearing away of the teeth. Complications include esophagitis, esophageal strictures, and Barrett's esophagus.[4]

Risk factors include obesity, pregnancy, smoking, hiatus hernia, and taking certain medicines.[4] Medications involved include antihistamines, calcium channel blockers, antidepressants, and sleeping medication. It is due to poor closure of the lower esophageal sphincter (the junction between the stomach and the esophagus). Diagnosis among those who do not improve with simpler measures may involve gastroscopy, upper GI series, esophageal pH monitoring, or esophageal manometry.[4]

Treatment is typically via lifestyle changes, medications, and sometimes surgery. Lifestyle changes include not lying down for three hours after eating, losing weight, avoiding certain foods, and stopping smoking.[4] Medications include antacids, H2 receptor blockers, proton pump inhibitors, and prokinetics.[4][7] Surgery may be an option in those who do not improve with other measures.[4]

In the Western world, between 10 and 20% of the population are affected by GERD.[7] Gastroesophageal reflux (GER) once in a while, without significant symptoms or complications, is more common.[4] The condition was first described in 1935 by the American gastroenterologist Asher Winkelstein.[8] The classic symptoms had been described earlier in 1925.[9]

Signs and symptoms

Adults

The most common symptoms of GERD in adults are an acidic taste in the mouth, regurgitation, and heartburn.[10] Less common symptoms include pain with swallowing/sore throat, increased salivation (also known as water brash), nausea,[11] chest pain, and coughing.

GERD sometimes causes injury of the esophagus. These injuries may include one or more of the following:

Some researchers have proposed that recurrent ear infections,[13] and idiopathic pulmonary fibrosis[14] might be tied, in some cases, to GERD; however, a causative role has not been established. GERD does not appear to be linked to chronic sinusitis.[15]

Children

GERD may be difficult to detect in infants and children, since they cannot describe what they are feeling and indicators must be observed. Symptoms may vary from typical adult symptoms. GERD in children may cause repeated vomiting, effortless spitting up, coughing, and other respiratory problems, such as wheezing. Inconsolable crying, refusing food, crying for food and then pulling off the bottle or breast only to cry for it again, failure to gain adequate weight, bad breath, and burping are also common. Children may have one symptom or many; no single symptom is universal in all children with GERD.

Of the estimated 4 million babies born in the US each year, up to 35% of them may have difficulties with reflux in the first few months of their lives, known as 'spitting up'.[16] One theory for this is the "fourth trimester theory" which notes most animals are born with significant mobility, but humans are relatively helpless at birth, and suggests there may have once been a fourth trimester, but children began to be born earlier, evolutionarily, to accommodate the development of larger heads and brains and allow them to pass through the birth canal and this leaves them with partially undeveloped digestive systems.

Most children will outgrow their reflux by their first birthday. However, a small but significant number of them will not outgrow the condition. This is particularly true when a family history of GERD is present.

Barrett's esophagus

GERD may lead to Barrett's esophagus, a type of intestinal metaplasia,[12] which is in turn a precursor condition for esophageal cancer. The risk of progression from Barrett's to dysplasia is uncertain, but is estimated at about 20% of cases.[17] Due to the risk of chronic heartburn progressing to Barrett's, EGD every five years is recommended for people with chronic heartburn, or who take drugs for chronic GERD.[18]

Causes

A comparison of a healthy condition to GERD

GERD is caused by a failure of the lower esophageal sphincter. In healthy patients, the "Angle of His"—the angle at which the esophagus enters the stomach—creates a valve that prevents duodenal bile, enzymes, and stomach acid from traveling back into the esophagus where they can cause burning and inflammation of sensitive esophageal tissue.

Factors that can contribute to GERD:

GERD has been linked to a variety of respiratory and laryngeal complaints such as laryngitis, chronic cough, pulmonary fibrosis, earache, and asthma, even when not clinically apparent. These atypical manifestations of GERD are commonly referred to as laryngopharyngeal reflux (LPR) or as extraesophageal reflux disease (EERD).

Factors that have been linked with GERD, but not conclusively:

In 1999, a review of existing studies found that, on average, 40% of GERD patients also had H. pylori infection.[25] The eradication of H. pylori can lead to an increase in acid secretion,[26] leading to the question of whether H. pylori-infected GERD patients are any different than non-infected GERD patients. A double-blind study, reported in 2004, found no clinically significant difference between these two types of patients with regard to the subjective or objective measures of disease severity.[27]

Diagnosis

Endoscopic image of peptic stricture, or narrowing of the esophagus near the junction with the stomach: This is a complication of chronic gastroesophageal reflux disease and can be a cause of dysphagia or difficulty swallowing.

The diagnosis of GERD is usually made when typical symptoms are present.[28] Reflux can be present in people without symptoms and the diagnosis requires both symptoms or complications and reflux of stomach content.[29]

Other investigations may include esophagogastroduodenoscopy (EGD). Barium swallow X-rays should not be used for diagnosis.[28] Esophageal manometry is not recommended for use in diagnosis, being recommended only prior to surgery.[28] Ambulatory esophageal pH monitoring may be useful in those who do not improve after PPIs and is not needed in those in whom Barrett's esophagus is seen.[28] Investigation for H. pylori is not usually needed.[28]

The current gold standard for diagnosis of GERD is esophageal pH monitoring. It is the most objective test to diagnose the reflux disease and allows monitoring GERD patients in their response to medical or surgical treatment. One practice for diagnosis of GERD is a short-term treatment with proton-pump inhibitors, with improvement in symptoms suggesting a positive diagnosis. Short-term treatment with proton-pump inhibitors may help predict abnormal 24-hr pH monitoring results among patients with symptoms suggestive of GERD.[30]

Endoscopy

Endoscopy, the looking down into the stomach with a fibre-optic scope, is not routinely needed if the case is typical and responds to treatment.[28] It is recommended when people either do not respond well to treatment or have alarm symptoms, including dysphagia, anemia, blood in the stool (detected chemically), wheezing, weight loss, or voice changes.[28] Some physicians advocate either once-in-a-lifetime or 5- to 10-yearly endoscopy for people with longstanding GERD, to evaluate the possible presence of dysplasia or Barrett's esophagus.[31]

Biopsies performed during gastroscopy may show:

Reflux changes may not be erosive in nature, leading to "nonerosive reflux disease".

Severity

Severity may be documented with the Johnson-DeMeester's scoring system: 0 - None 1 - Minimal - occasional episodes 2 - Moderate - medical therapy visits 3 - Severe - interfere with daily activities

Differential diagnosis

Other causes of chest pain such as heart disease should be ruled out before making the diagnosis.[28] Another kind of acid reflux, which causes respiratory and laryngeal signs and symptoms, is called laryngopharyngeal reflux (LPR) or "extraesophageal reflux disease" (EERD). Unlike GERD, LPR rarely produces heartburn, and is sometimes called silent reflux.

Treatment

The treatments for GERD include lifestyle modifications, medications, and possibly surgery. Initial treatment is frequently with a proton-pump inhibitor such as omeprazole.[28]

Lifestyle

Certain foods and lifestyle are considered to promote gastroesophageal reflux, but most dietary interventions have little supporting evidence.[33] Avoidance of specific foods and of eating before lying down should be recommended only to those in which they are associated with the symptoms.[29] Foods that have been implicated include coffee, alcohol, chocolate, fatty foods, acidic foods, and spicy foods.[29] Weight loss and elevating the head of the bed are generally useful.[34] Moderate exercise improves symptoms; however in those with GERD vigorous exercise may worsen them.[33] Stopping smoking and not drinking alcohol do not appear to result in significant improvement in symptoms.[34]

Medications

The primary medications used for GERD are proton-pump inhibitors, H2 receptor blockers and antacids with or without alginic acid.[7]

Proton-pump inhibitors (PPIs), such as omeprazole, are the most effective, followed by H2 receptor blockers, such as ranitidine.[29] If a once daily PPI is only partially effective they may be used twice a day.[29] They should be taken one half to one hour before a meal.[28] There is no significant difference between agents in this class.[28] When these medications are used long term, the lowest effective dose should be taken.[29] They may also be taken only when symptoms occur in those with frequent problems.[28] H2 receptor blockers lead to roughly a 40% improvement.[35]

The evidence for antacids is weaker with a benefit of about 10% (NNT=13) while a combination of an antacid and alginic acid (such as Gaviscon) may improve symptoms 60% (NNT=4).[35] Metoclopramide (a prokinetic) is not recommended either alone or in combination with other treatments due to concerns around adverse effects.[7][29] The benefit of the prokinetic mosapride is modest.[7]

Sucralfate has a similar effectiveness to H2 receptor blockers; however, sucralfate needs to be taken multiple times a day, thus limiting its use.[7] Baclofen, an agonist of the GABAB receptor, while effective, has similar issues of needing frequent dosing in addition to greater adverse effects compared to other medications.[7]

Surgery

The standard surgical treatment for severe GERD is the Nissen fundoplication. In this procedure, the upper part of the stomach is wrapped around the lower esophageal sphincter to strengthen the sphincter and prevent acid reflux and to repair a hiatal hernia.[36] It is recommended only for those who do not improve with PPIs.[28] Quality of life is improved in the short term compared to medical therapy, but there is uncertainty in the benefits over surgery versus long-term medical management with proton pump inhibitors.[37] When comparing different fundoplication techniques, partial posterior fundoplication surgery is more effective than partial anterior fundoplication surgery,[38] and partial fundoplication has better outcomes than total fundoplication.[39]

In 2012 the FDA approved a device called the LINX, which consists of a series of metal beads with magnetic cores that are placed surgically around the lower esophageal sphincter, for those with severe symptoms that do not respond to other treatments. Improvement of GERD symptoms is similar to those of the Nissen fundoplication, although there is no data regarding long-term effects. Compared to Nissen fundoplication procedures, the procedure has shown a reduction in complications such as gas bloat syndrome that commonly occur.[40] Adverse responses include difficulty swallowing, chest pain, vomiting, and nausea. Contraindications that would advise against use of the device are patients who are or may be allergic to titanium, stainless steel, nickel, or ferrous iron materials. A warning advises that the device should not be used by patients who could be exposed to, or undergo, magnetic resonance imaging (MRI) because of serious injury to the patient and damage to the device.[41]

In those with symptoms that do not improve with PPIs surgery known as transoral incisionless fundoplication may help.[42] Benefits may last for up to six years.[43]

Pregnancy

In pregnancy, dietary modifications and lifestyle changes may be attempted, but often have little effect. Calcium-based antacids are recommended if these changes are not effective. Aluminum- and magnesium-based antacids are also safe, as is ranitidine[44] and PPIs.[28]

Infants

Infants may see relief with changes in feeding techniques, such as smaller, more frequent feedings, changes in position during feedings, or more frequent burping during feedings.[45] They may also be treated with medicines such as ranitidine or proton pump inhibitors.[46] Proton pump inhibitors however have not been found to be effective in this population and there is a lack of evidence for safety.[47]

Overtreatment

The use of acid suppression therapy is a common response to GERD symptoms and many patients get more of this kind of treatment than their individual case merits.[48] The overuse of this treatment is a problem because of the side effects and costs which the patient will have from undergoing unnecessary therapy, and patients should not take more treatment than they need.[48]

In some cases, a person with GERD symptoms can manage them by taking over-the-counter drugs and making lifestyle changes.[49] This is often safer and less expensive than taking prescription drugs.[49] Some guidelines recommend trying to treat symptoms with an H2 antagonist before using a proton-pump inhibitor because of cost and safety concerns.[49]

Epidemiology

In Western populations, GERD affects approximately 10% to 20% of the population and 0.4% newly develop the condition.[7] For instance, an estimated 3.4 million to 6.8 million Canadians are GERD sufferers. The prevalence rate of GERD in developed nations is also tightly linked with age, with adults aged 60 to 70 being the most commonly affected.[50] In the United States 20% of people have symptoms in a given week and 7% every day.[7] No data support sex predominance with regard to GERD.

History

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.

Research

A number of endoscopic devices have been tested to treat chronic heartburn.

See also

References

  1. ↑ "Definition of "gastro-" - Collins American English Dictionary".
  2. ↑ "Definition of "esophagus" - Collins American English Dictionary".
  3. ↑ "reflux noun - Definition, pictures, pronunciation and usage notes - Oxford Advanced American Dictionary at OxfordLearnersDictionaries.com".
  4. 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 "Gastroesophageal Reflux (GER) and Gastroesophageal Reflux Disease (GERD) in Adults". NIDDK. November 13, 2014. Retrieved 13 September 2016.
  5. 1 2 Kahrilas, PJ; Shaheen, NJ; Vaezi, MF; American Gastroenterological Association, Institute; Clinical Practice and Quality Management, Committee (October 2008). "American Gastroenterological Association Institute technical review on the management of gastroesophageal reflux disease.". Gastroenterology. 135 (4): 1392–1413, 1413.e1–5. PMID 18801365. doi:10.1053/j.gastro.2008.08.044.
  6. ↑ Kahan, Scott (2008). In a Page: Medicine. Lippincott Williams & Wilkins. p. 124. ISBN 9780781770354.
  7. 1 2 3 4 5 6 7 8 9 10 11 Hershcovici T, Fass R (April 2011). "Pharmacological management of GERD: where does it stand now?". Trends in pharmacological sciences. 32 (4): 258–64. PMID 21429600. doi:10.1016/j.tips.2011.02.007.
  8. ↑ Arcangelo, Virginia Poole; Peterson, Andrew M. (2006). Pharmacotherapeutics for Advanced Practice: A Practical Approach. Lippincott Williams & Wilkins. p. 372. ISBN 9780781757843.
  9. ↑ Granderath, Frank Alexander; Kamolz, Thomas; Pointner, Rudolph (2006). Gastroesophageal Reflux Disease: Principles of Disease, Diagnosis, and Treatment. Springer Science & Business Media. p. 161. ISBN 9783211323175.
  10. ↑ Zajac P, Holbrook A, Super ME, Vogt M (March–April 2013). "An overview: Current clinical guidelines for the evaluation, diagnosis, treatment, and management of dyspepsia". Osteopathic Family Physician. 5 (2): 79–85. doi:10.1016/j.osfp.2012.10.005.
  11. 1 2 Kahrilas PJ (2008). "Gastroesophageal Reflux Disease". The New England Journal of Medicine. 359 (16): 1700–7. PMC 3058591 Freely accessible. PMID 18923172. doi:10.1056/NEJMcp0804684.
  12. 1 2 Wang KK, Sampliner RE (March 2008). "Updated guidelines 2008 for the diagnosis, surveillance and therapy of Barrett's esophagus" (PDF). Am J Gastroenterol. 103 (3): 788–97. PMID 18341497. doi:10.1111/j.1572-0241.2008.01835.x.
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  17. ↑ and Barrett's Esophagus. Retrieved on 2009-02-01.
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  25. ↑ O'Connor HJ (Feb 1999). "Helicobacter pylori and gastro-oesophageal reflux disease-clinical implications and management". Aliment Pharmacol Ther. 13 (2): 117–27. PMID 10102940. doi:10.1046/j.1365-2036.1999.00460.x.
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  28. 1 2 3 4 5 6 7 8 9 10 11 12 13 14 Katz PO, Gerson LB, Vela MF (March 2013). "Guidelines for the diagnosis and management of gastroesophageal reflux disease" (PDF). The American journal of gastroenterology. 108 (3): 308–28. PMID 23419381. doi:10.1038/ajg.2012.444.
  29. 1 2 3 4 5 6 7 Kahrilas PJ, Shaheen NJ, Vaezi MF, Hiltz SW, Black E, Modlin IM, Johnson SP, Allen J, Brill JV (October 2008). "American Gastroenterological Association Medical Position Statement on the management of gastroesophageal reflux disease". Gastroenterology. 135 (4): 1383–1391, 1391.e1–5. PMID 18789939. doi:10.1053/j.gastro.2008.08.045.
  30. ↑ Numans ME, Lau J, de Wit NJ, Bonis PA (April 2004). "Short-term treatment with proton-pump inhibitors as a test for gastroesophageal reflux disease: a meta-analysis of diagnostic test characteristics" (PDF). Annals of Internal Medicine. 140 (7): 518–27. PMID 15068979. doi:10.7326/0003-4819-140-7-200404060-00011.
  31. ↑ Patient information: Barrett's esophagus
  32. ↑ Mills, S (ed.) 2009.Sternberg's Diagnostic Pathology. 5th Edition. ISBN 978-0-7817-7942-5
  33. 1 2 Festi D, Scaioli E, Baldi F, Vestito A, Pasqui F, Di Biase AR, Colecchia A (Apr 14, 2009). "Body weight, lifestyle, dietary habits and gastroesophageal reflux disease". World journal of gastroenterology : WJG. 15 (14): 1690–701. PMC 2668774 Freely accessible. PMID 19360912. doi:10.3748/wjg.15.1690.
  34. 1 2 Kaltenbach T, Crockett S, Gerson LB (2006). "Are lifestyle measures effective in patients with gastroesophageal reflux disease? An evidence-based approach". Arch. Intern. Med. 166 (9): 965–71. PMID 16682569. doi:10.1001/archinte.166.9.965.
  35. 1 2 Tran T, Lowry AM, El-Serag HB (2007). "Meta-analysis: the efficacy of over-the-counter gastro-oesophageal reflux disease drugs". Aliment Pharmacol Ther. 25 (2): 143–53. PMID 17229239. doi:10.1111/j.1365-2036.2006.03135.x.
  36. ↑ Abbas AE, Deschamps C, Cassivi SD, Allen MS, Nichols FC, Miller DL, Pairolero PC (2004). "The role of laparoscopic fundoplication in Barrett's esophagus". Annals of Thoracic Surgery. 77 (2): 393–6. PMID 14759403. doi:10.1016/S0003-4975(03)01352-3.
  37. ↑ Garg, SK; Gurusamy, KS (5 November 2015). "Laparoscopic fundoplication surgery versus medical management for gastro-oesophageal reflux disease (GORD) in adults.". The Cochrane database of systematic reviews (11): CD003243. PMID 26544951.
  38. ↑ Kurian AA, Bhayani N, Sharata A, Reavis K, Dunst CM, Swanström LL (January 2013). "Partial anterior vs partial posterior fundoplication following transabdominal esophagocardiomyotomy for achalasia of the esophagus: meta-regression of objective postoperative gastroesophageal reflux and dysphagia". JAMA Surg. 148 (1): 85–90. PMID 23324843. doi:10.1001/jamasurgery.2013.409.
  39. ↑ Ramos, RF; Lustosa, SA; Almeida, CA; Silva, CP; Matos, D (October–December 2011). "Surgical treatment of gastroesophageal reflux disease: total or partial fundoplication? systematic review and meta-analysis.". Arquivos de gastroenterologia. 48 (4): 252–60. PMID 22147130.
  40. ↑ Badillo, Raul (2014). "Diagnosis and treatment of gastroesophageal reflux disease". World Journal of Gastrointestinal Pharmacology and Therapeutics. 5 (3): 105. doi:10.4292/wjgpt.v5.i3.105.
  41. ↑ Medical Device Approvals: LINX™ Reflux Management System - P100049, U.S. Food and Drug Administration, U.S. Department of Health and Human Services, Update of 01/17/2014
  42. ↑ Jain, D; Singhal, S (March 2016). "Transoral Incisionless Fundoplication for Refractory Gastroesophageal Reflux Disease: Where Do We Stand?". Clinical endoscopy. 49 (2): 147–56. PMC 4821522 Freely accessible. PMID 26878326. doi:10.5946/ce.2015.044.
  43. ↑ Hopkins, J; Switzer, NJ; Karmali, S (25 August 2015). "Update on novel endoscopic therapies to treat gastroesophageal reflux disease: A review.". World journal of gastrointestinal endoscopy. 7 (11): 1039–44. PMC 4549661 Freely accessible. PMID 26322157. doi:10.4253/wjge.v7.i11.1039.
  44. ↑ Mahadevan U, Kane S (July 2006). "American gastroenterological association institute medical position statement on the use of gastrointestinal medications in pregnancy". Gastroenterology. 131 (1): 278–82. PMID 16831610. doi:10.1053/j.gastro.2006.04.048.
  45. ↑ Infant acid reflux. MayoClinic.com (2013-03-28). Retrieved on 2013-09-27.
  46. ↑ Tighe MP, Afzal NA, Bevan A, Beattie RM (2009). "Current pharmacological management of gastro-esophageal reflux in children: an evidence-based systematic review". Paediatr Drugs. 11 (3): 185–202. PMID 19445547. doi:10.2165/00148581-200911030-00004.
  47. ↑ van der Pol RJ, Smits MJ, van Wijk MP, Omari TI, Tabbers MM, Benninga MA (May 2011). "Efficacy of proton-pump inhibitors in children with gastroesophageal reflux disease: a systematic review". Pediatrics. 127 (5): 925–35. PMID 21464183. doi:10.1542/peds.2010-2719.
  48. 1 2 Here is a plain English explanation, followed by specific studies.
  49. 1 2 3
  50. ↑ Fedorak RN, Veldhuyzen van Zanten S, Bridges R (July 2010). "Canadian Digestive Health Foundation Public Impact Series: Gastroesophageal reflux disease in Canada: Incidence, prevalence, and direct and indirect economic impact". Canadian Journal of Gastroenterology. 24 (7): 431–4. PMC 2918483 Freely accessible. PMID 20652158. Lay summary.
  51. ↑ Jafri SM, Arora G, Triadafilopoulos G (July 2009). "What is left of the endoscopic antireflux devices?". Current Opinion in Gastroenterology. 25 (4): 352–7. PMID 19342950. doi:10.1097/MOG.0b013e32832ad8b4.
  52. ↑ Lipka, S; Kumar, A; Richter, JE (June 2015). "No evidence for efficacy of radiofrequency ablation for treatment of gastroesophageal reflux disease: a systematic review and meta-analysis.". Clinical Gastroenterology and Hepatology. 13 (6): 1058–67.e1. PMID 25459556. doi:10.1016/j.cgh.2014.10.013.
  53. ↑ Perry, KA; Banerjee, A; Melvin, WS (August 2012). "Radiofrequency energy delivery to the lower esophageal sphincter reduces esophageal acid exposure and improves GERD symptoms: a systematic review and meta-analysis.". Surgical laparoscopy, endoscopy & percutaneous techniques. 22 (4): 283–8. PMID 22874675. doi:10.1097/sle.0b013e3182582e92.
  54. ↑ Testoni PA, Vailati C (August 2012). "Transoral incisionless fundoplication with EsophyX® for treatment of gastro-oesphageal reflux disease". Digestive and Liver Disease. 44 (8): 631–5. PMID 22622203. doi:10.1016/j.dld.2012.03.019.
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