Gastroesophageal reflux disease

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This article is about Gastroesophageal reflux disease. For other uses of the term Reflux, please see Reflux (disambiguation).

Gastroesophageal reflux disease (GERD) is a condition in which stomach acid repeatedly flows upwards into the esophagus and throat, causing "heartburn" and sometimes sore-throat pain and sinusitis. It is also spelled "Gastrooesophageal reflux disease" (abbreviated GORD) in Britain and Commonwealth countries.

Cause/etiology

Gastroesophageal reflux disease is a multifactorial disease.[1]

Twin studies suggest a genetic component.[2]

Obesity

Obesity if associated with gastroesophageal reflux disease.[3][4] Obesity may interfeere with function of the gastroesophageal junction.[5]

Hiatal hernia

The presence of a hiatal hernia correlates with abnormal 24 ph monitoring. In one study the presence of abnormal ph monitoring was:[6]

  • No hernia 18%
  • Hernia < 2cm 27%
  • Hernia > 2cm 35%

Psychological stress

Psychological stress may lead to physiologic abnormalities in the esophagus.[7]

Signs/symptoms

Patients with GERD may have heartburn or reflux symptoms; however, these symptoms may be due to peptic ulcer disease.[8][9]

GERD may be able to exacerbate asthma.[10]

It is unclear whether GERD can cause laryngeal symptoms such as chronic hoarseness.[11][12][13][14]

Diagnosis

There is no single test that can identify all patients with GERD. However, most patients with have abnormalities of either 24 hour ph monitoring or the Berstein test.[1]

Response to antisecretory therapy

One study found:[15]

This leads to a negative likelihood ratio of 0.35 which indicates the test, when the patient does not respond to treatment, has some value in excluding the diagnosis of GERD.

Endoscopy may be needed for patients with typical symptoms according to a randomized controlled trial.[16]

Radiology

Hiatal hernia

The accuracy of a radiologic hiatal hernia predicts abnormal 24 hour ph monitoring is:[6] Hernia of any size:

Hernia at least 2cm:

Reflux on manual stomach compression or valsalva

The accuracy of reflux during the upper gastrointestinal series predicts endoscopic esophagitis is:[17]

Spontaneous reflux:

Reflux during abdominal compression:

Esophagogastroduodenoscopy

Clinical practice guidelines recommend esophagogastroduodenoscopy if:[19]

Treatment

Avoid tight fitting garments.

  • Eating slower may help.[20]
  • The evidence for most dietary interventions is anecdotal.[21]
  • Positioning. A meta-analysis found that elevating the head of the bed may help.[21]. A subsequent randomized cross-over study showed benefit by avoiding eating two hours before bed.[22] Sleeping in the left lateral decubitus position might help.[23]
  • Weight loss might reduce symptoms.[21][24]

Medications

A meta-analysis found that "alginate/antacid combination (Gaviscon) had an absolute benefit increase of 26%(number needed to treat is 4), histamine H2 antagonists had an absolute benefit of 10-12%(number needed to treat is 9), and antacids had an absolute benefit increase 8% (number needed to treat is 12)."[25]

Regarding proton pump inhibitor medications, systematic reviews by the Cochrane Collaboration and Clinical Evidence concluded "PPI therapy is the most effective therapy in oesophagitis but H2RA therapy is also superior to placebo."[26][27] PPIs may be taken 'on-demand' for nonerosive GERD and continuous therapy for erosive GERD.[28]

Regarding prokinetic medications, systematic reviews by the Cochrane Collaboration and Clinical Evidence concluded "There is a paucity of evidence on prokinetic therapy but no evidence that it is superior to placebo."[26][27]

Although PPIs are the most effective individual drug, adding cisapride may give further benefit.[29] Cisapride is no longer on the market due to cardiac drug-related side effects and adverse reactionss.

Reducing medications

Some patients will be able to take 2-4 week course of medications as needed.[30]

15% of patients may be able to stop medications after symptoms are controlled.[31]

Stopping medications may lead to transient rebound hypersecretion of acid.[32]

Surgery

Laparoscopic fundoplication may be better than medical therapy at reducing chronic symptoms.[33]

Prognosis

Patients with reflux symptoms are at a small increased risk of Barrett esophagus.[34]

References

  1. 1.0 1.1 Howard PJ, Maher L, Pryde A, Heading RC (1991). "Symptomatic gastro-oesophageal reflux, abnormal oesophageal acid exposure, and mucosal acid sensitivity are three separate, though related, aspects of gastro-oesophageal reflux disease". Gut 32 (2): 128–32. PMID 1864528[e]
  2. Mohammed I, Cherkas LF, Riley SA, Spector TD, Trudgill NJ (2003). "Genetic influences in gastro-oesophageal reflux disease: a twin study". Gut 52 (8): 1085–9. PMID 12865263[e]
  3. El-Serag HB, Ergun GA, Pandolfino J, Fitzgerald S, Tran T, Kramer JR (2007). "Obesity increases oesophageal acid exposure". Gut 56 (6): 749–55. DOI:10.1136/gut.2006.100263. PMID 17127706. Research Blogging.
  4. Corley DA, Kubo A, Zhao W (2007). "Abdominal obesity, ethnicity and gastro-oesophageal reflux symptoms". Gut 56 (6): 756–62. DOI:10.1136/gut.2006.109413. PMID 17047097. Research Blogging.
  5. Pandolfino JE, El-Serag HB, Zhang Q, Shah N, Ghosh SK, Kahrilas PJ (2006). "Obesity: a challenge to esophagogastric junction integrity". Gastroenterology 130 (3): 639–49. DOI:10.1053/j.gastro.2005.12.016. PMID 16530504. Research Blogging.
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  7. Farré R, De Vos R, Geboes K, et al (2007). "Critical role of stress in increased oesophageal mucosa permeability and dilated intercellular spaces". Gut 56 (9): 1191–7. DOI:10.1136/gut.2006.113688. PMID 17272649. Research Blogging.
  8. Talley NJ, Weaver AL, Tesmer DL, Zinsmeister AR (1993). "Lack of discriminant value of dyspepsia subgroups in patients referred for upper endoscopy". Gastroenterology 105 (5): 1378–86. PMID 8224642[e]
  9. Johnsen R, Bernersen B, Straume B, Førde OH, Bostad L, Burhol PG (1991). "Prevalences of endoscopic and histological findings in subjects with and without dyspepsia". BMJ 302 (6779): 749–52. PMID 2021764[e] Fulltext
  10. Kiljander TO, Harding SM, Field SK, et al (2006). "Effects of esomeprazole 40 mg twice daily on asthma: a randomized placebo-controlled trial". Am. J. Respir. Crit. Care Med. 173 (10): 1091–7. DOI:10.1164/rccm.200507-1167OC. PMID 16357331. Research Blogging.
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  13. Vaezi MF (2007). "Are there specific laryngeal signs for gastroesophageal reflux disease?". Am. J. Gastroenterol. 102 (4): 723–4. DOI:10.1111/j.1572-0241.2007.01143.x. PMID 17397405. Research Blogging.
  14. Wo JM, Koopman J, Harrell SP, Parker K, Winstead W, Lentsch E (2006). "Double-blind, placebo-controlled trial with single-dose pantoprazole for laryngopharyngeal reflux". Am. J. Gastroenterol. 101 (9): 1972–8; quiz 2169. DOI:10.1111/j.1572-0241.2006.00693.x. PMID 16968502. Research Blogging.
  15. Aanen MC, Weusten BL, Numans ME, de Wit NJ, Baron A, Smout AJ (2006). "Diagnostic value of the proton pump inhibitor test for gastro-oesophageal reflux disease in primary care". Aliment. Pharmacol. Ther. 24 (9): 1377–84. DOI:10.1111/j.1365-2036.2006.03121.x. PMID 17059519. Research Blogging.
  16. Giannini EG, Zentilin P, Dulbecco P, Vigneri S, Scarlata P, Savarino V (2008). "Management strategy for patients with gastroesophageal reflux disease: a comparison between empirical treatment with esomeprazole and endoscopy-oriented treatment". Am. J. Gastroenterol. 103 (2): 267–75. DOI:10.1111/j.1572-0241.2007.01659.x. PMID 18289194. Research Blogging.
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  18. Sellar RJ, De Caestecker JS, Heading RC (1987). "Barium radiology: a sensitive test for gastro-oesophageal reflux". Clinical radiology 38 (3): 303–7. PMID 3581674[e]
  19. Shaheen, Nicholas J.; David S. Weinberg, Thomas D. Denberg, Roger Chou, Amir Qaseem, Paul Shekelle (2012-12-04). "Upper Endoscopy for Gastroesophageal Reflux Disease: Best Practice Advice From the Clinical Guidelines Committee of the American College of Physicians". Annals of Internal Medicine 157 (11): 808-816. DOI:10.7326/0003-4819-157-11-201212040-00008. ISSN 0003-4819. Retrieved on 2012-12-04. Research Blogging.
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  31. Inadomi JM, Jamal R, Murata GH, et al (2001). "Step-down management of gastroesophageal reflux disease". Gastroenterology 121 (5): 1095–100. PMID 11677201[e]
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  34. Ward EM, Wolfsen HC, Achem SR, et al (2006). "Barrett's esophagus is common in older men and women undergoing screening colonoscopy regardless of reflux symptoms". Am. J. Gastroenterol. 101 (1): 12–7. DOI:10.1111/j.1572-0241.2006.00379.x. PMID 16405528. Research Blogging.