GERD

Gastroesophageal reflux disease

• Consequences from the reflux of gastric contents into the esophagus
accompanied by a failure of anatomic and physiologic mechanisms to
protect the esophagus
Etiology
Etiologic factors
Dec. pressure of LES or alteration in
esophageal acid cleareance Gastric contents near junction
• Foods: chocolate, peppermint, fatty foods, citrus products, spicy
foods, garlic, onions • Recumbency
• beverages: coffee, carbonated drinks, alcohol
• Caffeine • Inc. intraabdominal pressure
• Nicotine (smoking)
• CNS depressant (morphine, diazepam)
• Other meds: calcium channel blockers, nitrates, aspirin, NSAIDS,
dopamine, theophylline, tricyclic depressants
• Estrogen therapy
• NGT
• Scleroderma
• Prolonged vomiting
• Right side lying; sitting
• Pregnancy (last trimester: inc. Progesterone relaxes the sphincter)
Pathophysiology
• See notebook
Clinical manifestations
• Heartburn and regurgitation- typical symptoms
• Dysphagia and chest pain- less common symptoms
• Other common sx:
• Chest pain
• Acid regurgitation
• Belching
• Dysphagia
• Nausea
• Vomiting
• Early satiety
• Odynophagia
• Heartburn occurs 30-60 mins after large meal or meal with alcohol,
spicy foods, fats, and citrus
• Lying down may worsen he symptoms
Extraesophageal manifestations
• 3 main extraesophageal manifestations:
• Asthma – causes GERD through microaspiration of reflux material and/or vagally mediated esophagobronchial
reflex
• Cough – develop from 2 diff. mechanisms:
• 1st: from direct reflux of gastroduodenal contents (inflammation can be seen endoscopically)
• 2nd: indirect vagal stimulation (inflammation not visible)

• Cough may be reported during the day, while upright, or eating

• Laryngitis – GERD is the most important cause of laryngitis
• Associated sx:
• Hoarseness
• Dysphagia
• Repeated throat clearing
• Sensation of having caught in the throat
• Cough
• Excessive phlegm
• Voice fatigue
• heartburn
Diagnosis
• Principally by symptoms, ie., heartburn occurring 2 or 3x per week
and/or complications with reflux.
• Diagnostic tools:
• Hx
• Endoscopy
• Barium radiography
• H. Pylori and esophageal pH monitoring (quantifying acid and reflux events
with a correlation with symptoms)
Differential diagnosis
• Infectious esophagitis
• Pill esophagitis
• Eosinophilic esophagitis
• Peptic ulcer disease
• Dyspepsia
• Biliary colic
• Coronary heart disease
• Esophageal motility disorders
Treatment
• Goals:
• Alleviate symptoms
• Heal esophagitis (if present)
• Maintain remission of the disease
• Manage any complications
Treatment 1: lifestyle modifications
• Routinely advocated as GERD therapy
• 3 categories:
• Avoidance of food that reduces LES pressure, making them refluxogenic (eg. Alcohol, fatty foods,
spearmint, peppermint, coffee, tea)
• Avoidance of acidic foods that are irritating (citrus fruits, tomato-based foods)
• Adoption of behaviors to minimize reflux and/or heartburn

• People with GERD should remain upright for at least 3hrs after meal and avoid meals
near bedtime or naptime
• Elevate head of bed when lying
• Lying down in the left lateral decubitus position – helpful for persons with nighttime sx
Treatment 2: medications
• Antacids – work by buffering gastric acid for a short period of time
• H2 blockers- block histamine (which normally induces parietal cells via gastrin to
secrete acid); more effective only for nighttime sx rather than meal- induced sx and
are less effective in healing esophagitis and other complications
• Eg.: ranitidine, cimetidine, famotidine
• Proton pump inhibitors- most effective therapy; acid suppression; reduce nighttime
and meal-induced acid production; superior to H2-blockers
• Main side effects: diarrhea and headache
• Omeprazole can interfere with warfarin

• Reducing acidity of gastric juice does not prevent reflux, but it ameliorates the reflux
sx and allows the esophagitis to heal
• Patients with mild to moderate disease can consider step-down
approach once PPI has healed esophagitis and relieved sx. This includes:
• Switch to h2-blocker
• PPI may inc. risk of CAP and enteric infections; and interfere with
calcium absorption, leading to osteoporosis.
• Prolonged use of antacids should be avoided as this can reduce the
body’s phosphate lvl., w/ resultant fatigue and loss of appetite
• Aluminum hydroxide- produce constipation
• Magnesium hydroxide- cause loose stool or diarrhea
Treatment 3: surgery
• Carefully selected when conservative (nonoperative care) has failed to
control sx
• Surgery attempts to:
• Reconstruct the normal anatomic and physologic function of the
diaphragmatic hiatus and eliminate the need for medications
• But many pts. May still require medication ff. Surgery
• Laparoscopic Nissen fundoplication
• The proximal stomach is wrapped around the distal esophagus to create an
antireflux barrier
• For chronic GERD