Gastro-esophageal Reflux Disease (GERD)

Gastroesophageal reflux disease (GERD) is a condition where normal stomach acid refluxes back into the esophagus causing symptoms of abdominal or chest discomfort.  This is the first step in a spectrum of disease that encompasses injuries to the esophagus, including esophagitis (inflammation of the esophagus), stricture (persistent narrowing of the esophagus), Barrett’s esophagus (histologic changes to the epithelial cells which is a precursor to cancer), and finally esophageal adenocarcinoma (cancer of the esophagus). 

Primarily due to Western diets, it is estimated that 25-40% of Americans experience symptomatic GERD at some point, with about 7-10% experiencing symptoms on a daily basis.1

Due to the fact that many people take over to counter antacids without seeking medical attention, this number is likely higher.

GERD patients have some degree of esophagitis.  Esophagitis occurs when gastric acid and pepsin (an enzyme that breaks down proteins) reflux back into the esophagus, causing varying levels of damage to the esophageal endothelium with erosions, ulcers, or necrosis of the lower esophagus.  This occurs via an inability of the lower esophageal sphincter to completely block acid from refluxing.  The primary mechanism of this is via transient lower esophageal relaxation through a vasovagal reflex caused by gastric distention; this accounts for about 90% of reflux in normal people.2

Typical symptoms of GERD include heartburn (a midsternal or midepigastric burning sensation) and regurgitation that usually occur after eating or lying down.  Less commonly, it may lead to patients complaining of chest pain or dysphagia.  Patients with dysphagia experience a sense that food is stuck, and can be an advanced symptom.  

Further symptoms that may present, although still less commonly, include chronic cough, laryngitis, hoarseness, dental erosions.  Cough or wheezing are symptoms that result from aspiration of gastric contents into the lungs.  Hoarseness results from irritation of the vocal cords.

Physical exam may only be notable for mild mid-epigastric abdominal tenderness to palpation, however this does not necessarily need to be present.  Physical exam is usually normal if not presenting with any tenderness on exam, as history and symptom description can primarily lead to suspected diagnosis.  

Initial workup includes evaluating for other causes of patient’s symptoms.  In patient’s complaining of abdominal discomfort, other etiologies of upper abdominal pain should be considered including biliary disease, cardiac disease, and vascular (abdominal aorta) disease.  Complaints of chest pain should warrant further cardiac workup depending on age and risk factors.

Once other causes are ruled out, and suspicion of GERD is raised, referral for upper endoscopy is warranted.  THe upper esophageal tract can be directly visualized for signs of inflammation.  Endoscopy helps to confirm diagnosis by showing complications of reflux such as esophagitis, stricture, and Barret’s esophagus.  Esophageal manometry can be performed to help determine the lower esophageal sphincter pressure and help guide decisions regarding surgical management.  

Optional studies include the 24 hour pH testing and upper GI series.  24 hour pH monitoring helps confirm diagnosis in white history is not clear.  Upper GI series x-ray can help to show anatomy.2

Lifestyle modifications in diet are routinely first line recommendations in therapy.  Avoidance of foods that commonly reduce lower esophageal sphincter pressure (fatty foods, alcohol, tomato-based foods, caffeine) and avoiding naturally acidic foods.

The main approach pharmacologically is with gastic acid secretion inhibitors, also known as “antacids.”  Reducing the amount of acid does not prevent reflux, but it helps reduce the amount of acid available to actually reflux.  By reducing acid, esophagitis is allowed to heal normally.  

• H2 receptor antagonists are first line therapy for mild to moderate symptoms, and include ranitidine, cimetidine, famotidine.  H2 receptor antagonists are effectine for healing only mild esophagitis.

• Proton pump inhibitors (PPI) are the most powerful medications available for treating GERD, which block acid secretion altogether; these include omeprazole, lansoprazole, and esomeprazole.

A research review by the Agency for Healthcare Research and Quality (AHRQ) concluded, on the basis of grade A evidence, that PPIs were superior to H2 receptor antagonists for the resolution of GERD symptoms at 4 weeks and healing of esophagitis at 8 weeks.  Additionally, no difference between individual PPIs for relief of symptoms were found.3

For patients where symptoms are not controlled by PPI therapy, presence of Barrett’s esophagus, or presence of extra-esophageal symptoms are some indications for surgical management.  Nissen fundoplication is the standard surgical treatment for severe GERD.  In this procedure, the upper part of the stomach is wrapped around the lower esophageal sphincter to strengthen the sphincter and prevent acid reflux.2

References

1) Herbella FA, Sweet MP, Tedesco P, Nipomnick I, Patti MG. Gastroesophageal reflux disease and obesity. Pathophysiology and implications for treatment. J Gastrointest Surg. 2007 Mar. 11(3):286-90.

2) Kahrilas, Peter J., and Ikuo Hirano.. "Diseases of the Esophagus." Harrison's Principles of Internal Medicine, 19e Eds. Dennis Kasper, et al. New York, NY: McGraw-Hill, 2014.

3) Agency for Healthcare Research and Quality. Comparative Effectiveness of Management Strategies for Gastroesophageal Reflux Disease - Executive Summary. AHRQ pub. no. 06-EHC003-1. December 2005.