Gastroesophageal reflux disease

Source: Wikipedia, the free encyclopedia.
"GERD" redirects here. For other uses, see Gerd.
"Acid reflux" redirects here. For the song by Oscar Jackson Jr., see Acid Reflex.

Gastroesophageal reflux disease
Other namesBritish: Gastro-oesophageal reflux disease (GORD);
prokinetics[6][9]
Frequency~15% (North American and European populations)[9]
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Gastroesophageal reflux disease (GERD) or gastro-oesophageal reflux disease (GORD) is a chronic upper gastrointestinal disease in which stomach content persistently and regularly flows up into the esophagus, resulting in symptoms and/or complications.[6][7][10] Symptoms include dental corrosion, dysphagia, heartburn, odynophagia, regurgitation, non-cardiac chest pain, extraesophageal symptoms such as chronic cough, hoarseness, reflux-induced laryngitis, or asthma.[10] In the long term, and when not treated, complications such as esophagitis, esophageal stricture, and Barrett's esophagus may arise.[6]

Risk factors include

esophageal manometry.[6]

Treatment options include lifestyle changes, medications, and sometimes surgery for those who do not improve with the first two measures. Lifestyle changes include not lying down for three hours after eating, lying down on the left side, raising the pillow or bedhead height, losing weight, and stopping smoking.

prokinetics.[6][9]

In the Western world, between 10 and 20% of the population is affected by GERD.[9] It is highly prevalent in North America with 18% to 28% of the population suffering from the condition.[13] Occasional gastroesophageal reflux without troublesome symptoms or complications is even more common.[6] The classic symptoms of GERD were first described in 1925, when Friedenwald and Feldman commented on heartburn and its possible relationship to a hiatal hernia.[14] In 1934 gastroenterologist Asher Winkelstein described reflux and attributed the symptoms to stomach acid.[15]

Signs and symptoms

Adults

The most common symptoms of GERD in adults are an acidic taste in the mouth,

coughing, and globus sensation.[18] The acid reflux can induce asthma attack symptoms like shortness of breath, cough, and wheezing in those with underlying asthma.[18]

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

  • Reflux esophagitis – inflammation of esophageal epithelium which can cause ulcers near the junction of the stomach and esophagus[19]
  • Esophageal strictures – the persistent narrowing of the esophagus caused by reflux-induced inflammation
  • Barrett's esophagus – intestinal metaplasia (changes of the epithelial cells from squamous to intestinal columnar epithelium) of the distal esophagus[20]
  • Esophageal adenocarcinoma – a form of cancer[17]

GERD sometimes causes injury of the larynx (LPR).[21][22] Other complications can include aspiration pneumonia.[23]

Children and babies

GERD may be difficult to detect in

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'.[24] About 90% of infants will outgrow their reflux by their first birthday.[25]

Mouth

Frontal view of severe tooth erosion in GERD[26]
Severe tooth erosion in GERD[26]

Acid reflux into the mouth can cause breakdown of the enamel, especially on the inside surface of the teeth. A dry mouth, acid or burning sensation in the mouth, bad breath and redness of the palate may occur.[27] Less common symptoms of GERD include difficulty in swallowing, water brash, chronic cough, hoarse voice, nausea and vomiting.[26]

Signs of enamel erosion are the appearance of a smooth, silky-glazed, sometimes dull, enamel surface with the absence of perikymata, together with intact enamel along the gum margin.[28] It will be evident in people with restorations as tooth structure typically dissolves much faster than the restorative material, causing it to seem as if it "stands above" the surrounding tooth structure.[29]

Barrett's esophagus

Main article: Barrett's esophagus

GERD may lead to Barrett's esophagus, a type of intestinal metaplasia,[20] 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 20% of cases.[30] 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.[31]

Causes

A comparison of a healthy condition to GERD

A small amount of acid reflux is typical even in healthy people (as with infrequent and minor

lower esophageal sphincter, which is at the junction between the stomach and the esophagus.[6]

Factors that can contribute to GERD:

  • Hiatal hernia, which increases the likelihood of GERD due to mechanical and motility factors.[32][33]
  • Obesity: increasing body mass index is associated with more severe GERD.[34] In a large series of 2,000 patients with symptomatic reflux disease, it has been shown that 13% of changes in esophageal acid exposure is attributable to changes in body mass index.[35]

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

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.[41]

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.[42] Reflux can be present in people without symptoms and the diagnosis requires both symptoms or complications and reflux of stomach content.[43]

Other investigations may include

Barium swallow X-rays should not be used for diagnosis.[42] Esophageal manometry is not recommended for use in the diagnosis, being recommended only prior to surgery.[42] 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.[42] Investigation for H. pylori is not usually needed.[42]

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-hour pH monitoring results among patients with symptoms suggestive of GERD.[44]

Endoscopy

blood in the stool (detected chemically), wheezing, weight loss, or voice changes.[42] 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.[45]

Biopsies performed during gastroscopy may show:

Reflux changes that are not erosive in nature lead to "nonerosive reflux disease".

Severity

Severity may be documented with the Johnson-DeMeester's scoring system:[47] 0 – None 1 – Minimal – occasional episodes 2 – Moderate – medical therapy visits 3 – Severe – interference with daily activities

Differential diagnosis

Other causes of

extraesophageal reflux disease (EERD). Unlike GERD, LPR rarely produces heartburn, and is sometimes called silent reflux.[48] Differential diagnosis of GERD can also include dyspepsia, peptic ulcer disease, esophageal and gastric cancer, and food allergies.[49]

Treatment

The treatments for GERD may include food choices, lifestyle changes, medications, and possibly surgery. Initial treatment is frequently with a

H2 antagonist before using a proton-pump inhibitor because of cost and safety concerns.[50]

Medical nutrition therapy and lifestyle changes

Medical nutrition therapy plays an essential role in managing the symptoms of the disease by preventing reflux, preventing pain and irritation, and decreasing gastric secretions.[10]

Some foods such as chocolate, mint, high-fat food, and alcohol have been shown to relax the lower esophageal sphincter, increasing the risk of reflux.[10] Weight loss is recommended for the overweight or obese, as well as avoidance of bedtime snacks or lying down immediately after meals (meals should occur at least 2–3 hours before bedtime), elevation of the head of the bed on 6-inch blocks, avoidance of smoking, and avoidance of tight clothing that increases pressure in the stomach. It may be beneficial to avoid spices, citrus juices, tomatoes and soft drinks, and to consume small frequent meals and drink liquids between meals.[43][10][53] Some evidence suggests that reduced sugar intake and increased fiber intake can help.[54][43] Although moderate exercise may improve symptoms in people with GERD, vigorous exercise may worsen them.[55] Breathing exercises may relieve GERD symptoms.[56]

Medications

Main article: Drugs for acid-related disorders

The primary medications used for GERD are proton-pump inhibitors,

antacids with or without alginic acid.[9] The use of acid suppression therapy is a common response to GERD symptoms and many people get more of this kind of treatment than their case merits.[50][57][58][52][51][59] The overuse of acid suppression is a problem because of the side effects and costs.[50][58][52][51][59]

Proton-pump inhibitors

Proton-pump inhibitors (PPIs), such as omeprazole, are the most effective, followed by H2 receptor blockers, such as ranitidine.[43] If a once-daily PPI is only partially effective they may be used twice a day.[43] They should be taken one half to one hour before a meal.[42] There is no significant difference between PPIs.[42] When these medications are used long-term, the lowest effective dose should be taken.[43] They may also be taken only when symptoms occur in those with frequent problems.[42] H2 receptor blockers lead to roughly a 40% improvement.[60]

Antacids

The evidence for

Gaviscon) may improve symptoms by 60% (NNT=4).[60] Metoclopramide (a prokinetic) is not recommended either alone or in combination with other treatments due to concerns around adverse effects.[9][43] The benefit of the prokinetic mosapride is modest.[9]

Other agents

Sucralfate has similar effectiveness to H2 receptor blockers; however, sucralfate needs to be taken multiple times a day, thus limiting its use.[9] 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.[9]

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.[61] It is recommended only for those who do not improve with PPIs.[42] Quality of life is improved in the short term compared to medical therapy, but there is uncertainty in the benefits of surgery versus long-term medical management with proton pump inhibitors.[62] When comparing different fundoplication techniques, partial posterior fundoplication surgery is more effective than partial anterior fundoplication surgery,[63] and partial fundoplication has better outcomes than total fundoplication.[64]

Esophagogastric dissociation is an alternative procedure that is sometimes used to treat neurologically impaired children with GERD.[65][66] Preliminary studies have shown it may have a lower failure rate[67] and a lower incidence of recurrent reflux.[66]

In 2012 the U.S.

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.[69]

Some patients who are at an increased surgical risk or do not tolerate PPIs[70] may qualify for a more recently developed incisionless procedure known as a TIF transoral incisionless fundoplication.[71] Benefits of this procedure may last for up to six years.[72]

Special populations

Pregnancy

GERD is a common condition that develops during pregnancy, but usually resolves after delivery.

antacids are recommended if these changes are not effective; aluminum- and magnesium hydroxide-based antacids are also safe.[73] Antacids that contain sodium bicarbonate or magnesium trisilicate should be avoided in pregnancy.[73] Sucralfate has been studied in pregnancy and proven to be safe [73] as is ranitidine[74] and PPIs.[75]

Babies

Babies may see relief with smaller, more frequent feedings, more frequent burping during feedings, holding the baby in an upright position 30 minutes after feeding, keeping the baby's head elevated while laying on the back, removing milk and soy from the mother's diet or feeding the baby milk protein-free formula.[76] They may also be treated with medicines such as ranitidine or proton pump inhibitors.[77] Proton pump inhibitors, however, have not been found to be effective in this population and there is a lack of evidence for safety.[78] The role of an occupational therapist with an infant with GERD includes positioning during and after feeding.[79] One technique used is called the log-roll technique, which is practiced when changing an infant's clothing or diapers.[79] Placing an infant on their back while having their legs lifted is not recommended since it causes the acid to flow back up the esophagus.[79] Instead, the occupational therapist would suggest rolling the child on the side, keeping the shoulders and hips aligned to avoid acid rising up the baby's esophagus.[79] Another technique used is feeding the baby on their side with an upright position instead of lying flat on their back.[79] The final positioning technique used for infants is to keep them on their stomach or upright for 20 minutes after feeding.[79][80]

Epidemiology

In Western populations, GERD affects approximately 10% to 20% of the population and 0.4% newly develop the condition.[9] For instance, an estimated 3.4 million to 6.8 million Canadians have GERD. 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.[81] In the United States 20% of people have symptoms in a given week and 7% every day.[9] No data supports sex predominance with regard to GERD.[82]

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. Vagotomy by itself tended to worsen contraction of the pyloric sphincter of the stomach, and delayed stomach emptying. Historically, vagotomy was combined with pyloroplasty or gastroenterostomy to counter this problem.[83]

Research

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

  • Endocinch puts stitches in the lower esophogeal sphincter (LES) to create small pleats to help strengthen the muscle. However, long-term results were disappointing, and the device is no longer sold by Bard.[84]
  • The Stretta procedure uses electrodes to apply radio-frequency energy to the LES. A 2015 systematic review and meta-analysis in response to the systematic review (no meta-analysis) conducted by SAGES did not support the claims that Stretta was an effective treatment for GERD.[85] A 2012 systematic review found that it improves GERD symptoms.[86]
  • NDO Surgical 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.
  • Transoral incisionless fundoplication, which uses a device called Esophyx, may be effective.[87]

See also

References

  1. ISBN 978-0-7020-7092-1
    . Gastro-oesophageal reflux disease (GORD) is defined as 'gastrooesophageal reflux' associated with complications including oesophagitis...
  2. ^ "Definition of "gastro-" - Collins American English Dictionary". Archived from the original on 8 December 2015.
  3. ^ "Definition of "esophagus" - Collins American English Dictionary". Archived from the original on 8 December 2015.
  4. ^ "reflux noun - Definition, pictures, pronunciation and usage notes - Oxford Advanced American Dictionary at OxfordLearnersDictionaries.com". Archived from the original on 8 December 2015.
  5. ^ "GORD | Meaning & Definition for UK English". Lexico.com. Archived from the original on 11 February 2022. Retrieved 11 February 2022.
  6. ^ a b c d e f g h i j k l m n o "Acid Reflux (GER & GERD) in Adults". National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK). 5 November 2015. Archived from the original on 22 February 2020. Retrieved 21 February 2020.
  7. ^
    PMID 18801365
    .
  8. ISBN 978-0-7817-7035-4. Archived
    from the original on 8 September 2017.
  9. ^
    PMID 21429600
    .
  10. ^
    ISSN 0884-5336
    .
  11. ^ "Best Sleeping Position For Acid Reflux: The Gerd Sleeping Position". SleepScore. 22 April 2019. Archived from the original on 26 April 2021. Retrieved 26 April 2021.
  12. PMID 18789939
    .
  13. PMID 23853213
    .
  14. ISBN 978-3-211-32317-5. Archived
    from the original on 1 January 2020. Retrieved 28 August 2017.
  15. ISBN 978-0-7817-5784-3. Archived
    from the original on 5 January 2020. Retrieved 28 August 2017.
  16. doi:10.1016/j.osfp.2012.10.005
    .
  17. ^
    PMID 18923172
    .
  18. ^
    PMID 30228725
    .
  19. ^ "Esophagitis". The Lecturio Medical Concept Library. Archived from the original on 22 July 2021. Retrieved 22 July 2021.
  20. ^
    S2CID 2274838. Archived
    from the original on 7 November 2020. Retrieved 7 October 2021.
  21. S2CID 52307468
    .
  22. S2CID 209482485
    .
  23. S2CID 23673597. Archived
    from the original on 4 October 2023 – via Wiley Online Library.
  24. ^ "Spitting Up in Babies". familydoctor.org. Archived from the original on 8 October 2008.
  25. ISBN 978-0-323-52950-1
    .
  26. ^
    PMID 22194748
    .
  27. PMC 4132436
    .
  28. PMID 18228059
    .
  29. PMID 20002921
    .
  30. ^ and Barrett's Esophagus Archived 19 April 2015 at the Wayback Machine. Retrieved on 1 February 2009.
  31. ^ "Patient information: Barrett's esophagus (Beyond the Basics)". June 2009. Archived from the original on 9 September 2017.
  32. PMID 10780568
    .
  33. S2CID 11965042
    .
  34. doi:10.14309/00000434-200709002-00059
    .
  35. PMID 19475461
    .
  36. PMID 15354276
    .
  37. PMID 17198758
    .
  38. PMID 29262107
    , retrieved 30 October 2022
  39. S2CID 41988457
    .
  40. PMID 9207257
    .
  41. S2CID 922610
    .
  42. ^
    PMID 23419381
    .
  43. ^
    PMID 18789939
    .
  44. S2CID 53088422
    .
  45. ^ Patient information: Barrett's esophagus, archived from the original on 9 September 2017
  46. ISBN 978-0-7817-7942-5
  47. ^ Michael F. Vaezi, MD PhD MSc. "Testing for refractory gastroesophageal reflux disease" (PDF). Archived (PDF) from the original on 20 August 2018. Retrieved 20 August 2018.
  48. ^ Stuart A. "Laryngopharyngeal Reflux (Silent Reflux): Causes, Treatment, Diet, and More". WebMD. Retrieved 30 October 2022.
  49. PMID 29132520
    .
  50. ^ a b c d e Using the Proton Pump Inhibitors to Treat Heartburn and Stomach Acid Reflux (PDF) (Report). Consumer Reports Best Buy Drugs. 2013. Archived (PDF) from the original on 22 February 2020. Retrieved 21 February 2020.
  51. ^
    PMID 18174564
    .
  52. ^
    PMID 22778788
    .
  53. PMID 16682569
    .
  54. S2CID 39516312
    .
  55. PMID 19360912
    .
  56. PMID 32233626
    .
  57. S2CID 37158104
    .
  58. ^
    PMID 11095327
    .
  59. ^
    PMID 18202040
    .
  60. ^
    S2CID 24358990
    .
  61. PMID 14759403
    .
  62. PMID 26544951
    .
  63. S2CID 9136476
    .
  64. PMID 22147130
    .
  65. PMID 11329564
    .
  66. ^
    PMID 16677883
    .
  67. PMID 15991170
    .
  68. PMID 25133039
    .
  69. ^ Medical Device Approvals: LINX Reflux Management System - P100049 Archived 10 November 2013 at the Wayback Machine, U.S. Food and Drug Administration, U.S. Department of Health and Human Services, Update of 17 January 2014
  70. PMID 33553587
    .
  71. PMID 26878326
    .
  72. PMID 26322157
    .
  73. ^
    PMID 27261898
    .
  74. PMID 16831610
    .
  75. PMID 23419381
    .
  76. ^ "Infant acid reflux - Diagnosis and treatment - Mayo Clinic". www.mayoclinic.org. Archived from the original on 14 May 2020. Retrieved 28 September 2018.
  77. S2CID 42736509
    .
  78. S2CID 207164814
    .
  79. ^ a b c d e f chantelpowellot (14 July 2014). "Helping Baby with Gastroesophageal Reflux Disorder (GERD)". Occupational Therapy Services in North County San Diego. Archived from the original on 4 May 2021. Retrieved 3 May 2021.
  80. PMID 22668689
    .
  81. PMID 20652158
    .
  82. PMID 27703114
    .
  83. PMID 1119866
    .
  84. S2CID 5280924
    .
  85. PMID 25459556
    .
  86. S2CID 5813552
    .
  87. PMID 22622203
    .

Further reading
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