Gastroesophageal Reflux Disease

Definitions
Occurs when the amount of gastric juice that refluxes into the esophagus exceeds the normal limit, causing symptoms with or without associated esophageal mucosal injury(esophagitis)


*Different from gastroesophageal reflux-  a normal physiologic phenomenon experienced intermittently by most people, particularly after a meal.
In paediatric, symptoms (vomiting, weight loss, failure to thrive) usually resolve by 18 months

Aetiology
Occurs with loss of the normal pressure gradient between the lower esophageal sphincter (LES) and the stomach
Most commonly due to inappropriate relaxation of LES:

• Foods (high fat, spicy, citrus, chocolate, peppermint, onions)
• Medications (anticholinergic, smooth muscle relaxants, i.e., calcium channel blockers, nitrates)

Other contributing factors include:

• Pregnancy (progestational hormones decrease LES pressure)
• Ineffective peristalsis
• Scleroderma
• Delayed gastric emptying
• Positional: Recumbency, bending

Obesity
Gene polymorphism identified

Association
Reflux esophagitis: Due to exposure to acid, pepsin; classified as erosive (mucosal damage apparent, ulcers, friability) or nonerosive
Extraesophageal reflux:- Aspiration, Chronic cough, Laryngitis, vocal cord granuloma, Sinusitis, Otitis media
Halitosis
Hiatal hernia

Definition	Hiatal hernia- Herniation of proximal stomach through the diaphragm
Type	Sliding(80%)- gastroesophageal junction slides up into the chest Rolling(20)- gastroesophageal junction remains in the abdomen but a bulge of stomach herniates up into the chest alongside the oesophagus
Features	Common: 30% of pt >50yrs, especially obese women. 50% have sympotomatic gastroesophageal reflux
Imaging	Barium swallow (diagnostic), endoscopy- cannot exclude hiatal hernia
Management	Lose weight, treat reflux symptoms, surgery (Nissen) if intractible, recurrent

Peptic stricture: In 10% with GERD
Barrett esophagus
Esophageal adenocarcinoma

Epidemiology
Prevalence of gastroesophageal reflux disease (GERD): 10–20% in the US
Prevalence of Barrett esophagus: 1.5%
65% adults have had heartburn, 15% have weekly symptoms
Children affected: 1/300–1,000

Presentation
Regurgitation of digested food (60%)
Anginalike chest pain (33%)
Abdominal pain (29%)
Hoarseness (21%)
Dysphagia (for solids; if solids and liquids, consider another cause) (20%)
Bronchospasm (asthma) (15–20%)
Aspiration (14%)
Chronic cough
Loss of dental enamel

DDx
Infectious esophagitis (Candida, herpes, HIV, cytomegalovirus), Chemical esophagitis (lye ingestion) ,Pill-induced esophagitis, Radiation injury, Crohn disease, Angina, Stricture, Esophageal carcinoma, Achalasia, Scleroderma, Peptic ulcer disease

Investigation

FBC	Check for anemia due to bleeding esophageal erosions or due to poor B12 absorption on proton pump inhibitor
Barium esophagogram	Presence of a sliding hiatal hernia appears to be a predictor of reflux esophagitis. Mucosal irregularity due to inflammation and edema
Esophagogastroduodenoscopy (EGD)	Indications: anemia, unintentional weight loss, progressive dysphagia, gastrointestinal (GI) bleeding, persistent vomiting, palpable epigastric mass, suspicion based on imaging study Recommended for patients >55 who continue with symptoms after 4 weeks of treatment Confirm mucosal injury, look for Barrett esophagus, biopsy for adenocarcinoma Barrett esophagus ~50–70% of patients with heartburn have negative findings on endoscopy (nonerosive or endoscopy-negative reflux disease). Savary-Miller classification: For grading esophagitis based on endoscopic findings: Grade I: ≥1 nonconfluent reddish spots, with or without exudate Grade II: Erosive and exudative lesions in the distal esophagus; may be confluent, but not circumferential Grade III: Circumferential erosions in the distal esophagus
Esophageal manometry	records pressure of LES (lower esophageal sphincter)  and effectiveness of peristalsis. is essential for correctly positioning the probe for the 24-hour pH monitoring. Indication: Persistence of symptoms while taking adequate antisecretory therapy, such as PPI therapy Recurrence of symptoms after discontinuation of acid-reducing medications Investigation of atypical symptoms, such as chest pain or asthma, in patients without esophagitis Confirmation of the diagnosis in preparation for antireflux surgery
24-hour pH monitoring	Gold standard for diagnosis; records number of reflux episodes, number that occur supine or upright, can be correlated with symptom diary
Radionuclide measurement of gastric emptying	delayed gastric emptying is present in as many as 60% of patients

Management

Lifestyle modifications include the following	Losing weight (if overweight) Avoiding alcohol, chocolate, citrus juice, and tomato-based products Avoiding large meals Waiting 3 hours after a meal before lying down Elevating the head of the bed 8 inches In pediatric Positional treatment: Use infant seat for 2–3 hours after meals; thickened feedings Avoid alcohol, nicotine, and caffeine. Avoid lying down immediately after a meal. Elevate head of bed
Medication	H2 blockers in equipotent oral doses (e.g., cimetidine 800 mg b.i.d. or 400 mg q.i.d., or ranitidine 150 mg b.i.d., or famotidine 20 mg b.i.d., or nizatidine 150 mg b.i.d. PPIs: Irreversibly bind proton pump, onset of effect 4 days. Include omeprazole 20 mg/d, lansoprazole 30 mg/d, pantoprazole 40 mg/d, rabeprazole 20 mg/d, esomeprazole 40 mg/d Erosive esophagitis: PPI given for 8 weeks will be effective for healing in 90%. PPI more effective than H2 blocker for healing erosive esophagitis. In paediatric, Antacids or liquid histamine type 2 blockers, omeprazole, metoclopramide
Surgery	Nissen Fundoplication to increase pressure gradient between stomach and esophagus by wrapping gastric fundus around distal esophagus, often circumferential (360-degree fundoplication) Indications: Evidence of severe esophageal injury, incomplete response to medical treatment, medication treatment that has been or is expected to be prolonged Rule out esophageal dysmotility prior to surgery. If motility problems, consider a partial (270-degree, Toupet) wrap. Open and laparoscopic procedures both produce >90% response, equally effective for symptom reduction, quality of life, and decreased need for medications. Cost analysis has indicated that if patient requires >10 years of PPI treatment, surgery may be more cost-effective.
Follow Up	Follow symptomatically. Repeat endoscopy at 4–8 weeks for poor symptomatic response to medical therapy, especially in older patients. Current guideline is endoscopic surveillance every 2–5 years in patients with Barrett esophagus, assuming treatment if cancer is detected

Complications
Esophagitis (esophageal mucosal damage) occurs in approximately 50%
Peptic stricture: 10–15%
Barrett esophagus: 10%:  -Adenocarcinoma from Barrett epithelium (rate of cancer development 0.5% annually)
Extraesophageal symptoms: 5–10%, including hoarseness, aspiration, including aspiration pneumonia
Bleeding due to mucosal injury
Noncardiac chest pain

Prognosis
Symptoms and esophageal inflammation often return promptly when treatment is withdrawn; to prevent relapse of symptoms, patients should be treated with continued antisecretory therapy:

• PPI maintenance therapy may improve quality of life better than H2 blocker maintenance.
• Full-dose PPIs more effective than 1/2 dose for maintenance
• In erosive esophagitis, daily maintenance therapy with a PPI has been proven to prevent relapse; intermittent PPI therapy has not been proven effective .

In terms of symptom reduction, medical and surgical therapy is equally effective .
Antireflux surgery (Nissen):

• 90–94% symptom response
• 5% continued symptoms, should have anatomy evaluated by esophagram
• Long-term follow-up shows some surgically treated patients may eventually require medical therapy.

Regression of Barrett epithelium does not routinely occur, despite aggressive medical or surgical therapy.