Gastroesophageal reflux disease (GERD) is a condition that develops when there is a retrograde flow of stomach contents causing symptoms or complications. GERD can present as Non-erosive reflux disease (NERD) when typical symptoms of GERD occur in the absence of visible mucosal injury during endoscopy, or as erosive esophagitis (EE) when patients have histopathological changes in esophageal mucosa. The latter is also called reflux esophagitis.
The typical symptom is heartburn. This most often occurs 30 min to 60 min after meals and upon reclining. Patients often report relief from antacids or baking soda. When patients present with this description of symptoms, the diagnosis can be established with a high degree of confidence.
GERD is extremely common, with a prevalence of approximately 20% of adults in the western culture. Most adults with GERD have mild disease, but esophageal mucosa damage (reflux esophagitis) can develop in up to a third of the patients. Symptoms occur daily in approximately 7% of patients, weekly in 14% and monthly in 15% to 40% of all patients.
There is no significant difference in prevalence among males and females, but males seem to have a higher rate of complications. The rate of esophagitis is 2:1 and the rate of Barrett's is 0:1 in males compared to females.
GERD incidence increases with age, particularly after age 40.
Obesity also seems to increase the risk of GERD. A meta-analysis published in the Annals of Internal Medicine in 2005 concluded that obesity was associated with a statistically significant increase in the risk of GERD symptoms, erosive esophagitis, and esophageal carcinoma. The ProGERD study published in 2005 evaluated the predictive factors for erosive reflux disease in more than six thousand patients with reflux disease. They found the odds ratio for erosive disease increased with the body mass index (BMI), with patients with a BMI greater than 30 Kg/m2 to 40 Kg/m2 having an odds ratio of 1.97 (95% confidence level 1.32 to 2.92).
There are few components of the pathophysiology of GERD.
The typical manifestation of GERD is heartburn, regurgitation, and dysphagia. Other symptoms include a globus (lump in the throat) sensation, odynophagia, and nausea. Heartburn is defined as a retrosternal burning discomfort, located in the epigastric area that may radiate up towards and neck and typically occurs in the postprandial period. Patients often report that postural changes, such as bending forward, can worsen the symptoms. Symptoms are usually also aggravated by ingestion of certain foods or beverages such as tomato sauce, chocolate, coffee, teas, and alcohol.
Atypical presentation refers to symptoms that are extraesophageal, including pulmonary, ear, nose and throat manifestations, as well as non-cardiac chest pain.
Initial diagnostic tests are not warranted for patients with typical GERD symptoms. Practitioners should further investigate patients with "alarm features" such as troublesome dysphagia, odynophagia, weight loss, iron deficiency anemia, and in patients with troublesome symptoms that persist despite appropriate empiric proton pump inhibitor therapy. It must be remembered that diabetic patients may present with dyspeptic symptoms during a myocardial infarction. Thus, a high index of suspicion should be maintained in these patients in the acute setting.
Radiographic studies are of limited use in the management of GERD due to poor sensitivity in milder forms of GERD, but they can detect moderate to severe esophagitis, strictures, hiatal hernia, and tumors. The studies most commonly used are the barium swallow, which only examines the esophagus, and the upper gastrointestinal series, which examines the esophagus, stomach, and small intestines.
In addition to excluding the presence of other diseases such as tumors and peptic ulcers, an upper endoscopy can detect and grade the severity of GERD-induced esophagitis. Upper endoscopy is highly specific for GERD (90% to 95%) but has a limited sensitivity (approximately 50%). The Los Angeles (LA) Classification grades reflux esophagitis on a scale of A (one or more isolated mucosal breaks less than 5 mm that do not extend between the tops of two mucosal folds) to D (one or more mucosal breaks that involve at least 75% of the esophageal circumference).
Esophageal pH or combined esophageal impedance testing is usually unnecessary in most patients but may be indicated in patients who have atypical or extraesophageal symptoms or who are being considered for antireflux surgery. Impedance testing detects changes in the resistance of electrical current on a catheter placed within the esophagus. In addition to recording the esophageal pH, it can differentiate both antegrade and retrograde transit of liquid and gas. The test is helpful in patients who have suspected GERD but negative pH tests. Doctors only recommend this test after standard testing has failed to demonstrate significant GERD in patients with typical or atypical symptoms and patients with refractory GERD.
The goals of treating GERD are to resolve symptoms, heal esophagitis, and prevent complications. Treatment options include lifestyle modifications, medical management with antacids and antisecretory agents, and mechanical therapies.
Barrett's esophagus is the only complication of GERD with malignant potential. Patients are typically middle-aged white males. In patient's with Barrett's esophagus, surveillance for dysplasia is warranted.
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