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Gastroesophageal reflux disease
Gastroesophageal Reflux Disease (GERD, or GORD when -oesophageal, the BE form, is substituted) is injury to the esophagus that develops from chronic exposure of the esophagus to acid coming up from the stomach (reflux). In contrast, heartburn is the symptom of acid in the esophagus, characterized by a burning discomfort behind the breastbone (sternum). Findings in GERD include esophagitis (reflux esophagitis) - inflammatory changes in the esophageal lining (mucosa), strictures, difficulty swallowing (dysphagia) and chronic chest pain. Patients may have only one of those findings. Atypical symptoms of GERD include cough, hoarseness, changes of the voice, and sinusitis. Complicatons of GERD include stricture formation, Barrett's esophagus, esophageal ulcers and possibly even to esophageal cancer.
Occasional heartburn is common but does not necessarily mean one has GERD. Patients that have heartburn symptoms more than once a week are at risk of developing GERD. A hiatal hernia is usually asymptomatic, but the presence of a hiatal hernia is a risk factor for development of GERD.
The most prominent symptom of GERD is heartburn, the sensation of burning pain in the chest coming upward towards the mouth caused by reflux of acidic contents from the stomach to the esophagus.
Patients with GERD also tend to get the feeling of a sour or salty taste at the back of their throats due to regurgitation. This can sometimes happen even if the pain of heartburn is absent.
Less common symptoms:
- Chest pain without any of the above
- Dysphagia (difficulty swallowing)
- Halitosis (bad breath)
- Regurgitation (vomit-like taste in the mouth)
- Repeated throat clearing
- Water brash (the sensation of a large amount of non-acid liquid due to sudden hypersecretion of saliva)
- Strictures or scarring of esophagus (especially young children).
- Barrett's esophagus (sometimes referred to as Barrett's Disease)
- Esophageal cancer
Important Warning symptoms:
- Trouble swallowing Dysphagia requires immediate medical attention
- Vomiting blood or partially digested blood (looks like coffee grounds) requires immediate medical attention as does digested blood in the stools.
GERD in Children
GERD is commonly overlooked in infants and children. Symptoms may vary from typical adult symptoms. GERD in children may cause repeated vomiting, effortless spitting up, coughing, and other respiratory problems. Inconsolable crying, failure to gain adequate weight, refusing food and bad breath are also common. Children may have one symptom or many - no single symptom is universally present in all children with GERD.
Babies' immature digestive systems are usually the cause, and most infants stop having acid reflux by the time they reach their first birthday. Some children don't outgrow acid reflux, however, and continue to have it into their teen years. Children that have had heartburn that doesn't seem to go away, or any other symptoms of GERD for a while, should talk to their parents and visit their doctor.
A detailed history taking is vital to the diagnosis. Useful investigations may include barium swallow X-rays, esophageal manometry, esophageal pH monitoring and Esophagogastroduodenoscopy (EGD). In general, an EGD is done when the patient does not respond well to treatment, has had symptoms or required medications for a prolonged time (generally 5 years), has dysphagia, anemia, blood in the stool (detected chemically), has weight loss, or has changes in the voice.
Esophagogastroduodenoscopy (EGD) (a form of endoscopy) involves the insertion of a thin scope through the mouth and throat into the esophagus and stomach (often while the patient is sedated) in order to assess the internal surface of the esophagus, stomach and duodenum
Biopsies can be performed during gastroscopy and these may show:
- Edema and basal hyperplasia (non-specific inflammatory changes)
- Lymphocytic inflammation (non-specific)
- Neutrophilic inflammation (usually either reflux or Helicobacter gastritis)
- Eosinophilic inflammation (usually due to reflux)
- Goblet cell intestinal metaplasia or Barretts esophagus.
- Dysplasia or pre-cancer.
- Rapid testing assays can quickly detect the presence of Helicobacter pylori in a biopsy sample through urease testing.
Having GERD indicates incompetence of the lower esophageal sphincter. Increased acidity or production of gastric acid can contribute to the problem, as can obesity, tight fitting clothes and pregnancy. It is also thought that yeast infections of the digestive tract can cause GERD-like symptoms.
Factors that can contribute to GERD are:
- Hiatus hernia increases the likelihood of GERD due to mechanical and motility factors.
- Zollinger-Ellison syndrome can present with increased gastric acidity due to gastrin production.
- Hypercalcemia can increase gastrin production, leading to increased acidity.
- Scleroderma and systemic sclerosis can feature esophageal dysmotility.
Avoiding aggravating factors
Certain foods and lifestyle tend to promote gastroesophageal reflux:
- Coffee, alcohol, calcium supplements, and excessive amounts of Vitamin C supplements are stimulants of gastric acid secretion so avoiding these helps.
- Foods high in fats and smoking reduce lower esophageal sphincter competence so avoiding these tends to help as well.
- Having more but smaller meals also reduces the risk of GERD as it means there is less in the stomach at any one time.
Advice generally given:
- avoid eating for 2 hours before bedtime
- avoid sodas that contain caffeine
- avoid chocolate and peppermint
- avoid spicy foods like pizza
- avoid acidic foods like oranges and tomatoes
- avoid fried and fatty foods
- avoid milk and heavily milk based products
A number of drugs is registered for the treatment of GERD, and they are amongst the most often prescribed forms of medication is most Western countries. They can be used in combination, although some antacids can impede the function of other medications:
- Antacids before meals or symptomatically after symptoms begin can reduce gastric acidity (increase the pH).
- Gastric H2 receptor blockers such as ranitidine or famotidine can reduce gastric secretion of acid. These drugs are technically antihistamines. They relieve complaints in about 50% of all GERD patients.
- Proton pump inhibitors such as omeprazole are even more effective in reducing gastric acid secretion.
- Prokinetics strengthen the LES and speed up gastric emptying. Cisapride, a member of this class, was withdrawn for causing Long QT syndrome.
The standard surgical treatment, sometimes preferred over longtime use of medication, is the Nissen fundoplication. The upper part of the stomach is wrapped around the LES to strengthen the sphincter and prevent acid reflux and to repair a hiatal hernia. The procedure is often done laparoscopically.
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.
In 2000, the U.S. Food and Drug Administration (FDA) approved two endoscopic devices to treat chronic heartburn. One system puts stitches in the LES to create little pleats that help strengthen the muscle. Another uses electrodes to create tiny cuts on the LES. When the cuts heal, the scar tissue helps toughen the muscle. The long-term effects of these two procedures are unknown.
Recently, the FDA approved an implant that may help people with GERD who wish to avoid surgery. It is a solution that is injected during endoscopy and becomes spongy, reinforcing the LES to keep stomach acid from flowing into the esophagus. The implant is approved for people who have GERD and who require and respond to proton pump inhibitors. The long-term effects of the implant are unknown.
Barrett's esophagus, a type of dysplasia, is a precursor high grade dysplasia, which is in turn is a precursor condition for carcinoma. The risk of progression from Barretts to dysplasia is uncertain but is estimated to include 0.1 to 0.5% of cases, and has probably been exaggerated in the past. Due to the risk of chronic heartburn progressing to Barrett's, EGD every 5 years is recommended for patients with chronic heartburn, or who take medication for GERD chronically.
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