GASTROESOPHAGEAL REFLUX DISEASE

Question 1

Definition

Answer 1

Reflux of stomach contents (gastric acid, pepsin, bile & duodenal content) into the esophagus caused by incompetent LES

Question 2

Causes (5)

Answer 2

1- Hiatal hernia (prolapse of the abdominal esophagus and stomach into the chest)
2- Increased intraabdominal pressure secondary to obstruction
3- Food or drug induced LES relaxation
4- Abnormal esophageal peristaltic activity
5- Others: systemic sclerosis, drugs (TCAs + nitrates), delayed gastric emptying, increased intra-abdominal pressure (obesity and pregnancy)

Question 3

Symptoms (2)

Answer 3

1- Heartburn, regurgitation, dysphagia and dyspepsia after heavy meals described as burning or discomfort in the epigastrium (most common symptom)
2- Pain relived by antacids and aggravated by lying supine or leaning forward, frequent consumption of caffiene/alcohol (affect LES competence)

Question 4

Late complications (4)

Answer 4

1- Schatzki’s ring: strictures of the distal esophagus
2- Barrett’s esophagus: intestinal metaplasia of the distal esophageal mucosa - predisposes to the development of high-grade dysplasia leading to malignant transformation to distal esophagus
3- Barrett’s esophagus associated with low grade dysplasia should undergo follow-up endoscopy every 6 to 12 months with biopsies
4- Peptic stricture (suspect if age >60, solid dysphagia. May need dilatation)

Question 5

Diagnosis (5)

Answer 5

1- Mainly clinical, a trial of PPIs for 2 weeks with patient response is usually sufficient to make a diagnosis, unless there are red flags (weight loss, dysphagia, hematemesis, anemia, new GERD > 55yrs, signs of obstruction)
2- 24-hour esophageal pH study confirms abnormal acid exposure in the distal esophagus: usually reserved for confirmation of GERD prior to surgery or to confirm diagnosis in patients non-responsive to PPIs
3- Barium study: reflux with hiatal hernias, distal stricture, or shortened esophagus
4- Esophageal manometery: identify motility disorders and dysfunction of LES
5- Upper endoscopy: indicated if there are any of the above red flags, age >55, not responding to treatment, or to monitor complications (e.g. Barrett’s). May be normal, or may show sign of esophagitis (erythema/erosion/ulceration), hiatal hernia, intestinal metaplasia, and atypia from Barrett’s disease

Question 6

Management (5)

Answer 6

1- Mild/no esophagitis: lifestyle changes (weight loss, avoiding eating 3 hours before bed, elevation of the head of the bed, stopping smoking, alcohol, and aggravating factors) + alginate-containing antacids
2- If antacids fail —> H2 receptor blockers (e.g. cimetidine, ranitidine)
3- Drug of choice for all but mild cases: Proton pump inhibitors
- E.g. omeprazole, esomeprazole
- Inhibit gastric H+/K+ ATPase —> decrease gastric secretion by 90%
- 60% of patients are symptom-free after 4 weeks
4- Metoclopramide (dopamine antagonist —> increases gastric emptying)
5- If medical fails or complications occur —> surgery (wraps fundus around esophagus to create sphincter- mainly Nissen’s fundoplication is performed); laparoscopic, transabdominal, or transthoracic