Module 6.1 - Gastroesophageal Reflux Disease Flashcards
What is Gastroesophageal reflux disease?
- A chronic condition that develops when the reflux of stomach contents causes macroscopic damage to the esophagus or causes symptoms that reduce the quality of life.
- Incidence: affects 20% of US adults at least weekly
What causes GERD?
GERD typically occurs when acid from the stomach backs up into the esophagus.
- The lower esophageal sphincter (LES), a muscle located at the bottom of the esophagus, opens to let food in and closes to keep it in the stomach. When this muscle relaxes too often or for too long, acid refluxes back into the esophagus, causing heartburn.
- Hiatal hernia which causes:
- Decreased esophageal clearance of gastric contents
- Composition of volume of reflux: acidic gastric fluid (pH < 4) extremely damaging to esophageal mucosa ( reflux composed of acid, pepsin and bile)
- Delayed gastric emptying secondary to gastroparesis or partial outlet obstruction- contributing factors- cause an increased gastric volume that may precipitate the reflux of contents
What is Barrett’s esophagus?
It is a serious complication of GERD. It is a condition in which the lining of the esophagus changes, becoming more like the lining of the small intestine. Occurs in the lower esophagus/GE junction; can develop into dysplasia (pre-cancerous)
What are the 2 classifications of GERD?
- Erosive esophagitis: characterized by endoscopically visible breaks in the distal esophageal mucosa with or without symptoms of GERD.
- Non-erosive reflux disease: characterized by the presence of troublesome symptoms of GERD without visible esophageal mucosal injury.
What are some dietary & nondietary factors that contribute to GERD?
Dietary
- Caffeinated food/drinks- chocolate, coffee, tea, colas
- Esophageal irritants – citrus, vinegar, spicy foods, tomatoes
- Excessive fluids with meals
- Large meals
- High fat meals
- Eating within 2-3 hours of bedtime
- LES relaxers – onions, garlic, mint and alcoholic beverages
- Lying supine immediately after eating
Non-dietary
- Obesity
- Anxiety
- Pregnancy
- Tight fitting pants/clothing around abdomen
- Smoking
What are some medications that can cause GERD?
- Alpha adrenergic antagonists
- Anticholinergics
- Antihistamines
- Aspirin
- Benzodiazepines
- Calcium channel blockers
- Beta adrenergic agonists
- Cholecystokinin
- Levodopa
- Nitrates
- NSAIDs
- Opioids
- Progestins
- Prostaglandins
- Secretin
- Somatostatin
- Transdermal nicotine
- Tricyclic antidepressants
What are the signs and symptoms of GERD?
-
Classic symptom: ‘heartburn’
- Substernal sensation of burning that can radiate to back, neck or throat
- Usually occurs 30-60 minutes after eating a large meal
- Aggravated by lying supine or bending over
- Regurgitation
- Dysphagia (difficulty swallowing)
- Odynophagia (Pain on swallowing)
- Hemorrhage
- Belching
- Early satiety
-
Atypical signs:
- Pulmonary symptoms- recurrent pneumonia, bronchospasm, cough
- Cardiac symptoms – chestpain
- ENT – hoarseness, sorethroat, halitosis, nighttime ‘choking’, hiccups
What are some characteristics of Barrett’s esophagus?
- Occurs in an estimated 10% of individuals with chronic GERD
- Typical patient is a white male between ages of 40 and 60 years of age
- Diagnosis requires both endoscopic gross and biopsy confirmation
- Once identified, a periodic surveillance endoscopy is performed to look for dysplasia or frank malignancy
- Multifocal high-grade dysplasia or carcinoma typically requires esophagectomy although newer modalities (laser ablation, photodynamic therapy) are also utilized.
What 4 tests are used to diagnose GERD?
1. Barium swallow - inexpensive test, less sensitive than other tests; can be used as a screening tool to rule out inflammation, ulcers or strictures; helpful in evaluating dysphagia, odynophagia, significant weight loss or occult blood loss
2. Upper endoscopy – not required for typical GERD symptoms of heartburn or regurgitation. EGD is recommended for the following cases *:
- Patients with heartburn and ‘alarm’ features- such as dysphagia, odynophagia, GI bleeding, anemia, weight loss, or recurrent vomiting
- Patients with severe erosive esophagitis-
- To screen for Barrett’s esophagus in patients with multiple risk factors, including:
- Chronic GERD
- Hiatal hernia
- Age > 50 years
- Male gender
- Caucasian ethnicity
- Elevated BMI
- Intra-abdominal fat distribution
- Patients with typical GERD symptoms that persist despite a trial of 4-8 weeks of twice-daily PPI therapy
3. 24 hour ambulatory pH monitoring - the most sensitive and specific diagnostic test used to detect the presence of abnormal acid reflux – the gold standard for most practitioners- performed by passing a small electrode pH probe intra-nasally and placing it approximately 5 cm above the LES
4. Esophageal manometry - measures esophageal pressures and identifies abnormalities of the LES and abnormal contractions of the esophageal muscle
How are patient’s with GERD managed?
- Patients are usually managed with a ‘step- up’ OR ‘step-down’ approach to therapy:
- Step- up: used in patients with mild to intermittent symptoms (< 2 times weekly) and have no evidence of erosive esophagitis on upper endoscopy (if performed); this approach involves incrementally increasing the potency of therapy until symptom control is achieved; changes are made at 2-4 week intervals.
- Step-down: used in patients with severe or frequent symptoms (> 2 times weekly) or erosive esophagitis; this approach starts with potent antisecretory agents and then involved incrementally decreasing the potency of therapy until breakthrough symptoms define the treatment necessary for symptom control.
What are the 4 steps used to manage GERD?
Step I :
- Elevate head of bed 4-6 inches (increases esophageal clearance)
- Avoid vigorous exercise 2-3 hours prior to bedtime
- Avoid large, high-fat meals and eating 2-3 hours prior to bedtime (decreases gastric volume)
- Avoid foods that may decrease LES pressure
- Avoid foods that have an irritant effect directly on esophageal mucosa
- Add protein rich meals to diet (to augment LES pressure)
- Reduce weight ( to reduce symptoms)
- Eliminate smoking ( to decrease esophageal sphincter relaxation)
- Avoid alcohol (to increase amplitude of the LES, peristaltic waves and frequency of contractions).
- Avoid tight-fitting clothes
- Eliminate exacerbating medications
- Use antacids PRN
- Try over the counter (OTC) H2RAs
Step 2:
- In addition to Step 1 measures, increase the dose of H2RAs to standard dose, bid for a minimum of 2 weeks.
Step 3:
- Discontinue H2RAs and initiate PPIs at low dose, then increase to standard dose if required for a minimum of 8 weeks of therapy. Non-responders to Step 3 should be referred to gastroenterologist for evaluation.
Step 4:
- Initiate standard dosing of PPI once daily for 8 weeks, in addition to lifestyle and dietary modifications. Subsequently, decrease acid suppression to low-dose PPIs and then to H2RAs if patients have mild or intermittent symptoms. Acid suppression agents are discontinued in all ASYMPTOMATIC patients with the EXCEPTION of patients with severe erosive esophagitis or Barrett’s esophagus, in whom maintenance PPI therapy is suggested.
When is surgical intervention used in GERD?
Reserved for patients in whom medical management has failed or complications have developed, including the following:
- Reflux-related pulmonary disease
- Persistent ulcerative esophagitis
- Recurrent esophageal strictures
- Large hiatal hernia
Surgical Procedures available:
- Nissen fundoplication- cure rate approx. 90%
- Stretta procedure – application of radiofrequency energy into the LES – outpatient procedure; indicated after chronic history of GERD with worsening symptoms after PPI use.
What medications are given to treat GERD?
