Gastro-Esophageal Reflux Disease (GERD)

Gastroesophageal reflux is a normal physiologic phenomenon experienced intermittently by most people, particularly after a meal. Gastroesophageal reflux disease (GERD) 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 (ie, esophagitis).

pathophysiology: The physiologic and anatomic factors that prevent the reflux of gastric juice from the stomach into the esophagus include the following: 1-The lower esophageal sphincter (LES) must have a normal length and pressure and a normal number of episodes of transient relaxation (relaxation in the absence of swallowing). 2-The gastroesophageal junction must be located in the abdomen so that the diaphragmatic crura can assist the action of the LES, thus functioning as an extrinsic sphincter. The presence of a hiatal hernia disrupts this synergistic action and can promote reflux . 3-Esophageal clearance must be able to neutralize the acid refluxed through the LES. (Mechanical clearance is achieved with esophageal peristalsis. Chemical clearance is achieved with saliva.) 4-The stomach must empty properly.

Pathophysiology Abnormal gastroesophageal reflux is caused by the abnormalities of one or more of the following protective mechanisms: A functional (frequent transient LES relaxation) or mechanical (hypotensive LES) problem of the LES is the most common cause of gastroesophageal reflux disease (GERD). Certain foods (eg, coffee, alcohol), medications (eg, calcium channel blockers, nitrates, beta-blockers), or hormones (eg, progesterone) can decrease the pressure of the LES. Obesity is a contributing factor in gastroesophageal reflux disease (GERD), probably because of the increased intra-abdominal pressure.

Clinical Manifestations The most common symptoms of GERD are: Heartburn (pyrosis). Regurgitation. Dysphagia. Other symptoms of GERD include: chest pain, water brash, globus sensation, odynophagia, and nausea

Differential Diagnosis Achalasia Esophagitis Cholelithiasis Gastritis, Chronic Coronary Artery Atherosclerosis Irritable Bowel Syndrome Esophageal Cancer Peptic Ulcer Disease Esophageal Spasm

Investigations Barium esophagogram Esophagogastroduodenoscopy (EGD) Esophageal manometry Ambulatory 24-hour pH monitoring Radionuclide measurement of gastric emptying

Treatment Lifestyle modification 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

Medical therapy H2-Receptor Antagonists Proton Pump Inhibitors Ranitidine Cimetidine Proton Pump Inhibitors Omeprazole Esomeprazole Prokinetics Metoclopramide

Surgical therapy (fundoplication ) Indications: Patients with symptoms that are not completely controlled by PPI therapy can be considered for surgery. The presence of Barrett esophagus . The presence of extraesophageal manifestations . Young patients Poor patient compliance with regard to medications Postmenopausal women with osteoporosis