Review of Common Conditions 

GASTROESOPHAGEAL REFLUX DISEASE (GERD) 

 

Clinical Highlights

• Pathologic reflux of gastric contents into the thoracic esophagus with or without associated symptoms. Increased exposure of the esophagus to refluxed gastric juice

• The digestive tract from the esophagus to the stomach functions in much the same way that a plumbing circuit does. The esophagus acts as an antegrade pump, the lower esophageal sphincter (LES) works as a valve, and the stomach functions as a tank. Abnormalities associated with GERD may result from a malfunction of any part of this system

• Insufficient esophageal motility inhibits clearing of acidic material

• A    defective    LES    results    in excessive reflux of gastric juice 

• Delayed   gastric  emptying  can

increase the volume and pressure in the stomach until the LES is no longer functioning, ultimately causing GERD

• Esophageal  defense mechanisms

• Mechanical esophageal clearance via  peristalsis

• Chemical esophageal clearance via saliva

• Mucosal resistance – mucosa guards against esophagitis and other complications of reflux

Causes:

Dysfunctional LES

• The LES is the manometric zone of increased intraluminal pressure at the esophagogastric junction

• Diaphragmatic crura act as an extrinsic sphincter

• LES dysfunction can occur via:

• Transient relaxation of the LES (most common)

• Permanent relaxation of the LES, or complete loss of LES tone

• Transient increase of intra-abdominal pressure surpassing LES pressure

Delayed Gastric Emptying

• Delayed gastric emptying leads to accumulation of gastric contents, which increases intra-abdominal pressure. When this pressure exceeds LES pressure, reflux results

Hiatal Hernia

• The LES may migrate proximally, causing a loss of the abdominal high pressure zone

• The hernia may widen the hiatus, impairing the ability of the diaphragmatic crus to act as an extrinsic sphincter

• Gastric contents may be trapped in the hernia sac and reflux proximally during relaxation

Obesity

• Increased intra-abdominal pressure and gastroesophageal pressure gradient

• Incompetence of the LES

• Increased frequency of transient LES relaxation

Risk Factors for GERD

• Obesity

• Hiatal hernia

• Straining that increases intra-abdominal pressure (eg, pregnancy, constipation)

• Heavy lifting

• Tobacco abuse

• Diet high in fats, chocolate, mints, coffee, citrus (unconfirmed)

 

History & Exam

• Typical

  • Heartburn

  • Regurgitation

  • Dysphagia

• Atypical

  • Coughing, hoarseness, or sore throat

  • Noncardiac chest pain

  • Enamel erosion or dental manifestations

  • Recurrent chest infections/pneumonia

  • History of nausea or vomiting, bloating/belching, or regurgitation should alert you to evaluate for delayed gastric emptying

 

Workup

• Esophagogastroduodenoscopy (EGD) – Used to evaluate for strictures, hiatal hernia, or abnormalities of the esophageal mucosa, such as Barrett’s or cancer 

• Esophageal manometry – Used to evaluate for esophageal dysmotility

• pH monitoring with Bravo probe or 24-hour pH testing – Used to objectively confirm presence of acid reflux. Data are measured and a composite score is provided (ie, DeMeester score >14.7 is pathologic)

  • Bravo probe– Capsule placed endoscopically at the distal esophagus. Pt. carries a pager- like  device  and  presses  button when symptoms are felt. Results are synthesized, and symptoms and acid exposure are assessed for possible correlation. Probe ultimately detaches and passes in stool

  • 24-hour pH testing– Nasoesophageal tube is put in place for 24 hours. Pt carries a pager-like device and presses button when symptoms are felt. Data are measured at distal and proximal channels – useful to evaluate for proximal reflux in patients with atypical symptoms

 

Management

• Stepwise approach with goals of controlling symptoms, healing esophagitis, and preventing complications such as recurrent esophagitis and Barrett’s esophagus

• Lifestyle modifications (see below) and control of gastric acid secretion through medical therapy (eg, antacids, PPIs) or surgery (ie, antireflux procedure)

• Recommended  lifestyle modifications

  • Lose weight if needed (this is a critical objective for overweight pts)

  • Limit alcohol consumption, stop smoking

  • Limit bending or stooping positions

  • Eat small, frequent meals throughout the day, avoiding spicy foods, chocolate, tomato-based products, peppermint, foods in the onion family, citrus juice, coffee, alcohol, and caffeine

  • Do not eat within 3 hours of bedtime, and sleep with the head of the bed elevated

 

Pharmacology

• TUMS

• H2 antagonists (pts. develop tolerance to these drugs)

  • Ranitidine- 150mg BID (Zantac)

  • Famotidine- 20-40mg daily or BID (Pepcid)

• PPIs (must be taken 30 to 60 minutes before eating)

  • Omeprazole- 40mg daily or BID

  • Pantoprazole- 40mg daily or BID

  • Dexlansoprazole- 30mg daily

  • Lansoprazole- 30mg daily

• Carafate- Coating agent for esophageal erosions/gastric erosions/ erosive esophagitis. 1g PO QID. Needs to be in liquid form for pts with esophageal problems. Can be expensive

 

Surgery

• Indications for surgery 

  • Patients whose GERD is inadequately controlled with PPIs

  • Patients with complications of GERD, such as esophagitis, ulcer, or stricture

  • Patients with Barrett’s esophagus or extra-esophageal manifestations:

    • Respiratory symptoms – cough, wheezing, aspiration, recurrent PNA

    • ENT symptoms – hoarseness, sore throat, otitis media

    • Dental symptoms – enamel erosion

  • Young patients

  • Patients who have poor compliance with medications

  • Postmenopausal women with osteoporosis

  • Patients with large HH or symptoms related to hernia, such as chest discomfort, anemia, torsion symptoms (eg, abdominal pain and distention, especially in the upper abdomen)

 

• Fundoplication – Laparoscopic vs. open (See Guidelines for Fundoplication) Involves:

  • Complete mobilization of the fundus of the stomach with division of the short gastric vessels

  • Right and left hiatal dissection

  • Mobilization of the esophagus

  • Reduction of the hernia

  • Closure of the esophageal hiatus

  • Creation of a fundoplication (ie, wrap)

    • Nissen: 360° posterior wrap

    • Toupet: 270° posterior wrap

    • Dor: partial 180° anterior stabilization

• Gastric diversion with Roux-en-Y. Indications:

  • Morbidly obese pts

  • Recalcitrant disease with aperistaltic esophagus

  • Multiple redo fundoplications