GERD

GERD- gastro-oesophagial reflux disease

GERD is a esophagogastric junction disorder where there is efflux of gastric contents due to laxity in LES

Pathophysiology

  • Reflux of gastric acid and pepsin into the oesophagus
  • Necrosis of the oesophageal mucosa causing erosions and ulcers.
  • Impaired clearance of the refluxed gastric juice.
  • GE junction incompetence-
    • Three mechanisms-
      • transient LES relaxations (vasovagal reflex in which LES relaxation is elicited by gastric distension)
      • LES hypotension
      • Anatomic distortion of the esophagogastric junction.
  • Reduced salivary function-
    • Normally after acid reflux peristalsis return the refluxed fluid back to stomach.
    • And also titrated with bicarbonate in swallowed saliva.
  • Bile reflux can also cause esophagitis and play role in barrettes esophagitis.

Symptoms

  • Dysphagia
  • Chest pain
  • Chronic cough
  • Laryngitis
  • Asthma
  • Dental erosions
  • Globus sensation
  • Other symptoms- repeated belching, bitter taste after belching etc.

Risk factors

  • Obesity.
  • Hiatus hernia.
  • Pregnancy.
  • Exogenous oestrogens.
  • Foods- high fat, chocolate, peppermint, caffeine, alcohol, smoking.
  • Drugs- anticholinergic, antidepressants, opioids, theophylline, diazepam, barbiturates.
  • Helicobacter pylori infestation.

Diagnostic tests

  • Clinical history- heartburn and/or regurgitation.
  • Upper G.I endoscopy- routine endoscopy not required in typical symptoms of GERD.
    • To evaluate for dysphagia or look for oesophageal mucosa (erosions/ metaplasia, dysplasia or mass lesions)
    • Grading of esophagitis:
      • Grade A – One or more mucosal breaks each ≤5 mm in length.
      • Grade B – At least one mucosal break >5 mm long, but not continuous between the tops of adjacent mucosal folds.
      • Grade C – At least one mucosal break that is continuous between the tops of adjacent mucosal folds, but which is not circumferential.
      • Grade D – Mucosal break that involves at least three-fourths of the luminal circumference.
  • Oesophageal manometry  manometry cannot diagnose GERD, but can be performed to exclude oesophageal motility disorders.
  • Ambulatory oesophageal pH monitoring  to confirm the diagnosis of GERD in those with persistent symptoms when twice daily trial of PPI has failed.
    • Can be performed with either a trans nasally placed catheter or a wireless, capsule shaped device that is affixed to the distal oesophageal mucosa.

Management

  • Life-style and dietary modification-
    • Weight loss
    • Elevation of head of the bed.
    • Elimination of dietary triggers  coffee, chocolate, spicy foods, food with high fat content, carbonated beverages and peppermint.
    • Avoid tight fitting garments.
    • Promotion of salivation through oral lozenges/ chewing gum to neutralize refluxed acid.
    • Avoidance of tobacco and alcohol.
  • Antacids:
    • Magnesium trisilicate
    • Aluminium hydroxide or calcium carbonate.
  • Surface agents:
    • sucralfate (aluminium sucrose sulphate)- adheres to the mucosal surface, promotes healing and protects from peptic injury by mechanisms that are incompletely understood.
    • Sodium alginate
  • Histamine 2 receptor antagonist:
    • Decreases secretion of acid by inhibiting Histamine 2 receptor on gastric parietal cell.
    • Develop tachyphylaxis within 2 weeks of use- hence limited use.
  • Proton pump inhibitors:
    • Potent inhitors of gastric acid secretion by irreversibly binding to and inhibiting the hydrogen-potassium ATPase pump.
    • Standard doses for eight weeks relieve symptoms of GERD and heal esophagitis in upto 86% of patients.

Surgical management:

  • Failed medical management.
  • Intolerance of medical therapy
  • Complication of GERD (peptic stricture, severe esophagitis, barrettes oesophagus, carcinoma, dysplasia)
  • Procedures:
    • Radiofrequency treatment – endoscopic
    • Transoral incisionless fundoplication- endoscopic
    • Surgical- laparoscopic hill gastropexy
    • Laparoscopic partial fundoplication
    • Laparoscopic Nissen fundoplication (complete)

Complications of GERD:

  • Severe esophagitis
  • barrettes oesophagus
  • dysplasia
  • oesophageal stricture
  • oesophageal carcinoma

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