Gastroenterology Book

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Gastroesophageal Reflux

Aka: Gastroesophageal Reflux, Reflux Esophagitis, Heartburn, Acid Reflux, Acid Regurgitation, Water Brash, Pyrosis, GERD
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  1. See Also
    1. Pediatric Reflux
    2. Hiatal Hernia
  2. Epidemiology
    1. Incidence: 36% in U.S.
    2. Most take OTC medications and do not seek medical help
    3. GERD patients wait 1-3 years before seeing a doctor
  3. Risk Factors: Reduced LES pressure
    1. Smooth muscle relaxants
      1. Aminophylline
      2. Nitrates
      3. Calcium Channel Blockers
      4. Caffeine
      5. Inhaled Albuterol
        1. Crowell (2001) Chest 120:1184-9
    2. Tobacco abuse
    3. Pregnancy
    4. Scleroderma
  4. Complications
    1. Barrett's Esophagus (10-20% Incidence)
    2. Asthma
    3. Persistent Chest Pain
    4. Chronic Cough
    5. Dental Erosions (dental enamel loss)
    6. Hoarseness
    7. Laryngeal cancer
    8. Persistent Pharyngitis
    9. Vocal Cord Polyps
    10. Subglottic Stenosis
    11. Interstitial fibrosis
  5. Symptoms: Classic
    1. Heartburn (Initial GERD symptom)
      1. Location: Epigastric and retrosternal Chest Pain
      2. Characteristic: Caustic or stinging
      3. No radiation to the back
    2. Acid Regurgitation (Water Brash or Pyrosis)
      1. Suggests progressing GERD
      2. Provoked by lying supine or leaning forward
      3. Regurgitation of digested food or clear burning fluid
      4. Undigested food suggests alternative diagnosis
        1. Achalasia
        2. Esophageal Diverticulum
    3. Difficult swallowing (Dysphagia)
      1. See Dysphagia from Esophageal Cause
      2. Mechanical obstruction of solid foods
        1. Suggests peptic stricture
      3. Liquid obstruction suggests alternative diagnosis
        1. Neuromuscular disorder
        2. Neoplasm
        3. Esophageal diverticulum
  6. Symptoms: Atypical
    1. Abdominal Pain (29%)
    2. Chronic Cough (27%)
    3. Hoarseness (21%)
    4. Belching (15%)
    5. Bloating (15%)
    6. Aspiration (14%)
    7. Wheezing (7%)
    8. Globus Hystericus (4%)
    9. Recurrent Pharyngitis
    10. Halitosis
  7. Signs: Orofacial effects of chronic Acid Reflux
    1. Dental Erosions (yellow discoloration)
    2. Masticatory Mucosa inflammation
    3. Chronic Sinusitis
  8. Red Flags: Symptoms Indicating Evaluation (e.g. Endoscopy)
    1. Dysphagia
      1. Immediately assess for Barrett's Esophagus
    2. Odynophagia
      1. Assess for Esophageal Ulcer
    3. Weight Loss (Suggests Dysphagia or Odynophagia)
    4. Early satiety or Vomiting
    5. Aspiration
    6. Wheezing or cough
    7. Gastrointestinal Bleeding
    8. Unexplained Iron Deficiency Anemia
      1. Suggests esophageal ulcer
    9. High risk patients
      1. Male over 45 years old with longstanding symptoms
      2. Elderly with reflux (use high level of suspicion)
        1. Even serious pathology may present as mild GERD
        2. Johnson (2004) Gastroenterology 126:660-4
  9. Differential Diagnosis
    1. Myocardial Ischemia (Angina)
    2. Peptic Ulcer Disease
    3. Cholelithiasis
    4. Esophageal Achalasia
    5. Esophageal Spasm
  10. Pathophysiology
    1. Transient relaxation of lower esophageal sphincter
  11. Diagnosis: Indicated for complicated or refractory cases
    1. pH probe (24 hour pH monitoring)
      1. Test Sensitivity: 70 to 96%
      2. Test Specificity: 70 to 96%
    2. Upper endoscopy
      1. Test Sensitivity and Specificity are low
      2. Standard for evaluating GERD complications
  12. Management: General Measures
    1. Drink 8 glasses (8 ounces) non-caffeinated fluid daily
    2. Decrease provocative foods
      1. Decrease or eliminate caffeine
      2. Avoid spicy foods
      3. Avoid milk products toward end of day
      4. Avoid chocolate
      5. Avoid fatty foods
    3. Tobacco Cessation
    4. No eating food 2-3 hours before bedtime
    5. Elevate head of bed to 30 degrees
      1. Place 6-8 inch blocks under legs at head of bed
      2. Place Styrofoam wedge under mattress
    6. Symptomatic therapy for mild intermittent symptoms
      1. OTC Antacid medications (e.g. Maalox, Tums, Rolaids)
        1. More effective than Placebo for GERD symptoms
        2. Chatfield (1999) Curr Med Res Opin 15:152-9
      2. Antacid chewing gum (Surpass by Wrigley)
  13. Management: Medications
    1. Institute general measures above
    2. Proton Pump Inhibitor
      1. All Proton Pump Inhibitors equivalent in GERD
        1. Klok (2003) Aliment Pharmacol Ther 17:1237-45
      2. Initial treatment for 6 to 12 weeks
        1. Use high dose (twice daily) for severe symptoms
      3. Taper to lower dose for 4 to 8 weeks
      4. Trial off Proton Pump Inhibitor
    3. Consider H2 Blocker maintenance therapy
    4. Medications not found to be beneficial
      1. Sucralfate (Carafate) offers minimal benefit in GERD
  14. Management: Refractory (persists despite Proton Pump Inhibitor or recurrs when stopped)
    1. Restart Proton Pump Inhibitor (e.g. Omeprazole)
    2. Consider Endoscopy (EGD)
      1. Evaluate for Barrett's Esophagus
    3. Consider evaluation for Anti-Reflux Surgery (Nissen Fundoplication)
      1. Upper Endoscopy (evaluate for Barrett's Esophagus)
      2. Upper Gastrointestinal Series (defines anatomy)
      3. Manometry
      4. 24-Hour pH Monitoring
    4. Consider other Esophageal Dysmotility
      1. Esophageal Achalasia
      2. Esophageal Spasm
  15. Follow-up
    1. Normal upper endoscopy (EGD)
      1. No repeat EGD for 10 years unless symptoms progress
      2. Schnell (2001) Gastroenterology 120:1607-19
  16. References
    1. Feldman (1998) Sleisenger GI, Saunders, p. 509-17
    2. Townsend (2001) Sabiston Surgery, Saunders, p. 755-66
    3. Devault (1999) Am J Gastroenterol 94:1434-42
    4. Heidelbaugh (2003) Am Fam Physician 68:1311-22
    5. Heidelbaugh (2008) Am Fam Physician 78(4): 483-8
    6. Horgan (1997) Surg Clin North Am 77(5):1063-82
    7. Peters (1998) Ann Surg 228(1):40-50

Gastroesophageal reflux disease (C0017168)

Definition (MSH) Retrograde flow of gastric juice (GASTRIC ACID) and/or duodenal contents (BILE ACIDS; PANCREATIC JUICE) into the distal ESOPHAGUS, commonly due to incompetence of the LOWER ESOPHAGEAL SPHINCTER.
Definition (NCI) A disorder characterized by reflux of the gastric and/or duodenal contents into the distal esophagus. It is chronic in nature and usually caused by incompetence of the lower esophageal sphincter, and may result in injury to the esophageal mucosal. Symptoms include heartburn and acid indigestion.
Definition (NCI) A chronic disorder characterized by reflux of the gastric and/or duodenal contents into the distal esophagus. It is usually caused by incompetence of the lower esophageal sphincter. Symptoms include heartburn and acid indigestion. It may cause injury to the esophageal mucosa.
Definition (MEDLINEPLUS)

Your esophagus is the tube that carries food from your mouth to your stomach. Gastroesophageal reflux disease (GERD) happens when a muscle at the end of your esophagus does not close properly. This allows stomach contents to leak back, or reflux, into the esophagus and irritate it.

You may feel a burning in the chest or throat called heartburn. Sometimes, you can taste stomach fluid in the back of the mouth. This is acid indigestion. If you have these symptoms more than twice a week, you may have GERD.

Anyone, including infants and children, can have GERD. If not treated, it can lead to more serious health problems. In some cases, you might need medicines or surgery. However, many people can improve their symptoms by

  • Avoiding alcohol and spicy, fatty or acidic foods that trigger heartburn
  • Eating smaller meals
  • Not eating close to bedtime
  • Losing weight if needed
  • Wearing loose-fitting clothes

NIH: National Institute of Diabetes and Digestive and Kidney Diseases
Definition (NCI) The backward flow of stomach acid contents into the esophagus (the tube that connects the mouth to the stomach).
Definition (NCI) The backward flow of liquid from the stomach into the esophagus.
Concepts Disease or Syndrome (T047)
MSH D005764
ICD9 530.81
ICD10 K21, K21.9
SnomedCT 235595009, 102620007, 54856001, 155673008, 196624002, 266498005, 196600005
English Esophageal Reflux, Gastro Esophageal Reflux, Gastro-Esophageal Reflux, Gastroesophageal Reflux, Reflux, Gastro-Esophageal, CARDIOESOPHAGEAL RELAXATION, GASTROESOPHAGEAL REFLUX, ESOPHAGEAL REFLUX, GASTROESOPHAGEAL REFLUX, GE REFLUX, Gastroesophageal reflux, Gastroesophageal reflux disease, GOR - Gastro-oeso reflux, GORD - Gastro-oeso reflux dis, Gastro-esophageal reflux dis, Gastro-oesophageal reflux dis, Gastrooesophageal reflux disease, GASTROESOPHAGEAL REFLUX DISEASE, GERD1, GER, GASTROESOPHAGEAL REFLUX, PEDIATRIC, GASTROESOPHAGEAL REFLUX DIS, Gastresophageal reflux, esophageal reflux (diagnosis), esophageal reflux, ge reflux, esophageal reflux disease, gerd, Acid Reflux, Esophageal reflux NOS, Gastroesophageal Reflux [Disease/Finding], reflux esophageal, diseases esophageal reflux, gastro esophageal reflux, reflux gastroesophageal, gastresophageal reflux disease, gastro-esophageal reflux disease, gastroesophageal reflux disease, Reflux;oesophageal, disease gastro-esophageal reflux, gastro oesophageal reflux, gerding, reflux disease esophageal, acid reflux, gastrooesophageal reflux, reflux acid, gastro-esophageal reflux, gastro-oesophageal reflux, gastroesophageal reflux disease (GERD), gastrooesophageal reflux disease, gastric reflux, reflux, gastroesophageal reflux, Acid Reflux, Gastric, Gastric Acid Reflux, Reflux, Gastric Acid, Gastric Acid Reflux Disease, Gastrooesophageal reflux, GERD, Gastro oesophageal Reflux, Gastro-oesophageal Reflux, Gastroesophageal Reflux Disease, Reflux, Gastro-oesophageal, Gastro-esophageal reflux, Esophageal reflux, Acid reflux, Oesophageal reflux, Gastro-esophageal reflux disease, Gastro-oesophageal reflux disease, GORD - Gastro-esophageal reflux disease, GORD - Gastro-oesophageal reflux disease, GOR - Gastro-esophageal reflux, GOR - Gastro-oesophageal reflux, Gastro-oesophageal reflux, Gastroesophageal reflux disease (disorder), gastroesophageal; reflux, reflux; gastroesophageal, Gastresophageal reflux disease, Gastroesophageal reflux (finding), Gastroesophageal reflux disease [Ambiguous], Reflux, Gastroesophageal, GERD - Gastro-esophageal reflux disease, Reflux;esophageal, oesophageal reflux
Portuguese REFLUXO GASTROESOFAGICO, Doença do refluxo gastresofágico, Refluxo esofágico, Refluxo gastresofágico, Doença de refluxo gastroesofágico, Afecção de refluxo gastroesofágico, Refluxo Esofágico, Refluxo Gastroesofágico
Spanish REFLUJO GASTROESOFAGICO, Reflujo esofágico, Reflujo gastroesofágico, Acid reflux, Oesophageal reflux, Esophageal reflux, Gastro-oesophageal reflux, Gastro-esophageal reflux, ERGE, RGE, enfermedad por reflujo gastroesofágico (concepto no activo), enfermedad por reflujo gastroesofágico (trastorno), enfermedad por reflujo gastroesofágico, esofagitis por reflujo, reflujo esofágico, reflujo gastroesofágico, reflujo ácido, Enfermedad por reflujo gastroesofágico, reflujo gastroesofágico (hallazgo), Reflujo Esofágico, Reflujo Gastroesofágico, Reflujo Esofagico, Reflujo Gastroesofagico
Italian Malattia da reflusso gastroesofageo, Reflusso esofageo, GERD, Reflusso gastro-esofageo, Malattia da reflusso g.e., Reflusso gastroesofageo
Dutch gastro-oesofageale reflux, oesofageale reflux, gastro-oesofagaal; reflux, reflux; gastro-oesofagaal, gastro-oesofageale refluxziekte, Aandoeningen door gastro-oesofagale reflux, Gastro-oesofageale reflux, Oesofageale reflux, Reflux, gastro-oesofageale
French Reflux gastro-oesophagien RGO, Maladie de reflux gastro-oesophagien, RGO (Reflux Gastro-Oesophagien), REFLUX GASTRO-OESOPHAGIEN, Reflux gastro-oesophagien, Reflux gastrooesophagien, Reflux oesophagien
German gastroesophagealer Reflux, Oesophagusreflux, GERD, Gastro-oesophageale Refluxkrankheit, GASTROOESOPHAGEALER REFLUX, Gastrooesophageale Refluxkrankheit, gastrooesophageale Refluxerkrankung, Gastroösophagealer Reflux, Ösophagealer Reflux, Reflux, gastroösophagealer
Japanese 胃食道逆流性疾患, ｼｮｸﾄﾞｳｷﾞｬｸﾘｭｳ, ｲｼｮｸﾄﾞｳｷﾞｬｸﾘｭｳｾｲｼｯｶﾝ, 食道逆流, 胃食道逆流症, 食道逆流現象, 胃･食道逆流現象, 食道逆流症, 胃食道逆流, ｲｼｮｸﾄﾞｳｷﾞｬｸﾘｭｳ
Swedish Gastroesofageal reflux
Czech gastroezofageální reflux, Gastroezofageální reflux, Refluxní choroba jícnu, Jícnový reflux, Choroga gastroezofágového refluxu
Finnish Gastroesofageaalinen refluksi
Russian ZHELUDOCHNO-PISHCHEVODNYI REFLIUKS, PISHCHEVODNYI REFLIUKS, ЖЕЛУДОЧНО-ПИЩЕВОДНЫЙ РЕФЛЮКС, ПИЩЕВОДНЫЙ РЕФЛЮКС
Korean 위-식도 역류질환
Croatian GASTROEZOFAGUSNI REFLUKS
Polish Refluks żołądkowo-przełykowy, Odpływ żołądkowo-przełykowy, GERD, Choroba refluksu żołądkowo-przełykowego, Zarzucanie żołądkowo-przełykowe
Hungarian Gastrooesophagealis reflux betegség, Gastrooesophagealis reflux, Oesophagealis reflux, GORB
Sources
Derived from the NIH UMLS (Unified Medical Language System)


Heartburn (C0018834)

Definition (MEDLINEPLUS)

Almost everyone has heartburn sometimes. Heartburn is a painful burning feeling in your chest or throat. It happens when stomach acid backs up into your esophagus, the tube that carries food from your mouth to your stomach. If you have heartburn more than twice a week, you may have gastroesophageal reflux disease (GERD). With GERD, the muscles at the end of your esophagus do not close tightly enough. This allows contents of the stomach to back up, or reflux, into the esophagus and irritate it.

Pregnancy, certain foods, alcohol and some medications can bring on heartburn. Treating heartburn is important because over time reflux can damage the esophagus. Over-the-counter medicines may help. If the heartburn continues, you may need prescription medicines or surgery.

If you have other symptoms such as crushing chest pain, it could be a heart attack. Get help immediately.
Definition (MSH) Substernal pain or burning sensation, usually associated with regurgitation of gastric juice into the esophagus.
Concepts Sign or Symptom (T184)
MSH D006356
ICD9 787.1
ICD10 R12
SnomedCT 207117006, 207120003, 207118001, 158428006, 271831008, 158426005, 139300004, 158425009, 16331000
English Pyroses, Pyrosis, BRASH, HEART BURN, HEARTBURN, PYROSIS, Heartburn NOS, [D]Heartburn (context-dependent category), [D]Heartburn NOS (context-dependent category), [D]Pyrosis (context-dependent category), [D]Heartburn, [D]Heartburn NOS, [D]Pyrosis, Heart burn, heartburn, heartburn (symptom), [D]Heartburn NOS (situation), [D]Pyrosis (situation), [D]Heartburn (situation), Heartburn [Disease/Finding], brash, Burning reflux, Heartburn symptom, Heartburn (finding), pyrosis, Heartburn
French PYROSIS, BRULURE EPIGASTRIQUE, Brulant/brulement/brulures, Brûlures gastriques, Brûlures épigastriques, Aigreurs d'estomac, Pyrosis, Brûlures d'estomac
Spanish PIROSIS, Ardor de estómago, [D]ardor epigástrico (categoría dependiente del contexto), [D]pirosis (categoría dependiente del contexto), [D]ardor epigástrico, SAI (categoría dependiente del contexto), [D]Heartburn NOS, Heartburn, [D]Heartburn, [D]Pyrosis, ARDOR EPIGASTRICO, [D]ardor epigástrico, SAI, [D]ardor epigástrico, SAI (situación), [D]pirosis (situación), [D]ardor epigástrico, [D]pirosis, [D]ardor epigástrico (situación), ardor retroesternal, acedía, acidez, ardor en el estómago, pirosis (hallazgo), pirosis, Pirosis
German SODBRENNEN, PYROSIS, Pyrosis, Sodbrennen
Portuguese PIROSE, Azia/pirose, Azia, Pirose
Dutch pyrosis, maagzuur, Zuurbranden [pyrosis], Zuurbranden, Brandend maagzuur, Pyrose, Pyrosis
Swedish Halsbränna, HALSBRANNA
Japanese ﾑﾈﾔｹ, 胸やけ, そうそう, そう囃, 呑酸, 胸焼け, 呑酸そう囃
Czech pyróza, Pyróza, Pálení žáhy, pálení žáhy
Finnish Närästys, NARASTYS
Russian IZZHOGA, ИЗЖОГА
Italian Bruciore di stomaco(pirosi), Pirosi
Norwegian HALSBRANN/KARDIALGI/SURE OPPSTOT
Danish Halsbrand/kardialgi/sure opstod
Hungarian gyomoreges, Gyomorégés, Pyrosis
Korean 속쓰림
Basque URDAIL SAMINTASUNA/BIOTZERRE
Hebrew tzarevet
Polish Zgaga
Sources
Derived from the NIH UMLS (Unified Medical Language System)


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