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