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.
- Three mechanisms-
- 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