Gastroesophageal Reflux Disease

Reflux of gastric contents into the esophagus.

In the USA, symptoms of gastroesophageal reflux disease (GERD) occur daily in about 7% of adults and monthly in about 44%. GERD occurs more frequently in men than women (2 to 3:1). Incidence in the elderly is uncertain but appears similar to that in younger persons.

Symptoms and Signs

The most common symptom is substernal burning (heartburn), most often after meals or on reclining. Atypical chest pain, which must be differentiated from cardiac pain, can also occur. Esophagitis occurs when the caustic gastric contents remain in contact with the esophageal mucosa long enough to overcome esophageal defense and tissue resistance. Other common symptoms include regurgitation, which causes a bitter or sour taste, and water brash (salivary secretions thought to be stimulated by acid reflux) due to increased salivary secretion. Nonesophageal symptoms can result from mucosal injury of the oropharynx, larynx, or respiratory tract. Oropharyngeal irritation can cause sore throat, earaches, gingivitis, poor dentition, and globus sensation. Laryngeal or respiratory irritation can cause hoarseness, wheezing, bronchitis, asthma, and aspiration pneumonia. Symptoms may be worsened by eating large meals, consuming foods and beverages high in fat or caffeine, using tobacco and alcohol, reclining after eating, and gaining weight.

The clinical course varies. Esophagitis can occur. Strictures can develop at sites of significant recurrent inflammation. Barrett's esophagus, which occurs in 10 to 15% of patients with erosive esophagitis and in up to 40% of patients with peptic strictures, does not worsen symptoms. However, Barrett's esophagus is a premalignant condition for adenocarcinoma. Dysphagia may result due to inflammation, scarring, or malignancy. Hemorrhage can occur due to erosions and ulcerations caused by severe mucosal injury. Rarely, deep esophageal ulcerations can result in perforation.

Diagnosis

Although most diagnostic tests are unnecessary to diagnose GERD or begin treatment, they should be performed in patients with persistent or worsening symptoms or signs suggestive of tissue injury or cancer, including atypical pain, anemia, and weight loss. Early assessment is also important in patients with equivocal symptoms in whom a diagnosis is uncertain.

The most frequently used test for diagnosing GERD is barium swallow. Upper endoscopy is the best method for assessing mucosal injury. Acid perfusion tests require the placement of an esophageal pH probe 5 cm above the lower esophageal sphincter to determine if refluxed acidic contents (confirmed by pH < 4) are present in the esophagus. Continuous intraesophageal pH monitoring records the esophageal pH for 24 hours, which is then correlated with the patient's symptoms. Radionuclide scanning can identify radiolabeled colloid in the area of the esophagus. In the Bernstein acid perfusion test, normal saline and 0.1 N-hydrochloric acid are infused into the esophagus to determine whether atypical chest pain is related to acid reflux. The sensitivity and specificity of these diagnostic tests vary widely.

Treatment

The goal of treatment is to control symptoms and heal any mucosal lesions. Most patients can be empirically managed with lifestyle changes (eg, elevating the head of the bed, reducing the size of meals, decreasing fat and caffeine intake, avoiding the supine position after eating, eliminating tobacco and alcohol use, losing weight if needed) and acid neutralization with antacids. If relief is incomplete, treatment can include sucralfate, H₂ blockers (cimetidine, famotidine, nizatidine, ranitidine), and proton-pump inhibitors (lansoprazole, omeprazole, rabeprazole). Adjunctive therapy with a prokinetic drug (metoclopramide, cisapride) can be used if necessary. Prokinetic drugs should be used with caution in the elderly because of potential neurologic or central nervous system disturbance. Cisapride has been associated with arrhythmias and death.

GERD patients with Barrett's esophagus require aggressive treatment with proton pump inhibitors. Regular endoscopic surveillance is mandatory. High-grade dysplasia dictates elective esophagectomy. Ablation with photodynamic therapy, laser therapy, or electrocauterization has had varying degrees of success and continues to be studied.

A few patients who continue to have symptoms, who have esophagitis that fails to heal, or who develop severe complications may require surgery. Belsey's and Nissen's fundoplication and Hill's posterior gastropexy are the most widely used procedures. They are estimated to be 85% successful, but symptoms recur in about 10% of patients. The morbidity rate is estimated to be 2 to 8%, and the mortality rate is about 1%. The most common complications from surgery are dysphagia and an inability to belch or vomit. Increasingly, Nissen's fundoplication is being performed laparoscopically, which may reduce short-term morbidity and length of hospital stay.