Patient will present as → a 55-year-old male with complaints of heartburn, belching, and epigastric pain which is aggravated by drinking coffee, eating fatty foods, and lying down. He says it gets better when he takes antacids.
Incompetence of the lower esophageal sphincter allows reflux of gastric contents into the esophagus, causing burning pain.
- Prolonged reflux may lead to esophagitis, stricture, and rarely metaplasia or cancer.
- Gastroesophageal reflux disease (GERD) is common, occurring in 10 to 20% of adults. It also occurs frequently in infants, typically beginning at birth
- Factors contributing to reflux include weight gain, fatty foods, caffeinated or carbonated beverages, alcohol, tobacco smoking, and drugs.
Drugs that lower LES pressure include anticholinergics, antihistamines, tricyclic antidepressants, Ca channel blockers, progesterone, and nitrates.
- The PH Probe study is the gold standard for diagnosis
- The upper GI study is a study of anatomy not for reflux
- A chronic cough can be an easily overlooked symptom of GERD
- Chronic GERD may predispose to Barrett's esophagus and cancer
"Once Barrett's esophagus has been identified, screening every 3 to 5 years by upper endoscopy is recommended to look for dysplasia or adenocarcinoma. There is an 11-fold increase in esophageal adenocarcinoma in a patient with Barrett's esophagus."
Patients with foul odor of the breath and increasing symptoms think Zenker's Diverticulum which is an outpouching of hypopharynx resulting in regurgitation of solid foods – needs surgical repair.
Patients with typical symptoms of GERD may be given a trial of therapy.
- Patients who do not improve, or have long-standing symptoms or symptoms of complications, should be studied.
Endoscopy, with cytologic washings and biopsy of abnormal areas, is the test of choice.
- Endoscopic biopsy is the only test that consistently detects the columnar mucosal changes of Barrett esophagus. Patients with unremarkable endoscopy findings who have typical symptoms despite treatment with proton pump inhibitors should undergo 24-h pH testing.
The PH Probe study is the gold standard for diagnosis
Management of uncomplicated GERD consists of elevating the head of the bed about 15 cm (6 in) and avoiding eating within 2 to 3 h of bedtime, strong stimulants of acid secretion (eg, coffee, alcohol), certain drugs (eg, anticholinergics), specific foods (eg, fats, chocolate), and smoking.
- Weight loss is recommended for overweight patients and those who have gained weight recently.
- Drug therapy is stepwise:
- Start with a low-dose histamine 2 receptor antagonists QD then increasing to BID if needed
- Switch to a proton pump inhibitor if symptoms persist. Start low dose and increase to standard dose if needed.
- Once symptoms are controlled, treatment should be continued for at least eight weeks.
|GERD is the reflux of gastric contents into the esophagus, which is characterized by inflammatory symptoms resulting from the irritating effects of gastric or duodenal contents on the esophageal mucosa. Patients who are obese are at increased risk for the disease due to increased intra-abdominal pressure, which allows the reflux (backward flow) of stomach contents into the esophagus.|
Eating smaller meals at a time
Eating smaller meals at a time reduces symptoms of GERD.
Elimination of acidic foods
Elimination of acidic foods reduces symptoms of GERD.
Weight loss; stop smoking and alcohol ingestion
Weight loss; stop smoking and alcohol ingestion reduces symptoms of GERD.
Lying down within 3 hours after meal
Proton pump inhibitors (PPI)
are not as effective as PPIs.
The dopamine antagonist prokinetic agents
The dopamine antagonist prokinetic agents are not as effective as PPIs.
H2-receptor antagonists are not as effective as PPIs.
Alginate-containing antacids are not as effective as PPIs.
Diffuse esophageal spasm
Hiatal hernia contributes to the development of GERD.
Excessive reflux is defined as a pH <4 for >4% of the time
In most patients with GERD, baseline LES pressures are normal (10–35 mm Hg).
Endoscopy is indicated in all cases of GERD.
Peptic Ulcer Disease