Overview and Risk Factors
Gastroesophageal reflux disease (GERD) is a syndrome of inappropriate backflow of gastric acid into the esophagus, which can result in inflammation and erosion of the esophageal mucosa. It is the most common upper-gastrointestinal disorder in Western nations, affecting 30% of Americans intermittently and up to 10% on a daily basis.
The pathophysiology involves defective lower esophageal sphincter function, due to inappropriate sphincter relaxation. This condition may be exacerbated by alcohol intake, smoking, fatty foods, caffeine, chocolate, or various medications (eg, anticholinergics, calcium channel blockers); inadequate sphincter size or muscle function; or abnormal sphincter position.
Symptoms include heartburn, dysphagia, hoarseness, regurgitation, belching, a full feeling in the throat, and a persistent, nonproductive cough. Because the characteristic heartburn may mimic cardiac chest pain, it is useful to characterize the heartburn pain to distinguish it from cardiac ischemia. The pain associated with reflux is of a burning quality and may radiate to the back. It usually occurs within 30 minutes after ingesting specific foods, is often exacerbated by recumbancy, and is relieved by antacids. Unlike cardiac chest pain, the symptoms of reflux are not related to exertion and are not associated with shortness of breath, nausea, diaphoresis, or pain radiation to the jaw or arms.
Chronic reflux can result in severe sequelae, including erosion, ulceration, scarring, or stricture of the esophageal mucosa. Further, a possible complication of chronic reflux is the development of Barrett's esophagus, in which metaplasia of the lower esophageal mucosa results in replacement of the squamous epithelium with columnar epithelium. Patients with Barrett's esophagus are at high risk for developing esophageal adenocarcinoma.
Risk Factors
Diet (see Nutritional Considerations).
Disorders and conditions that cause increased gastric pressure. Pregnancy and obesity cause increased intra-abdominal pressure that is translated to the stomach. Diabetes mellitus causes prolonged gastric emptying, resulting in increased gastric contents and gastric pressure. In each case, the increased gastric pressure exerts abnormally high pressure on the lower esophageal sphincter and predisposes the individual to reflux.
Hiatal hernia. In this syndrome, the stomach herniates upward through the diaphragm, displacing the lower esophageal sphincter from its anatomic position. As a result, the sphincter is often not functionally competent.
Disorders that result in esophageal dysmotility. Such disorders, which include scleroderma and Parkinson's disease, can impair esophageal clearance of refluxed gastric acid. Raynaud's phenomenon is also often complicated by reflux.
Diagnosis and Treatment
Diagnosis
Initial assessment should include a thorough history and physical examination to rule out a cardiac source of chest pain. Focused diagnostic testing may be necessary, including an EKG and cardiac enzymes.
In most cases, diagnosis can be made on the basis of the patient’s clinical response to proton pump inhibitors (eg, omeprazole). A therapeutic trial of lifestyle changes (see below), antacids, or H2 (Histamine–2) receptor blockers (eg, cimetidine) may also be attempted, although these are less reliable for diagnostic purposes.
Further diagnostic testing may include the following:
Upper GI endoscopy. Permits direct inspection of the inflamed mucosa and biopsy to rule out Barrett’s esophagus or malignancy.
Barium esophagram. Evaluates for anatomic causes and complications of gastroesophageal reflux disease (eg, hiatal hernia, strictures).
24–hour pH monitoring. Correlates esophageal pH to symptom onset in order to diagnose reflux.
Esophageal manometry. Measures pressure within the esophagus to evaluate esophageal sphincter function or esophageal dysmotility.
Treatment
Lifestyle modification is the initial therapy for mild–to–moderate disease. Along with weight loss, this may include dietary changes to eliminate or minimize predisposing agents, such as avoiding alcohol, caffeine, chocolate, peppermint, spicy foods, fatty foods, and other dietary triggers, and refraining from eating within 2 to 4 hours of bedtime. Other modifications include smoking cessation, avoiding postprandial recumbancy, elevation of the head of one’s bed by 6 to 8 inches, avoidance of tight–fitting clothing that may increase intra–abdominal pressure, and elimination of medications that decrease esophageal sphincter tone (eg, calcium channel blockers).
Medications are usually effective for symptomatic relief. Oral antacids or H2 receptor blockers (eg, cimetidine, ranitidine) are used when symptoms are mild and intermittent.
Proton pump inhibitors (eg, omeprozole) are generally reserved for severe or recurrent symptoms.
Severe reflux may require surgical fundoplication, which involves wrapping the distal end of the esophagus with the fundus of the stomach to restore the competence of the lower esophageal sphincter.
Patients who have been diagnosed with Barrett’s esophagus require regular screening endoscopies to monitor for esophageal carcinoma.
Attaining or maintaining a healthy body weight may be helpful. Compared with individuals with a body mass index (BMI) below 25 kg/m2, those with a BMI between 25 and 30 kg/m2 have roughly 1.5 times the risk for gastroesophageal reflux disease, while persons with a BMI > 30 have approximately double the risk for this disease.1 Available evidence is limited, but suggests that weight loss may bring symptomatic improvement.2,3
In addition, psychological distress, caused by either major life events4,5 or overt psychiatric disease,6 is associated with GERD symptoms. Limited evidence suggests that stress–reduction techniques (ie, relaxation training) may reduce symptoms in many persons.7
Nutritional Considerations
The role of dietary factors in GERD remains unsettled. It is noteworthy, however, that cultural differences are associated with differences in prevalence, suggesting a role for diet. The incidence of gastroesophageal reflux disease is lower in China (5% incidence) and certain other countries than in Western countries,8 which may reflect differences in eating styles, food choices, and body weight. Although dietary changes (eg, avoidance of offending foods and beverages) are often recommended to improve symptoms, reducing meal size and controlling weight may be equally important. The following factors appear to be associated with reduced GERD symptoms:
Eating more fiber. Persons eating the most fiber have a 30% lower risk for GERD, compared with those who eat the least.9 High–fiber bread in particular has been associated with reduced risk for this disease.10 Controlled clinical trials have not assessed the effectiveness of a high–fiber diet in treating this disorder.
Avoiding irritating foods. Although research is not abundant, available evidence indicates that fried, fatty, or spicy foods; raw onions; chocolate; alcohol; and drinks with high titratable acidity, such as citrus drinks and juices, all cause reflux and heartburn.11–14
Eliminating coffee. Coffee reduces lower esophageal sphincter pressure, permitting gastroesophageal reflux.15 Although studies have repeatedly shown that caffeine itself is not responsible for GERD, some evidence does indicate that decaffeination of coffee significantly reduces reflux.16,17 In addition, other compounds in coffee may trigger reflux.18
Avoiding alcohol. Compared with nondrinkers, alcohol consumers have at least double the risk of gastroesophageal reflux disease.19
Eating smaller meals. The total amount of food consumed during a meal appears to be related to reflux symptoms, perhaps because gastric distension triggers GERD symptoms.20 Reducing meal size may therefore be a reasonable prevention strategy,21,22 particularly for patients who frequently experience delayed gastric emptying.23
Thickened feedings. Thickened feedings for children under 2 years of age reduce regurgitation severity and emesis frequency, although this does not lower the reflux index.24
Orders
Avoid patient–specific food triggers, or eliminate potential triggers (as described above) prospectively.
Smoking cessation.
Alcohol restriction.
Stress reduction.
What to Tell the Family
Gastroesophageal reflux disease is a common disorder that may be preventable through maintaining a healthy weight, avoiding mealtime overeating, and avoiding caffeine and irritating foods. In chronic cases, treatment may also involve antacids, proton pump inhibitors, and even surgery to prevent erosive esophagitis and decrease the risk for esophageal cancer.
References
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