Gastroesophageal reflux disease (aka GERD) is a chronic disease where stomach acid comes up from the stomach into the esophagus, causing mucosal damage. Reflux is where this occurs in babies and young children, and is physiological.
Patient information
What is reflux?
It's where the contents of the stomach, comes up into the tube above, called the esophagus. It's a problem because the stuff in the stomach is quite acidic.
Pathophysiology
Caused by failure of the lower esophageal sphincter (i.e. barrier between the stomach and esophagus), whether permanent or temporary. It is caused by:
Abnormal relaxation in the lower esophageal sphincter (which normally holds the top of the stomach closed)
Impaired expulsion of gastric reflux from the esophagus
Hiatal hernia
Obesity
Zollinger-Ellison syndrome
High blood calcium, which can increase gastrin production, causing increased acidity
Scleroderm and esystemic sclerosis, which can cause esophageal dysmotility
Drugs, e.g. prednisolone
Visceroptosis or Glenard syndrome, where the stomach has sunk in the abdomen upsetting the motility and acid secretion of the stomach
Normally, the Angle of His (i.e. angle at which the esophagus enters the stomach) creates a valve that prevents duodenal bile, enzymes and stomacha cid from travelling back into the esophagus, where it can cause burning/inflammation of sensitive esophageal tissue
Patient information
Wait. Is this normal? Isn't the body designed so stuff in the tummy, stays in the tummy?
It is. Usually the lower esophageal sphincter holds the stuff in the tummy, in the tummy. But if it relaxes, stuff can go up, out of the tummy.
You said that a hiatal hernia can also cause this. What is that? What is a hiatus? Isn't that where you take a break from something ?
We're talking about the esophageal hiatus there, which is the opening in the diaphragm, through which the esophagus passes from the chest into the tummy area. Hiatus hernia is where part of the tummy herniates into the thorax, through a weakness in the diaphragm.
Sx
Most commonly:
Regurgitation
Heartburn
Painful swallowing
Increased salivation
Nausea
Chest pain
Coughing
In kids:
Repeated vomiting
Effortless spitting up
Coughing, or other respiratory problems (e.g wheezing)
Inconsolable crying
Refusing food
Crying for feed, and then pulling off the bottle or breast only to cry for it again
Failure to gain adequate weight
Bad breath
Belching or burping
Dx
Sx
Short term Tx w/ PPI's, showing improvement in Sx, suggesting positive Dx
EGD (esophagogastroduodenoscopy)
Esophageal pH monitoring, the gold standard, allows monitoring GERD in pt's in their response to medical or surgical Tx
Barium swallow x-rays, should NOT be used for Dx
Esophageal manometry is NOT recommended for use in Dx being recommended only prior to surgery
Ix for H pylori is usually NOT needed
Tx
Lifestyle changes, including:
Weight loss
Elevating the head
Moderate exercise, improves Sx, although vigorous exercise may worsen Sx
Avoiding certain foods, especially before lying down, that promote GERD, although there is little evidence. Foods implicated include coffee, alcohol, chocolate, fatty foods, acidic foods, and spicy foods
Stopping smoking, and not drinking alcohol, do NOT appear to result in significant improvement in Sx
Medications, including:
Antacids (see page)
PPI's (proton pump inhibitors)
H2 blockers
Surgery, in those who don't improve, including:
Nissen fundoplication, where the upper part of the stomach is wrapped around the lower esophageal sphincter to strengthen the sphincter, and prevent acid reflux, and to repair a hiatal hernia
LINX, involving a series of metal beeds w/ magnetic cores placed surgically around the lower esophageal sphincter
Epidemiology
Affects 10-20% of the population in the Western world
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