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Gastroesophageal Reflux Disease
Gastroesophageal Reflux Disease
Celiac disease
Crohn disease
Others
Plummer Vinson syndrome
Zollinger Ellison Syndrome
If the presenting symptom is chest pain, other diagnoses should be ruled out first. (See “Diagnostics” in “Chest pain” for a comprehensive workup.)
EGD [10][17][18][19]
Indications
o Alarm features
Dysphagia, odynophagia
Early satiety
Anemia or evidence of GI bleeding
Persisting vomiting
Unintentional weight loss
Aspiration pneumonia
o Risk factors for Barrett esophagus
o No symptomatic improvement after PPI trial
Supportive findings (typically in the lowest third of the esophagus)
[20]
o Erythema, edema, friability
o Erosions, mucosal breaks, ulcerations
o Peptic strictures and rings
o Salmon-pink mucosa (suggestive of Barrett esophagus)
o Proximal migration of the gastroesophageal junction (Z line), e.g., in Barrett esophagus or hiatal hernia [21]
Esophageal pH monitoring [10][20]
Esophageal pH monitoring is the gold standard and can be used to objectively identify abnormal reflux of gastric content into the esophagus. It is not a
routine diagnostic test. [10]
Indications
o Refractory GERD symptoms despite PPI therapy
o Confirmation of suspected NERD
Procedure
o Measurement of esophageal pH over 24–48 hours using a telemetry capsule or a transnasal catheter
o Documentation of relevant events by the patient
Supportive finding: Drops in esophageal pH to 4 or less that correlate with symptoms of acid reflux and precipitating activities.
[23]
Further diagnostic studies [10][20]
Not routinely indicated, as they play a limited role in the diagnosis of GERD; useful if endoscopy is inconclusive.
Esophageal barium swallow: Consider if the main symptom is dysphagia or if there is suspicion of structural abnormalities
or motility disorders
(see “Diagnostics” in “Dysphagia”).
Esophageal manometry: Consider if achalasia or esophageal hypermotility disorders are suspected.
[24]
NOTES
FEEDBACK
Treatment
The initial management of GERD consists of implementing lifestyle changes and initiating acid suppression therapy, preferably with PPIs. Surgical therapy is
not routinely indicated and should only be considered in select cases, e.g., patients who develop complications despite receiving optimal medical therapy.
Pharmacological therapy
[10][19]
See “Antacids and acid suppression medications” for agents and pharmacological considerations.
PPIs: standard dose of PPI for 8 weeks
o Indications
Empiric PPI trial in patients with typical symptoms
After EGD: ERD or presumed NERD
o Continuous management (based on the clinical response after 8 weeks) [25]
Good response and no complications: Discontinue PPI.
Good response in patients with complications
: Continue PPI at maintenance dose.
Partial response: Increase dose (to twice daily therapy), adjust timing, or switch to a different PPI.
No response: further diagnostic evaluation
H2 receptor antagonists: Consider as alternate maintenance therapy
Maintenance therapy: lowest effective dose of acid suppression medication
Lifestyle changes [10][19][30][31][32]
There is conflicting evidence as to which lifestyle modifications confer a significant benefit. The following recommendations are commonly mentioned in the
literature but should be approached on a case-by-case basis, as they may offer relief only for some patients.
Dietary recommendations
o Small portions
o Avoid eating at least 3 hours before bedtime.
o Avoid foods/beverages that appear to trigger symptoms.
[33]
Physical recommendations
o Weight loss in patients with obesity
o Elevate the head of the bed (10–20 cm) for patients with nighttime symptoms.
Reduce or avoid triggering substances
o Nicotine, alcohol, caffeine if the patient experiences a correlation with symptoms
o Medications that may worsen symptoms (e.g., CCBs, diazepam)
[8]
Surgical therapy [10][19][34]
Antireflux surgery may be considered for select patients after careful evaluation.
Indications
Discontinuation of medical therapy (e.g., due to nonadherence or side effects)
Symptoms refractory to medical therapy
Complications despite optimal medical therapy, e.g., severe esophagitis, strictures, recurrent aspiration
Fundoplication
Definition: an antireflux procedure in which the gastric fundus is wrapped around the lower esophagus and secured with stitches to form a cuff;
results in a narrowing of the distal esophagus and the gastroesophageal junction (GEJ), preventing reflux
Approach: Laparoscopic and open fundoplication are possible.
Techniques
[35]
o Partial fundoplication (fewer complications)
180° (Dor fundoplication)
270° (Toupet fundoplication)
o Complete fundoplication (Nissen fundoplication): 360°
Complications [35]
o Gas bloat syndrome: inability to belch, leading to bloating and an increase in flatulence
o Dysphagia
o Recurrence of reflux esophagitis
Considerations for patients with comorbidities
o Patients with obesity and reflux undergoing bariatric surgery: Consider Roux-en-Y.
o Hiatal hernias: Combine fundoplication with hiatoplasty and, in some cases, gastropexy.
NOTES
FEEDBACK
Complications
Barrett esophagus [19][37][38]
Definition: intestinal metaplasia of the esophageal mucosa induced by chronic reflux. Histopathological examination of the mucosa shows
a columnar epithelium instead of the normal squamous epithelium. These is a premalignant change that requires close surveillance. [37][39]
Incidence: up to 15% of patients with GERD
Risk factors for Barrett esophagus [10]
o Male sex
o European descent
o Age ≥ 50 years
o Obesity
o Symptoms ≥ 5 years
Pathophysiology
o Reflux esophagitis → stomach acid damages mucosa of distal esophagus → nonkeratinized stratified squamous epithelium is replaced by
nonciliated columnar epithelium and goblet cells (intestinal metaplasia, Barrett metaplasia) [14]
o The physiological transformation zone (Z line) between squamous and columnar epithelium is shifted upwards.
Pathology
o Short-segment (< 3 cm of columnar epithelium between Z line and GEJ)
o Long-segment (> 3 cm of columnar epithelium between Z line and GEJ): higher cancer risk
Complications: esophageal adenocarcinoma (see “Esophageal cancer”)
Management and surveillance
o PPI therapy [25]
Consider if asymptomatic.
Continue maintenance therapy long-term if symptomatic.
o Endoscopy with four-quadrant biopsies at every 2 cm of the suspicious area (salmon-colored mucosa)
If no dysplasia: Repeat endoscopy every 3–5 years.
If indefinite for dysplasia: Repeat endoscopy with biopsies after 3–6 months of optimized PPI therapy.
If low-grade dysplasia:
Endoscopic therapy of mucosal irregularities
Alternatively: surveillance every 6-12 months with biopsies every 1 cm
If high-grade dysplasia: endoscopic treatment of mucosal irregularities, e.g., radiofrequency ablation
o Consider antireflux surgery or resection of the segment based on a specialist's evaluation. [35][36]
Additional complications
Reflux esophagitis: most common complication of GERD [40]
Iron deficiency anemia: mucosal erosions and ulcerations → chronic bleeding → anemia
Esophageal stricture
o Etiology: most common sequela of reflux esophagitis
or ingestion of caustic substances [40]
o Clinical features: solid food dysphagia
o Diagnostics
Barium esophagram (best initial test): narrowing of the esophagus at the gastroesophageal junction
Endoscopy with biopsies: to rule out malignancy and eosinophilic esophagitis
o Treatment
First-line treatment: dilation with bougie dilator/balloon dilator and PPIs in patients with reflux
In refractory cases (multiple recurrences): steroid injection prior to dilation; endoscopic electrosurgical incision
o Recurrence occurs in the majority of patients; multiple treatment attempts are often necessary.
Esophageal ring [41]
o Schatzki rings: narrowing of the esophagus
Most commonly seen at the squamocolumnar junction
Usually caused by chronic acid reflux
Can lead to dysphagia
Complications due to aspiration of gastric contents
o Aspiration pneumonia
o Chronic bronchitis
o Asthma (exacerbation)
Reflux laryngitis: hoarseness (due to laryngopharyngeal reflux)