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Gastroesophageal Reflux Disease: a General Overview

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Gastroesophageal Reflux Disease: a General Overview Fashner. HCA Healthcare Journal of Medicine (2020) 1:4 https://doi.org/10.36518/2689-0216.1042 Clinical Review Gastroesophageal Reflux Disease: A General Author affiliations are listed Overview at the end of this article. Julia Fashner, MD, MPH1 Correspondence to: Abstract Julia Fashner, MD, MPH University of Central Description Gastroesophageal reflux disease (GERD) varies in presentation and the patient’s symptoms Florida College of Medicine, of regurgitation in the throat or epigastric pain do not necessarily correlate with the severity GME, Ocala Regional of their disease. This general overview of GERD will include information on guidelines and Medical Center, Family diagnostic testing; lifestyle, medical and surgical management; and GERD in special popu- Medicine lations. The pathophysiology of GERD is multifactorial, and a step-wise approach will assist physicians in making the diagnosis as GERD has a significant financial burden to the U.S. Residency Program, 1431 healthcare system. SW First Ave, Bitzer Bldg., Suite 7, Ocala, FL 34471 Keywords (Julia.Fashner@ gastroesophageal reflux/diagnosis; gastroesophageal reflux/physiopathology; gastroesoph- hcahealthcare.com) ageal reflux/therapy; heartburn; proton pump inhibitors; disease management Introduction may even disrupt a patient’s work or sleep. Gastrointestinal (GI) complaints are common in Other symptoms, which are often thought to all ages. The cost of treatments for such com- be GERD related but overlap with other con- plaints in the U.S. has a multi-billion dollar price ditions, including cough, laryngitis, chest pain, tag for medications and diagnostic testing.1 dyspepsia, epigastric pain, nausea, bloating This article will review the general concepts and belching. Physicians may consider a wider of gastroesophageal reflux disease (GERD), differential of peptic ulcer disease,Helicobacter including pathophysiology, diagnosis, and treat- pylori infection, respiratory or cardiac diseases ment options. GERD is prevalent in the U.S. in patients when they have these overlapping and ranges from 8-33% worldwide.1 GERD is symptoms. Alarm features (Table 1) are not seen in all ages and by many specialties due to specific for GERD and should alert physicians the overlap of symptoms. Medications such as to consider alternative diagnoses and addition- 3 acid reducers are available over the counter and al testing. There are also gender differences in may be used by patients without ever seeing a GERD presentation and consequence of long physician. standing disease (e.g. men being at higher risk for Barrett’s esophagus and esophageal adeno- carcinoma), which plays a role into the investi- Symptoms gative intensity of the physician.2 GERD varies in its clinical presentation and studies have found that symptoms do not necessarily correlate well with the presence or Pathophysiology degree of this condition. The consensus defi- The pathophysiology of GERD is multifactorial nition of GERD is a disease with symptoms and includes impairment of the lower esoph- or complaints resulting from regurgitation of ageal sphincter function or impaired esopha- stomach contents into the throat, hypophar- geal peristalsis, or delayed gastric emptying, ynx, larynx or lung.2,3 GERD symptoms vary in or increased intragastric pressure, or impaired their timing—daytime, nighttime, when upright, mucosal resistance or excess gastric acid secre- 3-5 when supine or post-prandial.2-4 The symptoms tion. With relaxation of the lower esophageal www.hcahealthcarejournal.com HCA Healthcare © 2020 HCA Physician Services, Inc. d/b/a Journal of Medicine Emerald Medical Education 191 HCA Healthcare Journal of Medicine sphincter, stomach contents of gastric acid, procedure not only assists with the diagnosis pepsin, bile, small intestine fluid or pancreatic of GERD—since it can find erosive esophagitis secretions can enter the esophagus and injure or strictures due to reflux, but can also help in the mucosa.5 Recently, a new mechanism for detecting alternative diagnoses.1,2 Biopsies may GERD has been proposed. Human and animal be taken to test for inflammation, infection studies show that esophagitis develops as a or malignancy.1,2 A screening EGD to look for cytokine-mediated inflammatory injury with Barrett’s esophagus is a recommendation if the hypoxia inducible factor-2 alpha playing a key patient is white, male, obese, over the age of part in the process.6 50 and has had long-term GERD symptoms.2,3 Diagnosis A subsequent diagnostic test to assist in As there are no physical manifestations for making a GERD diagnosis is ambulatory reflux GERD, the American College of Gastroenterol- monitoring, which measures pH. This exam- ogy (ACG) guidelines suggest that symptoms ination can demonstrate the number of reflux episodes, along with the duration of time the of heartburn and regurgitation are reliable in 1,2 making a presumptive diagnosis of GERD.2 esophagus is exposed to acid. Another way to An empiric trial of a once a day proton pump measure acid is with pH-impedence monitor- ing (pH-metry), which can detect liquid, gas inhibitor (PPI) can be used in these patients as 1 long as they do not have alarm symptoms. A or mixed reflux. This type of testing is done response to 8 weeks of PPI therapy assists in after an EGD in order to diagnose functional making a GERD diagnosis, with a reported sen- heartburn. With functional heartburn, the PPI 2 trial may have worked, but the EGD shows sitivity of 78% and specificity of 54%. Treating 1,2 empirically is less costly than diagnostic work no signs of reflux. The most important data ups, but this strategy is likely overdiagnosing from measuring pH is the acid exposure time GERD and leading to the over use of PPIs.1 (AET): > 6% is abnormal and < 4% is normal (physiologic).1 In counting episodes of reflux, > Most guidelines agree that if patients do not 80 episodes in 24 hours is considered abnormal respond to empiric PPI or if the patient has and < 40 is considered physiologic. This count alarm symptoms, the initial diagnostic test may be helpful when the AET is inconclusive should be an upper endoscopy (EGD). This (between 4 and 6%); by itself, it may not be Table 1. Alarm features which are not specific for gastroesophageal reflux disease and should lead physician to refer patient for endoscopy.3 Dysphagia Odynophagia Persistent cough Dysphonia GI tract bleeding Persistent pain Iron deficiency anemia Unintentional weight loss Lymphadenopathy Epigastric mass New onset of symptoms at age 45 to 55 Family history of esophageal or gastric adenocarcinoma 192 Fashner. (2020) 1:4. https://doi.org/10.36518/2689-0216.1042 clinically useful.1 The sensitivity of pH monitor- those who have a large waist circumference ing is 77–100%, with specificity being 85–100%.2 and patients who gain weight have increased Another use of pH monitoring is calculating GERD symptoms.2,3,9 There are mixed results the DeMeester score, which includes total when considering different foods that might reflux episodes the percent of total time with influence reflux. High dietary fat and con- symptoms, the upright time, and the supine sumption of carbonated drinks may be risk time with esophageal pH < 4; number of reflux factors for GERD.3 Chocolate and carbonated episodes that last over 5 minutes and longest beverages decrease the pressure in the low- reflux episode.7 This score correlates well with er esophageal sphincter, so they may cause the acid exposure time. reflux. Alcohol, caffeine, coffee, spicy foods and citrus, however, have no effect.2 Another Relaxation of the sphincter can be measured study found drinking alcohol (spirits or beer) during esophageal manometry testing.5 This and eating foods with more salt may increase test is useful when considering the diagnosis reflux.9 Smoking increases symptoms2,9 and is of functional heartburn. Functional heartburn a risk factor for Barrett’s esophagus in patients can be diagnosed in patients who failed PPI with GERD.10 Certain medications (Table 2) therapy and also had an endoscopy without may irritate the gastrointestinal tract or cause esophagitis.5,8 A more specific definition has delayed gastric emptying, and, therefore, also been given by the American Gastroenterologic affect GERD.3,4 Asking the patient about these Association in their clinical practice update for lifestyle factors and medical issues are import- functional heartburn.8 This diagnosis can be ant when discussing the patient’s history. considered when there is retrosternal burning pain despite a double-dose of PPI for three Physicians will need to consider patient behav- months. To make the diagnosis, the patient ior changes as part of their therapy. Weight should have no anatomic or mucosal problems loss, elevating the head off the bed, cutting out found on the EGD and biopsies and esophageal food 2–3 hours before reclining and avoiding high-resolution manometry rules out major meals with fatty content may improve symp- motor disorders. Because the patient may have toms and acid exposure.2,4 The ACG GERD a negative symptom index, pH monitoring guideline recommends the full removal of when the patient is not on PPIs will show acid foods that may increase reflux. On that list are exposure in the distal esophagus.8 Manometry chocolate, caffeine, alcohol, citrus and spicy alone is not useful for diagnosing GERD, but it foods.2 However, as mentioned before, evi- is required before any surgery for severe reflux dence is lacking that these foods cause GERD. is considered.2 The National Institute of Diabetes and Diges- tive and Kidney Disease’s website offers pa- A symptom index is given to patients during pH tient information on GERD and diet.11 The web- monitoring. This index shows the percentage site advises patients to avoid chocolate, coffee, of times that reflux precedes the symptom peppermint, greasy or spicy foods, tomatoes episodes measured in a 2 minute window.1 The and alcohol.
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