Thursday, December 3, 2009

Gastroesophageal Reflux Disease

eMedicine Specialties > Gastroenterology > Esophagus

Author: Piero Marco Fisichella, MD, Assistant Professor of Surgery, Stritch School of Medicine, Loyola University; Director, Esophageal Motility Center, Loyola University Medical Center
Coauthor(s): Marco G Patti, MD, Professor of Surgery, Director, Center for Esophageal Diseases, University of Chicago Pritzker School of Medicine
Contributor Information and Disclosures

Updated: Apr 28, 2009

Background

Gastroesophageal reflux is a normal physiologic phenomenon experienced intermittently by most people, particularly after a meal. Gastroesophageal reflux disease (GERD) occurs when the amount of gastric juice that refluxes into the esophagus exceeds the normal limit, causing symptoms with or without associated esophageal mucosal injury (ie, esophagitis).

For excellent patient education resources, visit eMedicine's Heartburn/GERD/Reflux Center and Esophagus, Stomach, and Intestine Center. Also, see eMedicine's patient education articles Gastroesophageal Reflux Disease (GERD), Heartburn, and Heartburn/GERD Medications.

Pathophysiology

The physiologic and anatomic factors that prevent the reflux of gastric juice from the stomach into the esophagus include the following:

  • The lower esophageal sphincter (LES) must have a normal length and pressure and a normal number of episodes of transient relaxation (relaxation in the absence of swallowing).
  • The gastroesophageal junction must be located in the abdomen so that the diaphragmatic crura can assist the action of the LES, thus functioning as an extrinsic sphincter. The presence of a hiatal hernia disrupts this synergistic action and can promote reflux (see Image 3 or below).
    Barium swallow indicating hiatal hernia.

    Barium swallow indicating hiatal hernia.

    Barium swallow indicating hiatal hernia.

    Barium swallow indicating hiatal hernia.

  • Esophageal clearance must be able to neutralize the acid refluxed through the LES. (Mechanical clearance is achieved with esophageal peristalsis. Chemical clearance is achieved with saliva.)
  • The stomach must empty properly.

Abnormal gastroesophageal reflux is caused by the abnormalities of one or more of the following protective mechanisms:

  • A functional (frequent transient LES relaxation) or mechanical (hypotensive LES) problem of the LES is the most common cause of gastroesophageal reflux disease (GERD).
  • Certain foods (eg, coffee, alcohol), medications (eg, calcium channel blockers, nitrates, beta-blockers), or hormones (eg, progesterone) can decrease the pressure of the LES.
  • Obesity is a contributing factor in gastroesophageal reflux disease (GERD), probably because of the increased intra-abdominal pressure.

From a therapeutic point of view, informing patients that gastric refluxate is made up not only of acid but also of duodenal contents (eg, bile, pancreatic secretions) is important.

Frequency

United States

Heartburn is a common problem in the United States and in the Western world. Approximately 7% of the population experience symptoms of heartburn daily. An abnormal esophageal exposure to gastric juice is probably present in 20-40% of this population, meaning 20-40% of the people who experience heartburn do indeed have gastroesophageal reflux disease (GERD). In the remaining population, heartburn is probably due to other causes. Because many individuals control symptoms with over-the-counter (OTC) medications and without consulting a medical professional, the condition is likely underreported.

Mortality/Morbidity

  • In addition to the typical symptoms of gastroesophageal reflux disease (GERD) (eg, heartburn, regurgitation, dysphagia), abnormal reflux can cause atypical symptoms, such as coughing, chest pain, and wheezing. Additional atypical symptoms from abnormal reflux include damage to the lungs (eg, pneumonia, asthma, idiopathic pulmonary fibrosis), vocal cords (eg, laryngitis, cancer), ear (eg, otitis media), and teeth (eg, enamel decay).
  • Approximately 50% of patients with gastric reflux develop esophagitis (see Image 6 or below).
    Peptic esophagitis. A rapid urease test (RUT) is ...

    Peptic esophagitis. A rapid urease test (RUT) is performed on the esophageal biopsy sample. The result is positive for esophagitis.

    Peptic esophagitis. A rapid urease test (RUT) is ...

    Peptic esophagitis. A rapid urease test (RUT) is performed on the esophageal biopsy sample. The result is positive for esophagitis.


    {{mediacaption:1674250_0}}Esophagitis is classified into the following 4 grades based on its severity:
    • Grade I – Erythema
    • Grade II – Linear nonconfluent erosions
    • Grade III – Circular confluent erosions
    • Grade IV – Stricture or Barrett esophagus. Barrett esophagus is thought to be caused by the chronic reflux of gastric juice into the esophagus. Barrett esophagus occurs when the squamous epithelium of the esophagus is replaced by the intestinal columnar epithelium (see Image 1 or below).
      Esophagogastroduodenoscopy indicating Barrett eso...

      Esophagogastroduodenoscopy indicating Barrett esophagus.

      Esophagogastroduodenoscopy indicating Barrett eso...

      Esophagogastroduodenoscopy indicating Barrett esophagus.


      {{mediacaption:176678_1}}Barrett esophagus is present in 8-15% of patients with gastroesophageal reflux disease (GERD) and may progress to adenocarcinoma (see Images 2 and 7 or below).
      Gastroesophageal reflux disease (GERD)/Barrett es...

      Gastroesophageal reflux disease (GERD)/Barrett esophagus/adenocarcinoma sequence.

      Gastroesophageal reflux disease (GERD)/Barrett esophagus/adenocarcinoma sequence.


      Endoscopy demonstrating intraluminal esophageal c...

      Endoscopy demonstrating intraluminal esophageal cancer.

      Endoscopy demonstrating intraluminal esophageal c...

      Endoscopy demonstrating intraluminal esophageal cancer.


      {{mediacaption:1674255_3}}See Esophageal Cancer.

Race

  • White males are at a greater risk for Barrett esophagus and adenocarcinoma than other populations.

Sex

  • No sexual predilection exists. Gastroesophageal reflux disease (GERD) is as common in men as in women.
  • The male-to-female incidence ratio for esophagitis is 2:1-3:1. The male-to-female incidence ratio for Barrett esophagus is 10:1.

Age

  • Gastroesophageal reflux disease (GERD) occurs in all age groups.
  • The prevalence of gastroesophageal reflux disease (GERD) increases in people older than 40 years.

Clinical

History

Gastroesophageal reflux disease (GERD) can cause typical (esophageal) symptoms or atypical (extraesophageal) symptoms. However, a diagnosis of gastroesophageal reflux disease (GERD) based on the presence of typical symptoms is correct in only 70% of patients.

  • Typical (esophageal) symptoms include the following:
    • Heartburn is the most common typical symptom of gastroesophageal reflux disease (GERD). Heartburn is felt as a retrosternal sensation of burning or discomfort that usually occurs after eating or when lying down or bending over.
    • Regurgitation is an effortless return of gastric and/or esophageal contents into the pharynx. Regurgitation can induce respiratory complications if gastric contents spill into the tracheobronchial tree.
    • Dysphagia occurs in approximately one third of patients because of a mechanical stricture or a functional problem (eg, nonobstructive dysphagia secondary to abnormal esophageal peristalsis). Patients with dysphagia experience a sensation that food is stuck, particularly in the retrosternal area.
  • Atypical (extraesophageal) symptoms include the following:
    • Coughing and/or wheezing are respiratory symptoms resulting from the aspiration of gastric contents into the tracheobronchial tree or from the vagal reflex arc producing bronchoconstriction. Approximately 50% of patients who have GERD-induced asthma do not experience heartburn.
    • Hoarseness results from irritation of the vocal cords by gastric refluxate and is often experienced by patients in the morning.
    • Reflux is the most common cause of noncardiac chest pain, accounting for approximately 50% of cases. Patients can present to the emergency department with pain resembling a myocardial infarction. Reflux should be ruled out (using esophageal manometry and 24-h pH testing if necessary) once a cardiac cause for the chest pain has been excluded. Alternatively, a therapeutic trial of a high-dose proton pump inhibitor (PPI) can be tried.
      Ambulatory pH monitoring indicating episodes of r...

      Ambulatory pH monitoring indicating episodes of reflux correlating with the heartburn experienced by the patient.

      Ambulatory pH monitoring indicating episodes of r...

      Ambulatory pH monitoring indicating episodes of reflux correlating with the heartburn experienced by the patient.

Physical

The physical examination is noncontributory.

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