Gastroesophageal reflux disease

Adults The most common symptoms of GERD in adults are an acidic taste in the mouth, regurgitation, and heartburn. Less common symptoms include pain with swallowing/sore throat, increased salivation (also known as water brash), nausea, chest pain, coughing, and globus sensation. The acid reflux can induce asthma attack symptoms like shortness of breath, cough, and wheezing in those with underlying asthma. • Esophageal strictures – the persistent narrowing of the esophagus caused by reflux-induced inflammation • Barrett's esophagus – intestinal metaplasia (changes of the epithelial cells from squamous to intestinal columnar epithelium) of the distal esophagus • Esophageal adenocarcinoma – a form of cancer Other complications can include aspiration pneumonia. Children and babies GERD may be difficult to detect in infants and children since they cannot describe what they are feeling, and indicators must be observed. Symptoms may vary from typical adult symptoms. GERD in children may cause repeated vomiting, effortless spitting up, coughing, and other respiratory problems, such as wheezing. Inconsolable crying, refusing food, crying for food and then pulling off the bottle or breast only to cry for it again, failure to gain adequate weight, bad breath, and burping are also common. Children may have one symptom or many; no single symptom is universal in all children with GERD. Of the estimated 4 million babies born in the US each year, up to 35% of them may have difficulties with reflux in the first few months of their lives, known as 'spitting up'. About 90% of infants will outgrow their reflux by their first birthday. Mouth , a type of intestinal metaplasia, Due to the risk of chronic heartburn progressing to Barrett's, EGD every five years is recommended for people with chronic heartburn, or who take drugs for chronic GERD. == Causes ==

A small amount of acid reflux is typical even in healthy people (as with infrequent and minor heartburn), but gastroesophageal reflux becomes gastroesophageal reflux disease when signs and symptoms develop into a recurrent problem. Frequent acid reflux can be caused by poor closure of the lower esophageal sphincter, which is at the junction between the stomach and the esophagus. • Obesity: increasing body mass index is associated with more severe GERD. In a large series of 2,000 patients with symptomatic reflux disease, it has been shown that 13% of changes in esophageal acid exposure is attributable to changes in body mass index. • GERD can be a symptom of mast cell activation syndrome (MCAS). Factors that have been linked with GERD, but not conclusively: • Obstructive sleep apnea • Gallstones, which can impede the flow of bile into the duodenum, which can affect the ability to neutralize gastric acid In 1999, a review of existing studies found that, on average, 40% of GERD patients also had H. pylori infection. The eradication of H. pylori can lead to an increase in acid secretion, leading to the question of whether H. pylori-infected GERD patients are any different from non-infected GERD patients. A double-blind study, reported in 2004, found no clinically significant difference between these two types of patients with regard to the subjective or objective measures of disease severity. The etiology of GERD appears to include the reflux of bile from the stomach into the esophagus, leading to the production of reactive oxygen species and oxidative stress and then inflammation and induction of DNA damage. In experimental models of GERD it was found that Lactobacilli facilitate the repair of such DNA damage indicating that administration of these potentially probiotic bacteria may be useful in patients suffering with GERD for preventing progression to Barrett's esophagus and esophageal adenocarcinoma. == Diagnosis ==

image of peptic stricture, or narrowing of the esophagus near the junction with the stomach: This is a complication of chronic gastroesophageal reflux disease and can be a cause of dysphagia or difficulty swallowing. The diagnosis of GERD is usually made when typical symptoms are present. Esophageal manometry is not recommended for use in the diagnosis, being recommended only before surgery. Endoscopy Endoscopy, the examination of the stomach with a fibre-optic scope, is not routinely needed if the case is typical and responds to treatment. Biopsies performed during gastroscopy may show: • Edema and basal hyperplasia (nonspecific inflammatory changes) • Lymphocytic inflammation (nonspecific) • Neutrophilic inflammation (usually due to reflux or Helicobacter gastritis) • Eosinophilic inflammation (usually due to reflux): The presence of intraepithelial eosinophils may suggest a diagnosis of eosinophilic esophagitis (EE) if eosinophils are present in high enough numbers. Less than 20 eosinophils per high-power microscopic field in the distal esophagus, in the presence of other histologic features of GERD, is more consistent with GERD than EE. • Goblet cell intestinal metaplasia or Barrett's esophagus • Elongation of the papillae • Thinning of the squamous cell layer • Dysplasia • Carcinoma Reflux changes that are not erosive in nature lead to "nonerosive reflux disease". Severity Severity may be documented with the Johnson-DeMeester's scoring system: • 0 – None • 1 – Minimal – occasional episodes • 2 – Moderate – medical therapy visits • 3 – Severe – interference with daily activities Differential diagnosis Other causes of chest pain, such as heart disease, should be ruled out before making the diagnosis. Differential diagnosis of GERD can also include dyspepsia, peptic ulcer disease, esophageal and gastric cancer, and food allergies. == Treatment ==

The treatments for GERD may include food choices, lifestyle changes, medications, and possibly surgery. Initial treatment is frequently with a proton-pump inhibitor such as omeprazole. Some evidence suggests that reduced sugar intake and increased fiber intake can help. Breathing exercises may relieve GERD symptoms. Medications The primary medications used for GERD are proton-pump inhibitors, H2 receptor blockers and antacids with or without alginic acid. The overuse of acid suppression is a problem because of the side effects and costs. Antacids The evidence for antacids is weaker with a benefit of about 10% (NNT=13) while a combination of an antacid and alginic acid (such as Gaviscon) may improve symptoms by 60% (NNT=4). It is recommended only for those who do not improve with PPIs. When comparing different fundoplication techniques, partial posterior fundoplication surgery is more effective than partial anterior fundoplication surgery, and partial fundoplication has better outcomes than total fundoplication. Esophagogastric dissociation is an alternative procedure that is sometimes used to treat neurologically impaired children with GERD. Preliminary studies have shown it may have a lower failure rate and a lower incidence of recurrent reflux. Adverse responses include difficulty swallowing, chest pain, vomiting, and nausea. Contraindications that would advise against use of the device are patients who are or may be allergic to titanium, stainless steel, nickel, or ferrous iron materials. A warning advises that the device should not be used by patients who could be exposed to, or undergo, magnetic resonance imaging (MRI) because of serious injury to the patient and damage to the device. Some patients who are at an increased surgical risk or do not tolerate PPIs may qualify for a more recently developed incisionless procedure known as a TIF transoral incisionless fundoplication. Benefits of this procedure may last for up to six years. Special populations Pregnancy GERD is a common condition that develops during pregnancy, but usually resolves after delivery. The severity of symptoms tends to increase throughout the pregnancy. and PPIs. They may also be treated with medicines such as PPIs or H2 receptor blockers. PPIs, however, have not been found to be effective in this population and there is a lack of evidence for safety. The role of an occupational therapist with an infant with GERD includes positioning during and after feeding. One technique used is called the log-roll technique, which is practiced when changing an infant's clothing or diapers. == Epidemiology ==

In Western populations, GERD affects approximately 10% to 20% of the population, and 0.4% newly develop the condition. In the United States 20% of people have symptoms in a given week and 7% every day. == History ==

An obsolete treatment is vagotomy ("highly selective vagotomy"), the surgical removal of vagus nerve branches that innervate the stomach lining. This treatment has been largely replaced by medication. Vagotomy by itself tended to worsen the contraction of the pyloric sphincter of the stomach and delay stomach emptying. Historically, vagotomy was combined with pyloroplasty or gastroenterostomy to counter this problem. == Research ==

Several endoscopic devices have been tested to treat chronic heartburn. • Endocinch puts stitches in the lower esophageal sphincter (LES) to create small pleats to help strengthen the muscle. However, long-term results were disappointing, and the device is no longer sold by Bard. • The Stretta procedure uses electrodes to apply radio-frequency energy to the LES. A 2015 systematic review and meta-analysis in response to the systematic review (no meta-analysis) conducted by SAGES did not support the claims that Stretta was an effective treatment for GERD. A 2012 systematic review found that it improves GERD symptoms. • NDO Surgical Plicator creates a plication, or fold, of tissue near the gastroesophageal junction, and fixates the plication with a suture-based implant. The company ceased operations in mid-2008, and the device is no longer on the market. • Transoral incisionless fundoplication, which uses a device called Esophyx, may be effective. == See also ==