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GERD

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GERD (gastroesophageal reflux disease) is a condition when food substance flows back from the stomach into the oesophagus (food pipe). It is known as acid reflux disease, and it occurs when the sphincter muscle (joint between esophagus and stomach) fails to close after the passage of food from the oesophagus into the stomach. In such cases, food reverts back towards the oesophagus, thus initiating the problem. The common symptoms of GERD are listed below:

  • Heartburn
  • Chest pain
  • Cough
  • Sour taste in the mouth
  • Feeling of lump formation in the throat

Medications such as antacids, H2 receptor blockers (ranitidine) and proton pump inhibitors such as omeprazole are primarily suggested by physicians to combat the situation. However, proper dietary modifications are recommended to overcome such ailments.

GERD is a chronic disorder and affects men and women across all age groups. The prevalence of GERD is higher in the western population compared to the eastern population.

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Stages

The severity of GERD can be determined by identifying the stage of the disease.

Grade 0: Here the oesophagal mucosa is normal

Grade I: in Grade I, there is erythema or diffused red mucosa and oedema causing accentuated folds

Grade II: There is the presence of isolated round or linear lesions that extend from the gastroesophageal junction upward and do not involve the entire circumference of the oesophagus

Grade III: Erosions are present on the entire circumference of the oesophagus or there may be the presence of superficial ulceration without stenosis

Grade IV: This represents complicated cases with the presence of erosion along with deep ulcerations, strictures, or columnar epithelium lined oesophagus.

Symptoms

The symptoms of GERD can be classified as follows:

Typical symptoms: These are symptoms that are aggravated by activities such as bending over, lying down or by eating meals that have a high fat content.


  • Heartburn

  • Burping/belching

  • Water brash during which excess saliva is produced in the mouth

  • Regurgitation, i.e., the backflow of food from the stomach into the oesophagus


Atypical Symptoms: These are extraesophageal symptoms. Certain people may exhibit only extraesophageal symptoms, which make it challenging to diagnose GERD.

  • Chest pain

  • Chronic cough

  • Asthma that is not triggered by any allergen

  • Pharyngitis/sore throat

  • Hoarseness of voice

  • Dental erosions


Complicated Symptoms: GERD progresses and develops various symptoms such as Barrett’s oesophagus, oesophagal strictures or oesophagal cancer. The following symptoms may be indicative of these complications.

  • Unexplained weight loss

  • Continuous pain

  • Bleeding

  • Choking

  • Difficulty or discomfort in swallowing

  • Pain while swallowing


The symptoms of GERD in infants and children involve:

  • Small episodes of vomiting, which is frequent

  • Inability to sleep after having food

  • Bad breath

  • Hiccups or burps

  • Constant crying (in infants and babies)

  • Loss of interest in eating or eating extremely small amounts of food.

Causes And Risk Factors

Causes

Weakness of the valve (lower oesophagal sphincter) at the end of the oesophagus causes GERD. Under normal circumstances, this valve tightly closes after the food reaches the stomach. This valve does not completely close in GERD, leading to the backflow of food contents from the stomach to the oesophagus or food pipe.

Other factors that can cause GERD are listed below:


  • Hiatal Hernia: This condition cause bulging or swelling of the upper part of the stomach into the diaphragm, which causes an obstruction in the passage of food into the stomach.

  • Consumption of certain food items can reduce the lower oesophagal sphincter pressure. These include onion, garlic, fatty food, chocolate, coffee, tea, and chilli peppers.

  • Medications used for treating asthma, hypertension and allergies can cause GERD.

  • Increased pressure on the abdomen.


 

Risk Factors

The presence of the following risk factors can increase the chances of a person to develop GERD.

  • During pregnancy, there is increased pressure on the abdomen, which increases the risk for gastroesophageal reflux

  • A person who is obese is at a higher risk for developing GERD

  • Smoking and passive smoking

  • Patients taking medications that lead to acid reflux are at risk of developing GERD.

Prevention

Simple lifestyle modifications can help prevent the development of GERD to a large extent.


  • Eating small and frequent meals rather than one big heavy meal

  • Quitting smoking

  • Avoiding the consumption of food items that trigger GERD

  • Avoid going to bed immediately after having food. It is recommended to wait 3–4 h after food to go to bed

  • Maintaining a healthy body weight

  • Clothes that are tight around the belly should be avoided. Tight clothes increase the pressure in the stomach and force the stomach acid upwards

  • Elevate the head of your bed, which can be achieved using wooden blocks under the bedpost

  • Sit in an upright position while eating

Diagnosis

GERD's diagnosis involves a combination of the patient's clinical symptoms, lifestyle habits, response to acid suppression treatment, and selective examination with upper endoscopy and oesophagal manometry.


  • Empirical Therapy: Patients with typical symptoms indicative of GERD, such as heartburn and regurgitations, are given empirical therapy with antacids, H2 receptor antagonist and proton pump inhibitors (PPI). If the patient responds to treatment, it suggests the presence of GERD and indicates further evaluation to determine oesophagal acid exposure.

  • Upper GI endoscopy and biopsy: This helps to examine the lining of the oesophagus, stomach and duodenum. They help in diagnosing the complications associated with GERD such as Barrett’s oesophagus, strictures and esophagitis.

  • Radiological Imaging: X-rays can help visualise any problems associated with the upper gastrointestinal tract.

  • Oesophagal manometry: This test determines the ability of the oesophagal valve and muscles to help the food pass from the oesophagus to the stomach.

  • Oesophageal pH monitoring: The acid amount that refluxes back from the stomach to the oesophagus is determined with this test's help.


 

Treatment

Simple lifestyle and dietary modifications can help manage symptoms of gastroesophageal reflux. However, with lifestyle and dietary modifications, pharmacological therapy is indicated if the patient fails to achieve the desired results.

Medications used for treating GERD include antacids, H2 blockers and PPIs. Mild symptoms such as heartburn can be treated with antacid, which helps to neutralise the acid in the stomach.

Both H2 blockers and PPIs reduce the amount of acid produced by the stomach. They help to heal the lining of the oesophagus and are used as long-term treatment for GERD.

When lifestyle changes and medications fail to treat GERD, the doctor starts looking for different treatment approaches such as surgery and other medical procedures.


  • Fundoplication: The most common type of surgery indicated for GERD patient is fundoplication. During this procedure, the top portion of the stomach is wrapped around the lower part of the food pipe. This adds pressure to the lower oesophagal sphincter, which helps to prevent the backflow of food contents from the stomach.

  • Bariatric Surgery: Obese patients with GERD can undergo bariatric surgery for weight loss, which helps to reduce GERD symptoms.

  • Endoscopy: Doctors may suggest using endoscopic procedures to sew the top part of the stomach around the lower oesophagal sphincter.

  • LINX Device Implantation: A LINX is a device composed of small rings of magnets, which have the strength to prevent acid reflux. However, they allow the passage of food via the food pipe to the stomach.


 

Lifestyle Modifications


  • Lifestyle interventions for managing GERD involve avoiding food items that trigger acid reflux. Food items that should be avoided include citrus fruits such as lemons and oranges, spicy and fried foods, alcohol, coffee, garlic, onion, tomato sauce, chocolate, fatty foods and carbonated drinks.

  • Medications that directly irritate the lining of the oesophagus should be taken with a lot of water.

  • Obesity increases intra-abdominal pressure, and hence losing weight can help provide relief to obese patients with GERD.

  • GERD patients who smoke should be encouraged to quit smoking.

Prognosis And Complications

Prognosis

The GERD prognosis is good if the patient is compliant with lifestyle modifications. In complicated cases, the patient may require surgery.

Complications

If left untreated, GERD can lead to the following complications:


  • Esophagitis: Oesophagitis is called as the inflammation of oesophagus. This can lead to ulcers, chest pain, heartburn and difficulty in swallowing.

  • Barrett's oesophagus: Long-term GERD can lead to the development of Barrett's oesophagus. With time, acid reflux damages cells, which lines the oesophagus.

  • Oesophagal strictures: With time, the backflow of acid from the stomach can damage the lining of the oesophagus, leading to strictures. Such strictures are known as peptic strictures, which can be both cancerous and non-cancerous. Strictures do not allow food and liquid to enter the stomach.

  • Oesophageal cancers: Adenocarcinoma and squamous cell carcinoma are two types of cancer that can occur in the oesophagus.

References

Dipiro JT, Talbert RL, Yee GC, Matzke GR, Wells BG, Posey LM. Pharmacotherapy: A Pathophysiologic Approach, ed. McGraw-Hill Medical, New York; 2014.

Cleveland Clinic. GERD (Chronic Acid Reflux) [Internet] [Updated on June 12, 2019] Available at: https://my.clevelandclinic.org/health/diseases/17019-gerd-or-acid-reflux-or-heartburn-overview. Accessed on March 25, 2021. (https://my.clevelandclinic.org/health/diseases/17019-gerd-or-acid-reflux-or-heartburn-overview)

Medline Plus. Gastroesophageal reflux disease – children [Internet] [Updated on July 22, 2020] Available at: https://medlineplus.gov/ency/article/007688.htm. Accessed on March 25, 2021. (https://medlineplus.gov/ency/article/007688.htm)

Badillo R, et al. World J Gastrointest Pharmacol Ther. 2014;5(3):105-12.

John Hopkins Medicine. Patient Information on Esophageal pH Monitoring [Internet] Available at: https://www.hopkinsmedicine.org/gastroenterology_hepatology/_forms/patient_info/esophageal_ph_monitoring.pdf. Accessed on March 25,2021. (https://www.hopkinsmedicine.org/gastroenterology_hepatology/_forms/patient_info/esophageal_ph_monitoring.pdf)

Stanford Health Care. Gastroesophageal reflux disease [Internet] Available at: https://stanfordhealthcare.org/medical-conditions/digestion-and-metabolic-health/gastroesophageal-reflux-disease-gerd.html. Assessed on March 25, 2021. (https://stanfordhealthcare.org/medical-conditions/digestion-and-metabolic-health/gastroesophageal-reflux-disease-gerd.html)

NIH. Treatment for GER and GERD [Internet] Available at: https://www.niddk.nih.gov/health-information/digestive-diseases/acid-reflux-ger-gerd-adults/treatment. Accessed on March 25, 2021. (https://www.niddk.nih.gov/health-information/digestive-diseases/acid-reflux-ger-gerd-adults/treatment)

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