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| {{Infobox_Disease | | | {{Infobox_Disease | |
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| MeshID = D005764 | | | MeshID = D005764 | |
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| {{SI}} | | {{Gastroesophageal reflux disease}} |
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| '''For patient information click [[{{PAGENAME}} (patient information)|here]]''' | | '''For patient information click [[{{PAGENAME}} (patient information)|here]]''' |
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| {{CMG}} | | {{CMG}}; {{AE}} {{AEL}} |
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| {{SK}} [[GERD]], [[GORD]],Gastroesophageal reflux, Oesophageal reflux, Peptic esophagitis, Esophageal reflux | | {{SK}} GERD, GORD, gastroesophageal reflux, oesophageal reflux, peptic esophagitis, esophageal reflux. |
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| ==Overview== | | ==[[Gastroesophageal reflux disease overview|Overview]]== |
| Gastroesophageal Reflux Disease is defined as chronic symptoms or [[mucosa]]l damage produced by the abnormal reflux in the [[esophagus]]<ref>DeVault KR, Castell DO. Updated guidelines for the diagnosis and treatment of gastroesophageal reflux disease. The Practice Parameters Committee of the American College of Gastroenterology. ''Am J Gastroenterol'' 1999;94:1434-42. PMID 10364004.</ref>.
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| This is commonly due to transient or permanent changes in the barrier between the esophagus and the [[stomach]]. This can be due to incompetence of the ''[[lower esophageal sphincter]]'' (LES), transient LES relaxation, impaired expulsion of gastric reflux from the esophagus, or a [[hiatal hernia]].
| | ==[[Gastroesophageal reflux disease historical perspective|Historical Perspective]]== |
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| ==Symptoms== | | ==[[Gastroesophageal reflux disease classification|Classification]]== |
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| ===Adults=== | | ==[[Gastroesophageal reflux disease pathophysiology|Pathophysiology]]== |
| [[Heartburn]] is the major symptom of acid in the esophagus, characterized by burning discomfort behind the breastbone ([[sternum]]). Findings in GERD include '''[[esophagitis]]''' (''reflux esophagitis'') — [[inflammation|inflammatory]] changes in the esophageal lining (mucosa) —, [[Stenosis|strictures]], difficulty swallowing ([[dysphagia]]), and chronic [[chest pain]]. Patients may have only one of those findings. Typical GERD symptoms include cough, hoarseness, voice changes, chronic ear ache, burning chest pains, nausea or [[sinusitis]]. GERD complications include stricture formation, [[Barrett's esophagus]], [[esophageal ulcer]]s, and possibly even lead to [[esophageal cancer]], especially in adults over 60 years old.
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| Occasional heartburn is common but does not necessarily mean one has GERD. Patients with heartburn symptoms more than once a week are at risk of developing GERD. A hiatal hernia is usually [[asymptomatic]], but the presence of a hiatal hernia is a risk factor for developing GERD.
| | ==[[Gastroesophageal reflux disease causes|Causes]]== |
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| ===Children=== | | ==[[Gastroesophageal reflux disease differential diagnosis|Differentiating Gastroesophageal Reflux Disease from other Diseases]]== |
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| GERD may be difficult to detect in infants and children. Symptoms may vary from typical adult symptoms. GERD in children may cause repeated [[vomiting]], effortless spitting up, [[coughing]], and other respiratory problems. Inconsolable crying, failure to gain adequate weight, refusing food, bad breath, and belching or burping are also common. Children may have one symptom or many — no single symptom is universal in all children with GERD.
| | ==[[Gastroesophageal reflux disease epidemiology and demographics|Epidemiology and Demographics]]== |
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| It is estimated that of the approximately 8 million babies born in the U.S. each year, up to 35% of them may have difficulties with reflux in the first few months of their life. Most of those children will outgrow their reflux by their first birthday. However, a small but significant number of them will not outgrow the condition.
| | ==[[Gastroesophageal reflux disease risk factors|Risk Factors]]== |
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| Babies' immature digestive systems are usually the cause, and most infants stop having acid reflux by the time they reach their first birthday. Some children do not outgrow acid reflux, however, and continue to have it into their teen years. Children that have had heartburn that does not seem to go away, or any other GERD symptoms for a while, should talk to their parents and visit their doctor.
| | ==[[Gastroesophageal reflux disease screening|Screening]]== |
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| ==Diagnosis== | | ==[[Gastroesophageal reflux disease natural history, complications and prognosis|Natural History, Complications and Prognosis]]== |
| [[Image:Peptic stricture.png|left|thumb|200px|[[Gastroscopy|Endoscopic]] 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]]
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| A detailed history taking is vital to the diagnosis. Useful investigations may include [[barium]] swallow [[X-ray]]s, esophageal manometry, 24 hour esophageal [[pH]] monitoring and [[Esophagogastroduodenoscopy]] (EGD). In general, an EGD is done when the patient does not respond well to treatment, or has alarm symptoms including: dysphagia, anemia, blood in the stool (detected chemically), [[asthma|wheezing]], weight loss, or voice changes. Some physicians advocate once-in-a-lifetime endoscopy for patients with longstanding GERD, to evaluate the possible presence of [[Barrett's esophagus]], a precursor lesion for [[esophageal cancer|esophageal adenocarcinoma]].
| | ==[[Gastroesophageal reflux disease diagnosis|Diagnosis]]== |
| | | [[Gastroesophageal reflux disease history and symptoms|History and Symptoms]] | [[Gastroesophageal reflux disease physical examination|Physical Examination]] | [[Gastroesophageal reflux disease laboratory findings|Laboratory Findings]] | [[Gastroesophageal reflux disease electrocardiogram|Electrocardiogram]] | [[Gastroesophageal reflux disease chest x ray|Chest X Ray]] | [[Gastroesophageal reflux disease CT|CT]] | [[Gastroesophageal reflux disease echocardiography or ultrasound|Echocardiography or Ultrasound]] | [[Gastroesophageal reflux disease other imaging findings|Other Imaging Findings]] | [[Gastroesophageal reflux disease other diagnostic studies|Other Diagnostic Studies]] |
| [[Esophagogastroduodenoscopy]] (EGD) (a form of [[endoscopy]]) involves insertion of a thin scope through the mouth and throat into the esophagus and stomach (often while the patient is sedated) in order to assess the internal surfaces of the esophagus, stomach, and [[duodenum]].
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| [[Biopsy|Biopsies]] can be performed during gastroscopy and these may show:
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| *Edema and basal hyperplasia (non-specific inflammatory changes)
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| *Lymphocytic inflammation (non-specific)
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| *Neutrophilic inflammation (usually due to reflux or ''[[Helicobacter]]'' [[gastritis]])
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| *Eosinophilic inflammation (usually due to reflux)
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| *Goblet cell intestinal metaplasia or Barretts esophagus.
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| *Elongation of the papillae
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| *Thinning of the squamous cell layer
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| *[[Dysplasia]] or pre-cancer.
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| *[[Carcinoma]].
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| ==Pathophysiology==
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| GERD is caused by a failure of the Anti-Reflux Barrier (ARB) and its primary component, the GastroEsophageal valve (GEV). The understanding of the GEV has continued to progress in recent years, and more focus is currently being placed on the GEV, rather than the Lower Esophageal Sphincter (LES), as the largest contributor to the ARB. Researchers have shown the GEV's robust nature and have shown that the intact GEV alone is highly competent to stop reflux. For example, in cadavers, where no muscle tone or LES pressure is present, the stomach ruptures when filled with water before reflux can occur. This shows the GEV's power to stop reflux even in the absence of any LES pressure.
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| In healthy patients, the "Angle of His," the angle at which the esophagus enters the stomach, is intact creating a valve that prevents duodenal bile, enzymes, and stomach acid from traveling back into the esophagus where it can cause burning and inflammation of sensitive esophageal tissue.
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| Another paradoxical cause of GERD-like symptoms is not enough stomach acid ([[hypochlorhydria]]). The valve that empties the stomach into the intestines is triggered by acidity. If there is not enough acid, this valve does not open and the stomach contents are churned up into the esophagus. However, there is still enough acidity to irritate the esophagus.
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| Factors that can contribute to GERD are:
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| *[[Hiatus hernia]], which increases the likelihood of GERD due to mechanical and motility factors<ref name="pmid17573791">{{cite journal |author=Piesman M, Hwang I, Maydonovitch C, Wong RK |title=Nocturnal reflux episodes following the administration of a standardized meal. Does timing matter? |journal=Am. J. Gastroenterol. |volume=102 |issue=10 |pages=2128-2134 |year=2007 |pmid=17573791 |doi=10.1111/j.1572-0241.2007.01348.x}}</ref>
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| *[[Obesity]]: increasing [[body mass index]] is associated with more severe GERD<ref name="pmid175737910">{{cite journal |author=Ayazi S, Crookes P, Peyre C, |title=Objective documentation of the link between gastroesophageal reflux disease and obesity |journal=Am. J. Gastroenterol. |volume=102 |issue=S |pages=138-139 |year=2007 }}</ref>
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| *[[Zollinger-Ellison syndrome]], which can be present with increased gastric acidity due to [[gastrin]] production
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| *[[Hypercalcemia]], which can increase [[gastrin]] production, leading to increased acidity
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| *[[Scleroderma]] and [[systemic sclerosis]], which can feature esophageal dysmotility
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| GERD has been linked to [[laryngitis]], chronic [[cough]], [[pulmonary fibrosis]], [[earache]], and [[asthma]], even when not clinically apparent, as well as to [[laryngopharyngeal reflux disease|laryngopharyngeal reflux]] and ulcers of the [[vocal cords]]. There appears to be an association with [[sleep apnea|obstructive sleep apnea]], although its conjectural relationship with GERD remains unproven.<ref>{{cite journal |author=Morse CA, Quan SF, Mays MZ, Green C, Stephen G, Fass R |title=Is there a relationship between obstructive sleep apnea and gastroesophageal reflux disease? |journal=Clin. Gastroenterol. Hepatol. |volume=2 |issue=9 |pages=761–8 |year=2004 |pmid=15354276 |doi=}}</ref> and PMID 17198758.
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| ==Treatment== | | ==Treatment== |
| The rubric "lifestyle modifications" is the term physicians use when recommending non-drug GERD treatments. A 2006 review suggested that evidence for most dietary interventions is anecdotal; only [[weight loss]] and elevating the head of the bed were supported by evidence<ref name="pmid16682569">{{cite journal |author=Kaltenbach T, Crockett S, Gerson LB |title=Are lifestyle measures effective in patients with gastroesophageal reflux disease? An evidence-based approach |journal=Arch. Intern. Med. |volume=166 |issue=9 |pages=965–71 |year=2006 |pmid=16682569 |doi=10.1001/archinte.166.9.965}}</ref>. A subsequent randomized [[crossover study]] showed benefit by avoiding eating two hours before bed.<ref name="pmid17573791">{{cite journal |author=Piesman M, Hwang I, Maydonovitch C, Wong RK |title=Nocturnal reflux episodes following the administration of a standardized meal. Does timing matter? |journal=Am. J. Gastroenterol. |volume=102 |issue=10 |pages=2128–34 |year=2007 |pmid=17573791 |doi=10.1111/j.1572-0241.2007.01348.x}}</ref>
| | [[Gastroesophageal reflux disease medical therapy|Medical Therapy]] | [[Gastroesophageal reflux disease surgery|Surgery]] | [[Gastroesophageal reflux disease primary prevention|Primary Prevention]] | [[Gastroesophageal reflux disease secondary prevention|Secondary Prevention]] | [[Gastroesophageal reflux disease cost-effectiveness of therapy|Cost-Effectiveness of Therapy]] | [[Gastroesophageal reflux disease future or investigational therapies|Future or Investigational Therapies]] |
| | | ==Case Studies== |
| ===Foods===
| | :[[Gastroesophageal reflux disease case study one|Case #1]] |
| Certain foods and lifestyle are considered to promote gastroesophageal reflux:
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| *[[Coffee]], [[alcoholic beverage|alcohol]], and excessive amounts of [[Vitamin C]] supplements stimulate gastric acid secretion. Taking these before bedtime especially can cause evening reflux. (Although a study published in 2006 by Stanford University researchers disputes the effect of coffee, acidic, spicy foods etc. as a myth.<ref name="pmid16682569"/>)
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| *[[Antacids]] based on [[calcium carbonate]] (but not [[aluminum hydroxide]]) were found to actually increase the acidity of the stomach. However, all antacids reduced acidity in the lower esophagus, so the net effect on GERD symptoms may still be positive.<ref>Decktor DL, Robinson M, Maton PN, Lanza FL, Gottlieb S. Effects of Aluminum/Magnesium Hydroxide and Calcium Carbonate on Esophageal and Gastric pH in Subjects with Heartburn. ''Am J Ther'' 1995;2:546-552. PMID 11854825.</ref>.
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| *Foods high in fats and [[tobacco smoking|smoking]] reduce lower esophageal sphincter competence, so avoiding these tends to help. Fat also delays stomach emptying.
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| *Eating shortly before bedtime (For clinical purposes, this usually means 2-3 hours before going to bed).
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| *Large meals. Having more but smaller meals reduces GERD risk, as it means there is less food in the stomach at any one time.
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| *Soda or pop (regular or diet).
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| *[[Chocolate]] and [[peppermint]].
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| *[[Acid]]ic foods, such as oranges and tomatoes.
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| *[[Cruciferous vegetables]]: onions, cabbage, cauliflower, broccoli, spinach, brussel sprouts.
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| *[[Milk]] and milk-based products contain calcium and fat, and should be avoided before bedtime.
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| ===Positional therapy===
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| Sleeping on one's left side has been shown to drastically reduce nighttime reflux episodes in patients.<ref>Khoury RM, Camacho-Lobato L, Katz PO, Mohiuddin MA, Castell DO. Influence of spontaneous sleep positions on nighttime recumbent reflux in patients with gastroesophageal reflux disease. ''Am J Gastroenterol'' 1999;94:2069-73. PMID 10445529.</ref>.
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| Elevating the head of the bed is also effective. When combining drug therapy, food avoidance before bedtime, and elevation of the head of the bed, over 95% of patients will have complete relief. Additional conservative measures may be considered if there is incomplete relief. Another approach is to apply all conservative measures for maximum response. A [[meta-analysis]] suggested that elevating the head of bed is an effective therapy, although this conclusion was only supported by nonrandomized studies <ref name="pmid16682569"/>.
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| Elevating the head of the bed can be done by using various items: plastic or wooden bed risers that support bed posts or legs, a bed wedge pillow, or a wedge or an inflatable mattress lifter that fits in between mattress and box spring. The height of the elevation is critical and must be at least 6 to 8 inches (15 to 20 cm) in order to be at least minimally effective to prevent the backflow of gastric fluids. It should be noted that some innerspring mattresses do not work well when inclined and tend to cause back pain, thus foam based mattresses or futons are to be preferred. Some report relief from back pain by sleeping with one leg bent at the knee, alternating legs. Moreover, some use higher degrees of incline than provided by the commonly suggested 6 to 8 inches (15 to 20 cm) and claim greater success.
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| ===Drug treatment===
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| A number of drugs are registered for GERD treatment, and they are among the most-often-prescribed forms of [[medication]] in most Western countries. They can be used in combination with other drugs, although some antacids can interfere with the function of other drugs:
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| *[[Proton pump inhibitor]]s are the most effective in reducing gastric acid secretion. These drugs stop acid secretion at the source of acid production, i.e., the proton pump.
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| *[[Antacid]]s before meals or symptomatically after symptoms begin can reduce gastric acidity (increase [[pH]]).
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| *[[Alginic acid]] ([[Gaviscon]]) may coat the mucosa as well as increase pH and decrease reflux. A [[meta-analysis]] of [[randomized controlled trials]] suggests [[alginic acid]] may be the most effective of non-prescription treatments with a [[number needed to treat]] of 4 <ref name="pmid17229239">{{cite journal |author=Tran T, Lowry A, El-Serag H |title=Meta-analysis: the efficacy of over-the-counter gastro-oesophageal reflux disease drugs |journal=Aliment Pharmacol Ther |volume=25 |issue=2 |pages=143-53 |year=2007 |id=PMID 17229239 | doi=10.1111/j.1365-2036.2006.03135.x}}</ref>.
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| *Gastric [[H2 antagonist|H<sub>2</sub> receptor blockers]] such as [[ranitidine]] or [[famotidine]] can reduce gastric secretion of acid. These drugs are technically [[antihistamine]]s. They relieve complaints in about 50% of all GERD patients. Compared to placebo (which also is associated with symptom improvement), they have a [[number needed to treat]] of eight (8) <ref name="pmid17229239">.</ref>.
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| *[[Prokinetic]]s strengthen the LES and speed up gastric emptying. [[Cisapride]], a member of this class, was withdrawn from the market for causing [[Long QT syndrome]].
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| *[[Sucralfate]] (Carafate®) is also useful as an adjunct in helping to heal and prevent esophageal damage caused by GERD, however it must be taken several times daily and at least two (2) hours apart from meals and medications.
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| === Posture and GERD === | |
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| In adults, a slouched posture is an important factor contributing to GERD. With a slouched posture there is no straight path between the stomach and esophagus; muscles around the esophagus go into a spasm. Gas and acidity get blocked in the spasm, causing coughing and other asthma-like symptoms. A [[meta-analysis]] suggested that elevating the head of the bed is an effective therapy, although this conclusion was only supported by nonrandomized studies.<ref name="pmid16682569"/>
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| ===Surgical treatment===
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| The standard surgical treatment, sometimes preferred over longtime use of medication, is the ''[[Nissen fundoplication]]''. The upper part of the stomach is wrapped around the LES to strengthen the sphincter and prevent acid reflux and to repair a hiatal hernia. The procedure is often done [[Laparoscopic surgery|laparoscopically]].<ref name=Abbas_2004>{{cite journal |author=Abbas A, Deschamps C, Cassivi SD, et al. |title=The role of laparoscopic fundoplication in Barrett’s esophagus |journal=Annals of Thoracic Surgery |volume=77 |issue=2 |pages=393-396 |year=2004 |pmid=14759403}}</ref>
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| 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.
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| ===Endoluminal fundoplication===
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| In June 2006 EndoGastric Solutions introduced [http://www.egseurope.eu EsophyX ELF] in the Europe Union as an alternative to surgical and pharmaceutical approaches for GERD treatment. EsophyX ELF is intended to deliver similar benefits as the time-proven laparoscopic fundoplication procedures, by reducing hiatal hernia, recreating the Angle of His, and creating a GastroEsophageal Valve (GEV). The key differences are that EsophyX ELF is an endoscopic non-invasive procedure that is performed transorally (through the mouth), does not require incisions, and does not dissect any part of the natural anatomy.
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| Previous endoluminal treatments focused predominantly on the LES. However, failure to effectively treat reflux long-term with endoluminal therapies that focused only on the Lower Esophageal Sphincter (LES) combined with the fact that surgical approaches like Nissen fundoplication recreate the GEV and have excellent long-term efficacy, has led to an awareness that the GEV is probably the most powerful component of the Anti-Reflux Barrier. The device has been designed to deploy multiple tissue fasteners to create a robust and durable valve and is intended to restore the geometry of the GastroEsophageal Junction and recreate the natural, unidirectional valve mechanism necessary to prevent GERD. [http://www.endogastricsolutions.com/index.php?src=news&submenu=News&refno=19 EsophyX ELF has recently been cleared by the US FDA] and is now available in the U.S.
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| ===Other treatments===
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| In 2000 , the U.S. [[Food and Drug Administration]] (FDA) approved two [[endoscopy|endoscopic]] devices to treat chronic heartburn. One system, Endocinch, puts stitches in the LES to create little pleats that help strengthen the muscle. Another, the [[stretta procedure|Stretta Procedure]], uses electrodes to apply radio frequency energy to the LES. The long term outcomes of both procedures compared to a Nissen fundoplication are still being determined.
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| Subsequently the NDO Surgical Plicator was FDA cleared for the endoscopic GERD treatment. The Plicator creates a plication, or fold, of tissue near the gastroesophageal junction, and fixates the plication with a suture-based implant. The Plicator is currently marketed by NDO Surgical, Inc. [http://www.ndosurgical.com].
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| Another treatment that involved injection of a solution during endoscopy into the lower esophageal wall was available for about one year ending in late 2005. It was marketed under the name Enteryx. It was removed from the market due to several reports of complications from misplaced injections.
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| ==Barrett's esophagus==
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| [[Barrett's esophagus]], a type of [[dysplasia]], is a precursor high-grade dysplasia, which is in turn a precursor condition for carcinoma. The risk of progression from Barrett's to dysplasia is uncertain but is estimated to include 0.1% to 0.5% of cases, and has probably been exaggerated in the past. Due to the risk of chronic heartburn progressing to Barrett's, EGD every 5 years is recommended for patients with chronic heartburn, or who take drugs for chronic GERD.
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| ==References==
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| {{Reflist|2}}
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| ==External links== | | ==External links== |
| *[http://digestive.niddk.nih.gov/ddiseases/pubs/gerd/ GERD patient information page] at [[NIH]] | | *[http://digestive.niddk.nih.gov/ddiseases/pubs/gerd/ GERD patient information page] at [[NIH]] |
| *[http://kidshealth.org/teen/diseases_conditions/digestive/gerd.html KidsHealth GERD Information for Kids]
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| *[http://www.mayoclinic.org/gerd/ Mayo Clinic review of diagnosis and treatment options]
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| *[http://www.clevelandclinicmeded.com/medicalpubs/diseasemanagement/gastro/acidpeptic/acidpeptic.htm Overview] at [[Cleveland Clinic]]
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