Gastroesophageal Reflux Disease

Description

• Changes of the esophageal mucosa resulting from reflux of gastric contents into the esophagus
• Often described as “heartburn,” “acid indigestion,” and “acid reflux”

Epidemiology

Incidence
Incidence: 5/1,000 person-years

Prevalence

• The prevalence of GERD in North America is ~15% (95% CI, 10.7–20.9%) (1).
• There is no association between sex and symptoms of GERD in North America.
• Advanced age increases your risk of GERD; >50 versus <50 years old, odds ratio (OR) of 1.32 (95% CI, 1.46–2.06) of having GERD (1)
• Pediatric population: Regurgitation occurs in nearly 50% of newborn infants, resolving spontaneously in 90% of children by age 1 year (1).

Etiology and Pathophysiology

• Stomach acid contacts the squamous mucosal lining of the esophagus, which is less acid resistant than gastric columnar mucosa, followed by release of chemokines and cytokines causing symptoms and disease.
• GERD can be the result of one or a combination of the following: lower esophageal sphincter (LES) dysfunction, esophageal hypersensitivity, delayed gastric emptying, and increased gastroesophageal junction distensibility.
• Patients with severe GERD often have evidence of a hiatal hernia which can trap acid, impair acid emptying, reduce LES pressure, and increase retrograde acid flow.

Genetics
Genetic heterogeneity may account for 31–43% of the predisposition to develop GERD (2).

Risk Factors

• Obesity; OR of 1.7 (95% CI, 1.4–2.1) (1)
  • Higher prevalence of hiatal hernia; increased intra-abdominal pressure; increased estrogen, bile, and pancreatic enzymes
• Tobacco use; OR of 1.2 (95% CI, 1.04–1.5) (1)
• Hiatal hernia
• Pregnancy
• Diet; alcohol use
• Scleroderma; neuromuscular disorders

General Prevention

• Weight loss (1)[A],(2)[A]
• Tobacco cessation (1)[B]
• Change of diet: Decrease consumption of spicy, acidic and fatty foods, alcoholic and carbonated beverages, chocolate, and caffeine (2)[C].
• Elevate head of bed at night for selected patients (2)[C].
• Avoid meals within 2 to 3 hours of bedtime (2)[C].
• Smaller portions
• Staying upright during and after meals
• Infants: Use car seat for 2 to 3 hours after meals, thickened feedings, burp frequently while feeding

Commonly Associated Conditions

• Nonerosive and erosive esophagitis, the latter occurs in 18–25% of patients with GERD (1).
• Barrett esophagus: prevalence of 7% (95% CI, 5%–9%) in patients with GERD (1)
• Esophageal adenocarcinoma
• Peptic ulcer disease (PUD)
• Peptic esophageal stricture
• Extraesophageal reflux: asthma, aspiration, chronic cough, laryngitis, vocal cord granuloma, sinusitis, otitis media
• Halitosis