Gastroesophageal Reflux Disease

Gastroesophageal Reflux Disease is a topic covered in the 5-Minute Clinical Consult.

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Basics

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
  • 10–20% in the United States
  • 40% of adults in the United States have reflux symptoms.
  • 50–85% of gastroesophageal reflux disease (GERD) patients have nonerosive reflux disease.
  • Chronic GERD is a risk factor for Barrett esophagus.
  • 10% of patients with chronic GERD have Barrett esophagus.
  • Risk of adenocarcinoma without Barrett esophagus and no dysplasia: 0.1–0.5% per patient-year
  • Risk of adenocarcinoma with Barrett esophagus and high-grade dysplasia: 6–19% per patient-year
  • Pediatric population: Regurgitation occurs at least once a day in 2/3 of 4-month-old infants, decreasing to 21% at age 6 to 7 months, and 5% at 10 to 12 months.

Etiology and Pathophysiology

  • The pattern and mechanism of reflux varies depending on the severity of disease.
  • GERD begins when acidic stomach contents contact the squamous mucosal lining of the esophagus, at the esophagogastric junction (EGJ).
  • Inappropriate transient lower esophageal sphincter (LES) relaxation. Foods that are spicy; acidic; and high in fat, caffeine, alcohol, tobacco, anticholinergic medications, nitrates, smooth muscle relaxants affect LES relaxation.
  • Patients with severe GERD often have evidence of a hiatal hernia, which can (1):
    • Trap acid in the hernia sac
    • Impair acid emptying
    • Increase retrograde acid flow rate
    • Reduce the EGJ sphincter pressure
    • Increase frequency of transient LES relaxations

Genetics
Genetic heterogeneity has been associated with GERD.

Risk Factors

  • Obesity
  • Hiatal hernia
  • Scleroderma
  • Alcohol use
  • Tobacco use
  • Pregnancy

General Prevention

  • Decrease consumption of food and beverage triggers such as spicy, fatty foods, alcohol, and caffeine.
  • Weight loss
  • Avoid lying down after meals.
  • Tobacco and alcohol cessation
  • Elevate head of bed at night.
  • Avoid meals close to bedtime.
  • Infants: Use car seat for 2 to 3 hours after meals; thickened feedings

Commonly Associated Conditions

  • Nonerosive esophagitis
  • Erosive esophagitis
  • Irritable bowel syndrome
  • Peptic ulcer disease
  • Extraesophageal reflux: aspiration, chronic cough, laryngitis, vocal cord granuloma, sinusitis, otitis media
  • Halitosis
  • Hiatal hernia: acid pocket (zone of high acidity in the proximal stomach above the diaphragm) (2)[B]
  • Peptic stricture: 10% of patients with GERD
  • Barrett esophagus
  • Esophageal adenocarcinoma

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