Diagnosis

Gastroesophageal reflux disease

Etiology

Cause/Pathophysiology [iir]

1. Esophagus: Poor esophageal motility, impaired protective saliva or mucosa

2. Lower esophageal sphincter: The high resting tone prevents regurgitation

   • Drugs: nitrates, calcium channel blocker agents, and anticholinergics reduces the lower esophageal sphincter pressure --> allows reflux

3. Diaphragm: Provides extrinsic reinforcement to the lower esophageal sphincter

   • Diaphragmatic hiatus hernia --> lack of reinforcement and compression of stomach

4. Stomach:

   • Delayed gastric emptying can increase volume and pressure

5. Intra-abdominal pressure due to obesity, pregnancy, ascites --> GERD

Risk factors [iir]

• Esophageal hiatal hernia

• Age > 50

• Male

• Body mass index >30

• Smoking

• Alcohol use

• Drugs: Aspirin, NSAIDs, nitrates, calcium channel blocker agents, anticholinergics, α-adrenergic agonists, theophylline, and morphine

• Dietary factors: fatty, spicy, and acidic foods

• Decreased physical activity

Complications [iir]

• Esophagitis

• Upper GI bleeding, anemia

• Sricture

• Barrett esophagus

• Esophageal cancer

• Laryngeal cancer

• Extra-gastrointestinal complications: dental erosions, laryngitis, cough, asthma, sinusitis, and idiopathic pulmonary fibrosis

Epidemiology

Prevalence per 100.000 [udq][mpa][4t2][g7z]

Incidence per 100.000 [udq][mpa][4t2][g7z]

Approach

• Chest x-ray

• Abdominal x-ray

• Barium enema

• Gastroscopy

• Esophageal pH monitoring

• Esophageal manometry

Classification [iir]

• Grade A: ≥1 esophageal mucosal breaks <5 mm long

• Grade B: ≥1 mucosal breaks >5 mm but with continuity across mucosal folds

• Grade C: Mucosal breaks of ≥2 mucosal folds involving <75% of the circumference

• Grade D: Mucosal breaks involving >75% of the esophageal sphincter

Treatment

1. Goals: [s6a]

   • Control symptoms

   • Heal and prevent recurrent esophagitis

2. Lifestyle modifications: [s6a][iir]

   • Weight loss (if overweight)

   • Avoiding alcohol, chocolate, citrus juice, peppermint, coffee, tomato products

   • Avoiding peppermint, coffee, and possibly the onion family

   • Avoid large meals

   • Waiting 3 hours after a meal to lie down

   • Refraining from ingesting food (except liquids) within 3 hours of bedtime

   • Elevating the head of the bed by 8 inches

   • Avoiding bending or stooping positions

3. Control of gastric acid secretion:

   • Pharmacotherapy

     • H2 receptor antagonists (eg, cimetidine, famotidine, nizatidine)

     • Proton pump inhibitors (eg, omeprazole, lansoprazole, rabeprazole, esomeprazole, pantoprazole) 

     • Potassium-competitive acid blockers (eg, vonoprazan) 

     • Prokinetic agents (eg, metoclopramide)

     • Antacids (eg, aluminum hydroxide, magnesium hydroxide)

   • Surgical treatment: antireflux fundoplication

     • If symptoms that are not completely controlled by PPI

     • Patients who desire definitive, one-time treatment

     • The presence of Barrett esophagus

     • The presence of extraesophageal manifestations

     • Young patients

     • Poor patient compliance with medications

     • Postmenopausal women with osteoporosis

     • Patients with cardiac conduction defects

     • Cost of medical therapy

Differential diagnoses

Achalasia, Acute laryngitis, Asthma, Cholelithiasis, Diabetic gastroparesis, Eosinophilic esophagitis, Esophageal cancer, Esophageal diverticula, Esophageal hiatal hernia, Esophageal perforation, Esophageal spasm, Esophageal stricture, Esophagitis, Gastric cancer, Gastritis, Intestinal malrotation, Irritable bowel syndrome, Lung cancer, Myocardial infarction, Pneumonia, Ulcer disease