Gastroesophageal Reflux Disease

Gastroesophageal (pronounced: gas-tro-ih-sah-fuh- jee -ul) reflux disease is a disorder that results from stomach acid moving backward from the stomach into the esophagus.

Gastroesophageal refers to the stomach and esophagus. Reflux means flow back or return. Gastroesophageal reflux is the return of the stomach's contents back up into the esophagus.

The backflow or reflux of gastric and duodenal contents into the esophagus and past the lower esophageal sphincter (LES), without associated belching or vomiting, is called gastroesophageal reflux. Reflux mayor may not cause symptoms or pathologic changes. Persistent reflux may cause reflux esophagitis (inflammation of the esophageal mucosa). The prognosis varies with the underlying cause.

Causes

Gastroesophageal reflux is a common condition that often occurs without symptoms after meals. In some people, the reflux is related to a problem with the lower esophageal sphincter, a band of muscle fibers that usually closes off the esophagus from the stomach. If this sphincter doesn't close properly, food and liquid can move backward into the esophagus and may cause the symptoms.

Signs and symptoms

Gastroesophageal reflux doesn't always cause symptoms. The most common feature of this disorder is heartburn, which may become more severe 30 to 60 minutes after meals and on reclining and with vigorous exercise, bending, or lying down and may be relieved by antacids or sitting upright.

The pain of esophageal spasm resulting from reflux esophagitis tends to be chronic and may mimic that of angina pectoris, radiating to the neck, jaws, and arms. Other symptoms include odynophagia, which may be followed by a dull substernal ache from severe, long-term reflux;dysphagia from esophageal spasm, stricture, or esophagitis; bleeding (bright red or dark brown);and Barrett's metaplasia. Many patients have a lesser degree of dyspeptic symptoms with or without heartburn.

Rarely, nocturnal regurgitation wakens the patient with coughing, choking, and a mouthful of saliva. Reflux may be associated with hiatal hernia. Direct hiatal hernia becomes clinically significant only when reflux is confirmed.

Pulmonary symptoms result from reflux of gastric contents into the throat and subsequent aspimtion. They include chronic pulmonary disease or nocturnal wheezing, bronchitis, asthma, morning hoarseness, and cough.

In children, other signs consist of failure to thrive and forceful vomiting from esophageal irritation. Such vomiting sometimes causes aspiration pneumonia.

Diagnosis

An infant who spits or vomits may have GER. The doctor or nurse will talk with you about your child's symptoms and will examine your child. If the infant is healthy, happy, and growing well, no tests or treatment may be needed. Tests may be ordered to help determine whether your child's symptoms are related to GER. Sometimes, treatment is started without tests.

Treatment

Effective management relieves symptoms by reducing intra-abdominal pressure and reflux through gravity, neutralizing gastric contents, strengthening the LES with drug therapy and, in severe cases, performing surgery.

Positional therapy

To reduce intra-abdominal pressure and reflux, the patient should sleep in a reverse Trendelenburg position (with the head of the bed elevated) and should avoid lying down after meals and late night snacks. In uncomplicated cases, positional therapy is especially useful in infants and children.

Antacids

Antacids given 1 hour and 3 hours after meals and at bedtime are effective for intermittent reflux. Hourly administration is necessary for intensive therapy. A non-diarrheal, nonmagnesium antacid (aluminum carbonate, aluminum hydroxide) may be preferred, depending on the patient's bowel status.

Drug therapy

Bethanechol, a drug that helps to increase LES pressure, stimulates smooth-muscle contraction and decreases esophageal acidity after meals (proven with pH probe). Metoclopramide and cimetidine have also been used with beneficial results.

If possible, NG intubation should not be continued for more than 5 days because the tube interferes with sphincter integrity and itself allows reflux, especially when the patient lies flat.

Surgery

Surgical intervention may be necessary to control severe and refractory symptoms, such as pulmonary aspiration, hemorrhage, obstruction, severe pain, perforation, incompetent LES, and associated hiatal hernia.

Surgical procedures that create an artificial closure at the gastroesophageal junction include the Belsey Mark IV operation (which invaginates the esophagus into the stomach) and the Hill or Nissen operation (which creates a gastric wraparound with or without fixation). Also, vagotomy or pyloroplasty may be combined with an antireflux regimen to modify gastric contents.

Prevention

Avoid foods and activities that worsen symptoms. Maintain a healthy weight.
Teach the patient how to avoid and treat reflux.

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