Gastro-esophageal Reflux Disease

Welcome to today’s episode, where we dive into Gastroesophageal Reflux Disease (GERD). We’ll explore what causes, its symptoms, and effective treatment options. 

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Transcript

Welcome to today’s episode of AudioBoards. In this episode, we’re diving deep into Gastroesophageal Reflux Disease—a condition that affects millions of people around the world. GERD develops when stomach contents reflux back into the esophagus, causing troublesome symptoms or complications. Let’s break down what causes it, how it manifests, and the treatment options available.

One of the primary contributing factors to GERD is an incompetent lower esophageal sphincter (LES), which causes stomach acid to flow back into the esophagus. This is especially problematic when someone is lying down or when intra-abdominal pressure increases, such as during activities like lifting or bending. Another factor is hiatal hernias. In these cases, the LES moves above the diaphragm, disrupting the barrier between the stomach and esophagus, which allows acid to move up into the esophagus. Next up is truncal obesity, where increased intra-abdominal pressure forces stomach contents upward.

There are also several medical conditions that can worsen GERD. For instance, systemic sclerosis can cause diminished peristalsis, leading to delayed clearance of stomach acid, making reflux more likely. Other conditions, such as Sjögren syndrome, certain anticholinergic medications, and oral radiation therapy, can also exacerbate GERD. These conditions affect the production of saliva, and since saliva plays a crucial role in neutralizing acid, reduced saliva production increases the likelihood of acid reflux.

Similarly, impaired gastric emptying, or gastroparesis, as well as partial gastric outlet obstruction, can worsen GERD. In these cases, the stomach takes longer to empty, which increases pressure and the likelihood of reflux.

Now, there’s an interesting phenomenon called reflux hypersensitivity. Some patients experience reflux symptoms even when they have normal levels of acid reflux. These individuals may have a heightened sensitivity to acid. Stress and anxiety can often exacerbate this sensitivity.

The typical symptom of GERD is heartburn, which often occurs 30 to 60 minutes after meals and can worsen when reclining. Another hallmark symptom is regurgitation, where sour or bitter gastric contents flow back into the mouth. Dysphagia, or difficulty swallowing, may occur due to erosive esophagitis, abnormal esophageal peristalsis, or the development of an esophageal stricture.

Patients may also experience atypical or extraesophageal manifestations, such as asthma, chronic cough, chronic laryngitis, sore throat, non-cardiac chest pain, and even sleep disturbances.

For those with alarm symptoms, like severe dysphagia, odynophagia, hematemesis, malena, iron deficiency anemia, or unexplained weight loss, upper endoscopy is recommended. This test helps to identify complications of reflux disease and assess the risk for Barrett’s esophagus in patients with chronic reflux lasting more than 5 years, especially if they have risk factors such as being over 50, obese, White, male, a smoker, or having a family history.

For patients with typical GERD symptoms, but no alarm signs, initial treatment is usually empirical with a once-daily PPI for 4 to 8 weeks. If symptoms persist despite this therapy, further investigations, like upper endoscopy or ambulatory esophageal pH monitoring, may be necessary.

An upper endoscopy is ideal for documenting tissue damage in the esophagus and identifying complications such as esophageal stricture, Barrett’s metaplasia, and even esophageal adenocarcinoma. Barium esophagography is not routinely performed but may be used in cases of severe dysphagia before endoscopy to assess for strictures. It’s also helpful prior to antireflux surgery to evaluate the size of a hiatal hernia.Another diagnostic tool is esophageal pH monitoring, which measures acid reflux into the esophagus.

Let’s talk about the differential diagnosis. GERD can sometimes be confused with other conditions, such as angina pectoris, eosinophilic esophagitis, esophageal motility disorders, dyspepsia, peptic ulcers, or even functional disorders. Reflux erosive esophagitis can also be mistaken for pill-induced esophagitis, eosinophilic esophagitis, or infections like CMV, herpes, or Candida.

Now let’s talk about the complications of GERD.

Barrett’s Esophagus is a condition in which the squamous epithelium of the esophagus is replaced by metaplastic columnar epithelium, containing goblet and columnar cells. This is confirmed through biopsies obtained during an endoscopy.

It is typically treated with long-term proton pump inhibitors, taken once or twice daily to control reflux symptoms. This does not reverse the changes in the esophagus, but reduces the risk of cancer. The most serious complication of Barrett’s Esophagus is the development of esophageal adenocarcinoma.

If a patient has nondysplastic Barrett’s Esophagus, surveillance endoscopy is recommended every 3 to 5 years to monitor for any changes. During an endoscopy, biopsies are taken from nodular or irregular mucosa, and also randomly from the esophagus every 1 to 2 cm to look for abnormal tissue.

For patients with high-grade dysplasia or well-differentiated mucosal adenocarcinoma, endoscopic therapy is the standard treatment. This may involve removing nodules through mucosal snare resection or dissection techniques to assess for cancer presence and depth.

After removal, ablation of any remaining Barrett’s tissue is typically done using either radiofrequency wave electrocautery or cryotherapy. These techniques do come with risks, such as bleeding, perforation, and the potential for strictures. Because of this, endoscopic eradication therapy is not recommended for patients with nondysplastic Barrett’s Esophagus who have a low risk of developing cancer.

Moving on to Peptic Strictures, which manifest as gradual solid food dysphagia that progresses over months to years. To diagnose it, endoscopy with biopsy is mandatory to differentiate it from a stricture caused by esophageal carcinoma. The treatment for peptic strictures typically involves dilation, either with graduated polyvinyl catheters or balloons that are passed fluoroscopically or through an endoscope. Long-term therapy with PPIs is required to prevent the recurrence of the stricture by controlling acid reflux.

Now, let’s discuss the treatment options, starting with strategies for mild, intermittent symptoms. It begins with lifestyle changes and dietary modifications. To reduce symptoms, patients should try eating smaller meals throughout the day and eliminate foods that trigger reflux. These include fatty foods, caffeine, spicy foods; acidic foods, chocolate, peppermint, alcohol, and cigarettes. Weight loss is strongly recommended for individuals who are overweight or have recently gained weight.

It’s also important to avoid lying down within three hours of eating. For patients with nocturnal symptoms, elevating the head of the bed using 6-inch blocks or a foam wedge can help reduce reflux and improve esophageal clearance. Sleeping on the left side is particularly effective in reducing nighttime acid exposure to the esophagus.

For infrequent heartburn, over-the-counter treatments such as antacids or oral H2-receptor antagonists may provide relief. However, be cautious with antacids containing magnesium or aluminum, as they are not recommended for patients with kidney disease. H2-receptor antagonists can be used on demand for intermittent heartburn or taken prophylactically before meals that trigger symptoms. These medications take about 30 minutes to start working but can relieve heartburn for up to 8 hours.

For troublesome GERD symptoms, initial therapy typically involves a once-daily PPI for 4 to 8 weeks, taken 30 minutes before the first meal of the day. If symptoms persist, the dosage may be increased to twice daily.

For patients whose symptoms return after stopping therapy, treatment options include continuous PPI therapy, intermittent 2- to 4-week courses, or on-demand therapy. Patients who need twice-daily PPIs for effective symptom control, or those with complications like erosive esophagitis, Barrett’s esophagus, or peptic stricture, should remain on long-term therapy with a PPI at the lowest effective dose. However, long-term PPI use can carry a small risk of complications, including infectious gastroenteritis, small intestinal bacterial overgrowth, and deficiencies in iron, vitamin B12, or magnesium. Therefore, PPIs should be prescribed with caution, only for appropriate indications, and at the lowest possible dose.

For patients with unresponsive disease, further investigation is needed. Endoscopy is recommended to rule out severe, inadequately treated reflux esophagitis, as well as other conditions that might mimic GERD, such as eosinophilic esophagitis or achalasia.

In cases where refractory symptoms persist, ambulatory esophageal pH monitoring is recommended. This test helps determine whether symptoms correlate with reflux episodes. If no significant reflux is detected and the symptoms don’t match up with reflux episodes, the condition may be diagnosed as functional heartburn. For these patients, treatments like cognitive behavioral therapy, diaphragmatic breathing exercises, or low-dose tricyclic antidepressants may be beneficial.

Now, let’s talk about extraesophageal reflux symptoms which are asthma, hoarseness, chronic cough, and sleep disturbances. For these, current guidelines recommend a trial of a twice-daily PPI for 2 to 3 months, especially if they also have typical GERD symptoms. Improvement in extraesophageal symptoms suggests that acid reflux could be the cause, but further testing with esophageal impedance-pH testing may be required if symptoms persist beyond 3 months of PPI therapy.

Now, for patients who don’t respond to medical therapy, surgical options can be considered. Surgical treatments for GERD include fundoplication, where the top of the stomach is wrapped around the esophagus to prevent acid reflux. Additionally, a minimally invasive magnetic artificial sphincter is FDA-approved for patients with hiatal hernias less than 3 cm in size.

Surgery is generally not recommended for patients who are well-controlled with medical therapies. However, it may be an option for patients with severe reflux disease who are not willing to continue lifelong medical therapy, or for those with refractory GERD symptoms that don’t respond to PPIs. For patients with obesity, gastric bypass surgery may be a better option than fundoplication to manage GERD.

That’s all for today’s episode. Thanks for listening to AudioBoards. Stay tuned for more educational content in our next episode! The views and opinions expressed on the AudioBoards Podcast do not necessarily reflect those of our employers. This podcast is for educational purposes only and should not be used to diagnose or treat any medical conditions. It is not a substitute for professional medical advice. Always consult a qualified, board-certified healthcare provider for any medical concerns.