Gastroesophageal reflux disease (GERD) , gastro-oesophageal reflux disease (GORD) , gastric reflux disease , or acid reflux disease is defined as chronic symptoms or mucosal damage produced by the abnormal reflux in the esophagus.
This is commonly due to transient or permanent changes in the barrier between the esophagus and the stomach. This can be due to incompetence of the lower esophageal sphincter, transient lower esophageal sphincter relaxation, impaired expulsion of gastric reflux from the esophagus, or a hiatal hernia. Respiratory and laryngeal manifestations of GERD are commonly referred to as extraesophageal reflux disease (EERD).
Signs and symptoms
Adults
The most-common symptoms of GERD are:
- Heartburn
- Regurgitation
- Trouble swallowing (dysphagia)
- False hunger pangs
Less-common symptoms include:
- Pain with swallowing (odynophagia)
- Excessive salivation (this is common during heartburn, as saliva is generally slightly basic and is the body's natural response to heartburn, acting similarly to an antacid)
- Nausea
- Chest pain
GERD sometimes causes injury of the esophagus. These injuries may include:
- Reflux esophagitis—necrosis of esophageal epithelium causing ulcers near the junction of the stomach and esophagus.
- Esophageal strictures—the persistent narrowing of the esophagus caused by reflux-induced inflammation.
- Barrett's esophagus—metaplasia (changes of the epithelial cells from squamous to columnar epithelium) of the distal esophagus.
- Esophageal adenocarcinoma—a rare form of cancer.
Several other atypical symptoms are associated with GERD, but there is good evidence for causation only when they are accompanied by esophageal injury. These symptoms are:
- Chronic cough
- Laryngitis (hoarseness, throat clearing)
- Asthma
- Erosion of dental enamel
- Dentine hypersensitivity
- Sinusitis and damaged teeth
Some people have proposed that symptoms such as pharyngitis, sinusitis, recurrent ear infections, and idiopathic pulmonary fibrosis are due to GERD; however, a causative role has not been established.
Children
GERD may be difficult to detect in infants and children. Symptoms may vary from typical adult symptoms. GERD in children may cause repeated vomiting, effortless spitting up, coughing, and other respiratory problems. Inconsolable crying, failure to gain adequate weight, refusing food, bad breath, and belching or burping are also common. Children may have one symptom or many — no single symptom is universal in all children with GERD.
Common symptoms of Pediatric Reflux
- Irritability and pain, sometimes screaming suddenly when asleep. Constant or sudden crying or “colic” like symptoms. Babies can be inconsolable especially when laid down flat.
- Poor sleep habits typically with arching their necks and back during or after feeding
- Excessive possetting or vomiting
- Frequent burping or frequent hiccups
- Excessive dribbling or running nose
- Swallowing problems, gagging and choking
- Frequent ear infections or sinus congestion
- Babies are often very gassy and extremely difficult to “burp” after feeds
- Refusing feeds or frequent feeds for comfort
- Night time coughing, extreme cases of acid reflux can cause apnoea and respiratory problems such as asthma, bronchitis and pneumonia if stomach contents are inhaled.
- Bad breath – smelling acidy
- Rancid/acid smelling diapers with loose stool. Bowel movements can be very frequent or babies can be constipated.
Vomiting feeds
Possetting after a feed is quite normal with most infants. They gain weight, feed well and have no other symptoms, but still this can be upsetting for parents. As the child gets older the lower oesophageal sphincter becomes more competent so the vomiting should begin to show signs of improvement and eventually stop. Some babies suffer more with reflux and about 60% of these babies with persistent reflux may have weight gain issues. It is a very popular misconception though that all babies and children with reflux are underweight . This isn't always the case, some may comfort eat and feed very frequently and not all are sick. Many doctors advise that babies outgrow reflux once they can sit up, or once they stand. Many do, but some will not only fail to outgrow it, but will noticeably worsen with developmental milestones, teething episodes, viral illness and weaning.
Silent Reflux
Some babies with reflux do not vomit at all. This is actually more of a problem because the acidic stomach contents go up the throat and back down again, causing twice the pain and twice the damage. There is no clear relationship between symptoms and the severity of reflux.
It is estimated that of the approximately 4 million babies born in the U.S. each year, up to 35% of them may have difficulties with reflux in the first few months of their life, known as spitting up . Most of those children will outgrow their reflux by their first birthday. However, a small but significant number of them will not outgrow the condition. This is particularly true where there is a family history of GERD present.
Barrett's esophagus
Main article: Barrett's EsophagusGERD may lead to Barrett's esophagus, a type of metaplasia which is in turn a precursor condition for carcinoma. The risk of progression from Barrett's to dysplasia is uncertain but is estimated at about 20% of cases. Due to the risk of chronic heartburn progressing to Barrett's, EGD every 5 years is recommended for patients with chronic heartburn, or who take drugs for chronic GERD.
Diagnosis
A detailed historical knowledge is vital for an accurate diagnosis. Useful investigations may include ambulatory Esophageal pH Monitoring, barium swallow X-rays, esophageal manometry, and Esophagogastroduodenoscopy (EGD). The current gold standard for diagnosis of GERD is esophageal pH monitoring. It is the most objective test to diagnose the reflux disease and it also allows to monitor GERD patients in regards of their response to medical or surgical treatment. In general, an EGD is done when the patient either does not respond well to treatment or has alarm symptoms including dysphagia, anemia, blood in the stool (detected chemically), wheezing, weight loss, or voice changes. Some physicians advocate either once-in-a-lifetime or 5/10-yearly endoscopy for patients with longstanding GERD, to evaluate the possible presence of dysplasia or Barrett's esophagus, a precursor lesion for esophageal adenocarcinoma.
Esophagogastroduodenoscopy (EGD) (a form of endoscopy) involves insertion of a thin scope through the mouth and throat into the esophagus and stomach (often while the patient is sedated) in order to assess the internal surfaces of the esophagus, stomach, and duodenum.
Biopsies can be performed during gastroscopy and these may show:
- Edema and basal hyperplasia (non-specific inflammatory changes)
- Lymphocytic inflammation (non-specific)
- Neutrophilic inflammation (usually due to reflux or Helicobacter gastritis)
- Eosinophilic inflammation (usually due to reflux)
- Goblet cell intestinal metaplasia or Barretts esophagus
- Elongation of the papillae
- Thinning of the squamous cell layer
- Dysplasia or pre-cancer
- Carcinoma
Reflux changes may be non-erosive in nature, leading to the entity "non-erosive reflux disease".
Pathophysiology
GERD is caused by a failure of the cardia. In healthy patients, the "Angle of His"—the angle at which the esophagus enters the stomach—creates a valve that prevents duodenal bile, enzymes, and stomach acid from traveling back into the esophagus where they can cause burning and inflammation of sensitive esophageal tissue.
Another paradoxical cause of GERD-like symptoms is not enough stomach acid (hypochlorhydria). The valve that empties the stomach into the intestines is triggered by acidity. If there is not enough acid, this valve does not open, and the stomach contents are churned up into the esophagus. However, there is still enough acidity to irritate the esophagus.
Factors that can contribute to GERD:
- Hiatal hernia, which increases the likelihood of GERD due to mechanical and motility factors.
- Obesity: increasing body mass index is associated with more severe GERD.. In a large series of 2000 patients with symptomatic reflux disease, it has been shown that 13 % of changes in esophageal acid exposure is attributable to changes in body mass index.</ref>
- Zollinger-Ellison syndrome, which can be present with increased gastric acidity due to gastrin production
- Hypercalcemia, which can increase gastrin production, leading to increased acidity
- Scleroderma and systemic sclerosis, which can feature esophageal dysmotility
- The use of medicines such as prednisolone
- Visceroptosis or Glénard syndrome, in which the stomach has sunk in the abdomen upsetting the motility and acid secretion of the stomach.
GERD has been linked to a variety of respiratory and laryngeal complaint
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