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Look Up > Conditions > Gastroesophageal Reflux Disease
Gastroesophageal Reflux Disease
Overview
Definition
Etiology
Risk Factors
Signs and Symptoms
Differential Diagnosis
Diagnosis
Physical Examination
Pathology/Pathophysiology
Imaging
Other Diagnostic Procedures
Treatment Options
Treatment Strategy
Drug Therapies
Complementary and Alternative Therapies
Patient Monitoring
Other Considerations
Prevention
Complications/Sequelae
Prognosis
Pregnancy
References

Overview
Definition

Gastroesophageal reflux disease (GERD), a disorder associated with a range of clinical manifestations, results from the reflux of gastroduodenal contents into the esophagus. A common and often chronic condition, GERD affects a large percentage of healthy individuals, both male and female, many of whom have experienced symptoms for more than a decade. Heartburn, the primary symptom, is often exacerbated by lying down after eating. Complications are more common with older patients. Although nearly 20% of adults use indigestion aids at least weekly, only about one-quarter of those who experience true GERD seek medical attention.

GERD is generally not considered to be a disease unless the symptoms are severe and occur frequently or the esophageal mucosa is damaged. It is important to note that individual symptoms do not always reflect the severity of esophageal mucosal damage.


Etiology
  • Lower esophageal sphincter (LES) dysfunction
  • Peptic stricture
  • Esophageal inflammation
  • Peristaltic dysfunction
  • Esophageal cancer
  • Abnormal saliva
  • Excessive acid production
  • Delayed gastric emptying
  • Reflux of bile salts
  • Reflux of pancreatic enzymes
  • Scleroderma
  • Decreased LES pressure resulting from progestational hormones during pregnancy
  • Chalasia in infants
  • Heller's myotomy for achalasia

Risk Factors
  • Esophageal clearance dysfunction (possibly hiatal hernia)
  • Taking medications that lower LES pressure
  • Eating foods that lower LES pressure
  • Exposure to substances that irritate esophageal mucosa
  • Smoking
  • Alcohol or coffee consumption
  • Chest trauma
  • Indwelling nasogastric tube
  • Elimination of H. pylori infection (controversial)
  • Children: cerebral palsy, Down syndrome, mental retardation

Signs and Symptoms
  • Heartburn
  • Regurgitation
  • Dysphagia
  • Odynophagia
  • Water brash
  • Belching
  • Retrosternal burning sensation
  • Chest pain (similar to angina)
  • Bronchospasm (asthma)
  • Laryngitis
  • Chronic cough
  • Recurrent aspiration
  • Pulmonary fibrosis
  • Wheezing
  • Hoarseness
  • Sore throat
  • Globus sensation in the neck
  • Infants: apnea syndrome, failure to thrive, recurrent emesis

Differential Diagnosis
  • Esophagitis
  • Angina
  • Respiratory ailments
  • Ear, nose, and throat ailments
  • Radiation exposure
  • Crohn's disease
  • Esophageal carcinoma
  • Achalasia
  • Ulcer disease

Diagnosis
Physical Examination

Usually normal


Pathology/Pathophysiology
  • Abnormal peristalsis
  • Poor LES tone
  • Actual mucosal damage (including from cell damage), ranging from shallow, linear erosions to denudation
  • Hyperplasia
  • Barrett's epithelium changes
  • Acute esophageal inflammation, including erosions, ulceration, and strictures

Imaging
  • Barium swallow: reveals reflux, esophageal damage (not effective for mild esophagitis), and hiatal hernia; simple and inexpensive
  • Radionuclide scintigraphy: reveals reflux

Other Diagnostic Procedures

Can be used to confirm GERD, determine if GERD resulted from acid reflux, determine if mucosal inflammation or other damage has resulted, and ascertain the severity of the condition.

  • Esophageal manometry: indicates abnormal peristalsis and poor LES tone; does not show reflux
  • Prolonged esophageal pH monitoring: enables comparison of symptoms to actual acid levels
  • Acid perfusion (Bernstein) test: indicated for patients with atypical symptoms or treatment complications
  • Endoscopy with biopsy: most effective assessment of reflux-induced mucosal damage; recommended with complications (e.g., stricture or Barrett's epithelium)
  • Gastric analysis

Treatment Options
Treatment Strategy

The goal of GERD treatment depends on the severity of the condition:

  • Patients without esophagitis: relieve symptoms
  • Patients with esophagitis: relieve symptoms, treat damage, and prevent complications

GERD treatment is generally based on three levels of severity:

  • Patients with mild symptoms but without esophagitis: modify lifestyle, prescribe PRN medications (H2 antagonists, antacids, alginic acid, prokinetics), maintain with PRN medications
  • Patients with moderate to severe symptoms but without significant esophagitis: modify lifestyle, prescribe daily medications (H2 antagonists and prokinetics), maintain with same medications
  • Patients with intractable symptoms and severe esophagitis and patients who have not responded to other drug therapy: modify lifestyle, prescribe daily medication (proton-pump inhibitor), maintain with proton-pump inhibitor, consider antireflux surgery

Drug Therapies
  • Antacids and alginic acid—appropriate for mild and infrequent symptoms; ineffective for esophagitis. Gaviscon, 10 ml qid (30 minutes after meals and at bedtime).
  • Prokinetics—effectively relieve heartburn; debatable effectiveness for esophagitis. Bethanechol, 10 to 15 mg qid or metoclopramide (both 30 minutes before meals and at bedtime); frequent side effects in young and older patients. Cisapride, 10 mg qid (30 minutes before meals and at bedtime); increases LES pressure; minimal side effects; useful for maintenance therapy for symptoms and mild esophagitis; should be used cautiously with antifungal imidazole agents.
  • H2 antagonists—effectively relieve symptoms and generally heal mild-to-moderate esophagitis; can prevent relapse with mild GERD. Cimetidine or famotidine or nizatidine or ranitidine, once or twice/day; some interactions.
  • Proton-pump inhibitors (PPIs)—potent, long-acting acid secretion inhibitors; relieve severe symptoms and heal esophagitis; provide effective maintenance therapy; minimal short-term side effects, long-term side effects unknown. Omeprazole or lansoprazole.

Complementary and Alternative Therapies

Dietary changes can be very important in decreasing the irritation of GERD. Herbs may be very effective at healing esophagitis. The correct homeopathic treatment may also be quite helpful.


Nutrition
  • Digestive enzymes may assist in decreasing the occurrence of heartburn.
  • Avoid any known allergens. May be helpful to test for food allergies.
  • Avoid sweets, oils, fats, and caffeine.

Herbs

Herbs are generally a safe way to strengthen and tone the body's systems. As with any therapy, it is important to ascertain a diagnosis before pursuing treatment. Herbs may be used as dried extracts (capsules, powders, teas), glycerites (glycerine extracts), or tinctures (alcohol extracts). Unless otherwise indicated, teas should be made with 1 tsp. herb per cup of hot water. Steep covered 5 to 10 minutes for leaf or flowers, and 10 to 20 minutes for roots. Drink 2 to 4 cups/day. Tinctures may be used singly or in combination as noted.

Herbs used as carminatives often contain volatile oils that may actually worsen relaxation of LES. Instead, digestive bitters are often astringent and tonic to mucous membranes.

  • Licorice (Glycyrrhiza glabra)—anti-inflammatory, antispasmodic, and analgesic specific for the gastrointestinal tract. Glycyrrhetinic acid has been shown in studies to aid healing of gastric, peptic, and mouth ulcers. In patients with hypertension, use deglycyrrhizinated licorice (DGL) to prevent aggravating hypertension. Prolonged use may lead to pseudoaldosteronism, which resolves with discontinuation of the herb. Chewable lozenges may be the best form for treating GERD, 380 to 1,140 mg/day.
  • Slippery elm (Ulmus fulva)—demulcent (protects irritated tissues and promotes their healing), 60 to 320 mg/day; 1 tsp. powder may be mixed with water tid to qid.

In addition, a combination of four of the following herbs may be used as either a tea (1 cup tid) or tincture (30 to 60 drops tid):

  • Valerian (Valeriana officinalis)—bitter, sedative, especially for anxiety or depression and poor digestion
  • Wild yam (Dioscorea villosa)—antispasmodic, anti-inflammatory, especially for fatigue from long-term stress or maldigestion
  • St. John's wort (Hypericum perforatum)—analgesic, antidepressant, historically used to treat adhesions and strictures, especially for anxiety or pain
  • Skullcap (Scutellaria lateriflora)—antispasmodic, sedative, nervine, especially for disturbed sleep
  • Linden flowers (Tilia cordata)—antispasmodic, mild diuretic, gentle bitter, especially for dyspepsia

Homeopathy

An experienced homeopath should assess individual constitutional types and severity of disease to select the correct remedy and potency. For acute prescribing use 3 to 5 pellets of a 12X to 30C remedy every one to four hours until acute symptoms resolve.

  • Arsenicum album for burning pain that feels better with warmth, especially with anxiety
  • Carbo vegatabilis for bloating and indigestion that is worse from lying down, especially with flatulence and fatigue
  • Lycopodium for heartburn that feels worse with eating, and bloating that is relieved by eructation
  • Nux vomica for heartburn with cramping and constipation, especially with irritability

Acupuncture

May be helpful to normalize digestion and alleviate stress


Patient Monitoring

Repeat endoscopy 6 to 12 weeks if symptoms not relieved. Annual endoscopy/biopsy for Barrett's esophagus. Attentive management when complications are present.


Other Considerations
Prevention
  • Reduce LES pressure: avoid fats, chocolate, coffee, and carminatives. Avoid medications that lower LES pressure (e.g., antidepressants, calcium-channel blockers, nitrates, progesterone, and theophylline).
  • Avoid esophageal irritants: avoid spicy foods, tomato-based foods, and citrus. Avoid medications associated with drug-induced esophagitis.
  • Improve acid clearance: change sleeping angle by elevating head of bed or upper body. Do not lie down after meals. Avoid voluntary eructation.
  • Reduce gastric distension: avoid excessive eating. Avoid food and liquid two to three hours before bedtime or lying down. Lose weight. Avoid tight-fitting garments. Avoid bending and stooping.
  • Maintenance drug therapy, if needed.
  • Possible periodic dilation of peptic stricture.
  • Surgery (primarily laparoscopic) as alternative to long-term drug therapy.

Complications/Sequelae
  • Esophageal (peptic) stricture
  • Esophageal ulcer
  • Adenocarcinoma
  • Pulmonary aspiration
  • Upper GI hemorrhage
  • Esophageal mucosa damage, possibly severe
  • Ear, nose, and throat complications
  • Loss of dental enamel
  • Vocal cord granuloma
  • Halitosis
  • Pneumonia

Prognosis

A chronic condition, GERD lapses and relapses (generally when treatment concludes), producing symptoms with varying intensity over time.


Pregnancy

GERD is common in pregnancy, especially in the third trimester. Chewable papaya tablets may provide relief and are safe for pregnant women.


References

Andreoli TE, Bennett JC, Carpenter CCJ. Cecil Essentials of Medicine. 3rd ed. Philadelphia, Pa: WB Saunders Co; 1993:285-287.

Barker LR, Burton JR, Zieve PD, eds. Principles of Ambulatory Medicine. 4th ed. Baltimore, Md: Williams & Wilkins; 1995:443-446.

Bartram T. Encyclopedia of Herbal Medicine. Dorset, England: Grace Publishers; 1995:217.

Dambro MR, ed. Griffith's 5 Minute Clinical Consult. Baltimore, Md: Lippincott Williams & Wilkins; 1999:422-423.

Kelley WN, ed. Essentials of Internal Medicine. Philadelphia, Pa: JB Lippincott Company; 1994:104-106.

Morrison R. Desktop Guide to Keynotes and Confirmatory Symptoms. Albany, Calif: Hahnemann Clinic Publishing; 1993:39-43, 102-103, 229-231, 272-275.

Stoller JK, Ahmad M, Longworth DL, eds. The Cleveland Clinic Intensive Review of Internal Medicine. Baltimore, Md: Williams & Wilkins; 1998:595-599.

Werbach MR. Nutritional Influences on Illness. New Canaan, Conn: Keats Publishing Inc; 1987:210.


Copyright © 2000 Integrative Medicine Communications

This publication contains information relating to general principles of medical care that should not in any event be construed as specific instructions for individual patients. The publisher does not accept any responsibility for the accuracy of the information or the consequences arising from the application, use, or misuse of any of the information contained herein, including any injury and/or damage to any person or property as a matter of product liability, negligence, or otherwise. No warranty, expressed or implied, is made in regard to the contents of this material. No claims or endorsements are made for any drugs or compounds currently marketed or in investigative use. The reader is advised to check product information (including package inserts) for changes and new information regarding dosage, precautions, warnings, interactions, and contraindications before administering any drug, herb, or supplement discussed herein.