Gastroesophageal reflux disease

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Cause/etiology

Gastroesophageal reflux disease is a multifactorial disease.[1]

Twin studies suggest a genetic component.[2]

Obesity

Obesity if associated with gastroesophageal reflux disease.[3][4] Obesity may interfeere with function of the gastroesophageal junction.[5]

Hiatal hernia

The presence of a hiatal hernia correlates with abnormal 24 ph monitoring. In one study the presence of abnormal ph monitoring was:[6]

  • No hernia 18%
  • Hernia < 2cm 27%
  • Hernia > 2cm 35%

Psychological stress

Psychological stress may lead to physiologic abnormalities in the esophagus.[7]

Signs/symptoms

Patients with GERD may have heartburn or reflux symptoms; however, these symptoms may be due to peptic ulcer disease.[8][9]

It is unclear whether GERD can cause laryngeal symptoms.[10][11][12]

GERD may be able to exacerbate asthma.[13]


Diagnosis

There is no single test that can identify all patients with GERD. However, most patients with have abnormalities of either 24 hour ph monitoring or the Berstein test.[1]

Response to antisecretory therapy

One study found:[14]

This leads to a negative likelihood ratio of 0.35 which indicates the test, when the patient does not respond to treatment, has some value in excluding the diagnosis of GERD.

Radiology

Hiatal hernia

The accuracy of a radiologic hiatal hernia predicts abnormal 24 hour ph monitoring is:[6] Hernia of any size:

Hernia at least 2cm:

Reflux on manual stomach compression or valsalva

The accuracy of reflux during the upper gastrointestinal series predicts endoscopic esophagitis is:[15]

Spontaneous reflux:

Reflux during abdominal compression:

Treatment

Avoid tight fitting garments.

  • Eating slower may help.[17]
  • The evidence for most dietary interventions is anecdotal.[18]
  • Positioning. A meta-analysis found that elevating the head of the bed may help.[18]. A subsequent randomized crossover study showed benefit by avoiding eating two hours before bed.[19] Sleeping in the left lateral decubitus position might help.[20]
  • Weight loss might reduce symptoms.[18][21]

Medications

A meta-analysis found that "alginate/antacid combination (Gaviscon) had an absolute benefit increase of 26%(number needed to treat is 4), histamine-2 receptor antagonists had an absolute benefit of 10-12%(number needed to treat is 9), and antacids had an absolute benefit increase 8% (number needed to treat is 12)."[22]

A meta-analysis of randomized controlled trials by the international Cochrane Collaboration (that did not include trials of antacids and alginate concluded "PPI therapy is the most effective therapy in oesophagitis but H2RA therapy is also superior to placebo. There is a paucity of evidence on prokinetic therapy but no evidence that it is superior to placebo."[23]

PPIs are the most effective individual drug, but adding cisapride helped further.[24] Cisapride is no longer on the market due to cardiac adverse drug reactions.

Reducing medications

Some patients will be able to take 2-4 week course of medications as needed.[25]

15% of patients may be able to stop medications after symptoms are controlled.[26]

Stopping medications may lead to transient rebound hypersecretion of acid.[27]

Prognosis

Patients with reflux symptoms are at a small increased risk of Barrett's esophagitis.[28]

References

  1. ↑ 1.0 1.1 Howard PJ, Maher L, Pryde A, Heading RC (1991). "Symptomatic gastro-oesophageal reflux, abnormal oesophageal acid exposure, and mucosal acid sensitivity are three separate, though related, aspects of gastro-oesophageal reflux disease". Gut 32 (2): 128–32. PMID 1864528. [e]
  2. ↑ Mohammed I, Cherkas LF, Riley SA, Spector TD, Trudgill NJ (2003). "Genetic influences in gastro-oesophageal reflux disease: a twin study". Gut 52 (8): 1085–9. PMID 12865263. [e]
  3. ↑ El-Serag HB, Ergun GA, Pandolfino J, Fitzgerald S, Tran T, Kramer JR (2007). "Obesity increases oesophageal acid exposure". Gut 56 (6): 749–55. DOI:10.1136/gut.2006.100263. PMID 17127706. Research Blogging.
  4. ↑ Corley DA, Kubo A, Zhao W (2007). "Abdominal obesity, ethnicity and gastro-oesophageal reflux symptoms". Gut 56 (6): 756–62. DOI:10.1136/gut.2006.109413. PMID 17047097. Research Blogging.
  5. ↑ Pandolfino JE, El-Serag HB, Zhang Q, Shah N, Ghosh SK, Kahrilas PJ (2006). "Obesity: a challenge to esophagogastric junction integrity". Gastroenterology 130 (3): 639–49. DOI:10.1053/j.gastro.2005.12.016. PMID 16530504. Research Blogging.
  6. ↑ 6.0 6.1 Ott DJ, Gelfand DW, Chen YM, Wu WC, Munitz HA (1985). "Predictive relationship of hiatal hernia to reflux esophagitis". Gastrointestinal radiology 10 (4): 317–20. PMID 4054494. [e]
  7. ↑ Farré R, De Vos R, Geboes K, et al (2007). "Critical role of stress in increased oesophageal mucosa permeability and dilated intercellular spaces". Gut 56 (9): 1191–7. DOI:10.1136/gut.2006.113688. PMID 17272649. Research Blogging.
  8. ↑ Talley NJ, Weaver AL, Tesmer DL, Zinsmeister AR (1993). "Lack of discriminant value of dyspepsia subgroups in patients referred for upper endoscopy". Gastroenterology 105 (5): 1378–86. PMID 8224642. [e]
  9. ↑ Johnsen R, Bernersen B, Straume B, Førde OH, Bostad L, Burhol PG (1991). "Prevalences of endoscopic and histological findings in subjects with and without dyspepsia". BMJ 302 (6779): 749–52. PMID 2021764. [e] Fulltext
  10. ↑ Vavricka SR, Storck CA, Wildi SM, et al (2007). "Limited diagnostic value of laryngopharyngeal lesions in patients with gastroesophageal reflux during routine upper gastrointestinal endoscopy". Am. J. Gastroenterol. 102 (4): 716–22. DOI:10.1111/j.1572-0241.2007.01145.x. PMID 17397404. Research Blogging.
  11. ↑ Vaezi MF (2007). "Are there specific laryngeal signs for gastroesophageal reflux disease?". Am. J. Gastroenterol. 102 (4): 723–4. DOI:10.1111/j.1572-0241.2007.01143.x. PMID 17397405. Research Blogging.
  12. ↑ Wo JM, Koopman J, Harrell SP, Parker K, Winstead W, Lentsch E (2006). "Double-blind, placebo-controlled trial with single-dose pantoprazole for laryngopharyngeal reflux". Am. J. Gastroenterol. 101 (9): 1972–8; quiz 2169. DOI:10.1111/j.1572-0241.2006.00693.x. PMID 16968502. Research Blogging.
  13. ↑ Kiljander TO, Harding SM, Field SK, et al (2006). "Effects of esomeprazole 40 mg twice daily on asthma: a randomized placebo-controlled trial". Am. J. Respir. Crit. Care Med. 173 (10): 1091–7. DOI:10.1164/rccm.200507-1167OC. PMID 16357331. Research Blogging.
  14. ↑ Aanen MC, Weusten BL, Numans ME, de Wit NJ, Baron A, Smout AJ (2006). "Diagnostic value of the proton pump inhibitor test for gastro-oesophageal reflux disease in primary care". Aliment. Pharmacol. Ther. 24 (9): 1377–84. DOI:10.1111/j.1365-2036.2006.03121.x. PMID 17059519. Research Blogging.
  15. ↑ Fransson SG, Sökjer H, Johansson KE, Tibbling L (1989). "Radiologic diagnosis of gastro-oesophageal reflux". Acta radiologica (Stockholm, Sweden : 1987) 30 (2): 187–92. PMID 2923744. [e]
  16. ↑ Sellar RJ, De Caestecker JS, Heading RC (1987). "Barium radiology: a sensitive test for gastro-oesophageal reflux". Clinical radiology 38 (3): 303–7. PMID 3581674. [e]
  17. ↑ Wildi SM, Tutuian R, Castell DO (2004). "The influence of rapid food intake on postprandial reflux: studies in healthy volunteers". Am. J. Gastroenterol. 99 (9): 1645–51. DOI:10.1111/j.1572-0241.2004.30273.x. PMID 15330896. Research Blogging.
  18. ↑ 18.0 18.1 18.2 Kaltenbach T, Crockett S, Gerson LB (2006). "Are lifestyle measures effective in patients with gastroesophageal reflux disease? An evidence-based approach". Arch. Intern. Med. 166 (9): 965–71. DOI:10.1001/archinte.166.9.965. PMID 16682569. Research Blogging.
  19. ↑ Piesman M, Hwang I, Maydonovitch C, Wong RK (2007). "Nocturnal reflux episodes following the administration of a standardized meal. Does timing matter?". Am. J. Gastroenterol. 102 (10): 2128–34. DOI:10.1111/j.1572-0241.2007.01348.x. PMID 17573791. Research Blogging.
  20. ↑ Khoury RM, Camacho-Lobato L, Katz PO, Mohiuddin MA, Castell DO (1999). "Influence of spontaneous sleep positions on nighttime recumbent reflux in patients with gastroesophageal reflux disease". Am. J. Gastroenterol. 94 (8): 2069–73. PMID 10445529. [e]
  21. ↑ Jacobson BC, Somers SC, Fuchs CS, Kelly CP, Camargo CA (2006). "Body-mass index and symptoms of gastroesophageal reflux in women". N. Engl. J. Med. 354 (22): 2340–8. DOI:10.1056/NEJMoa054391. PMID 16738270. Research Blogging.
  22. ↑ Tran T, Lowry AM, El-Serag HB (2007). "Meta-analysis: the efficacy of over-the-counter gastro-oesophageal reflux disease therapies". Aliment. Pharmacol. Ther. 25 (2): 143–53. DOI:10.1111/j.1365-2036.2006.03135.x. PMID 17229239. Research Blogging.
  23. ↑ Khan M, Santana J, Donnellan C, Preston C, Moayyedi P (2007). "Medical treatments in the short term management of reflux oesophagitis". Cochrane database of systematic reviews (Online) (2): CD003244. DOI:10.1002/14651858.CD003244.pub2. PMID 17443524. Research Blogging.
  24. ↑ Vigneri S, Termini R, Leandro G, et al (1995). "A comparison of five maintenance therapies for reflux esophagitis". N. Engl. J. Med. 333 (17): 1106–10. PMID 7565948. [e]
  25. ↑ Bardhan KD, Müller-Lissner S, Bigard MA, et al (1999). "Symptomatic gastro-oesophageal reflux disease: double blind controlled study of intermittent treatment with omeprazole or ranitidine. The European Study Group". BMJ 318 (7182): 502–7. PMID 10024259. [e]
  26. ↑ Inadomi JM, Jamal R, Murata GH, et al (2001). "Step-down management of gastroesophageal reflux disease". Gastroenterology 121 (5): 1095–100. PMID 11677201. [e]
  27. ↑ Fossmark R, Johnsen G, Johanessen E, Waldum HL (2005). "Rebound acid hypersecretion after long-term inhibition of gastric acid secretion". Aliment. Pharmacol. Ther. 21 (2): 149–54. DOI:10.1111/j.1365-2036.2004.02271.x. PMID 15679764. Research Blogging.
  28. ↑ Ward EM, Wolfsen HC, Achem SR, et al (2006). "Barrett's esophagus is common in older men and women undergoing screening colonoscopy regardless of reflux symptoms". Am. J. Gastroenterol. 101 (1): 12–7. DOI:10.1111/j.1572-0241.2006.00379.x. PMID 16405528. Research Blogging.
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