Gastroesophageal Reflux Disease

Introduction

Gastroesophageal reflux disease (GERD) occurs when refluxed stomach contents lead to troublesome symptoms and/or complications.

Episodic heartburn that is not frequent or painful enough to be bothersome is not included in the definition. The key factor is abnormal reflux of gastric contents from the stomach into the esophagus.

In some cases, reflux is associated with defective lower esophageal sphincter (LES) pressure or function.

Patients may have decreased LES pressure from spontaneous transient LES relaxations, transient increases in intraabdominal pressure, or an atonic LES. Some foods and medications decrease LES pressure.

CLINICAL PRESENTATION

• Symptom-based GERD (with or without esophageal tissue injury) typically presents with heartburn, usually described as a substernal sensation of warmth or burning rising up from the abdomen that may radiate to the neck.
• It may be waxing and waning in character and aggravated by activities that worsen reflux (e.g., recumbent position, bending-over, eating a high-fat meal).
• Other symptoms are water brash (hypersalivation), belching, and regurgitation. Alarm symptoms that may indicate complications include dysphagia, odynophagia, bleeding, and weight loss.
• Tissue injury–based GERD (with or without esophageal symptoms) may present with esophagitis, esophageal strictures, Barrett esophagus, or esophageal carcinoma. Alarm symptoms may also be present.
• Extraesophageal symptoms may include chronic cough, laryngitis, asthma, and dental enamel erosion.

Diagnosis

Clinical history is sufficient to diagnose GERD in patients with typical symptoms.

• Perform diagnostic tests in patients who do not respond to therapy or who present with alarm symptoms. Endoscopy is preferred for assessing mucosal injury and identifying Barrett esophagus and other complications.
• Ambulatory pH monitoring, esophageal manometry, combined impedance–pH monitoring, high-resolution esophageal pressure topography (HREPT), and an empiric trial of a proton pump inhibitor may be useful in some situations.

TREATMENT

• Goals of Treatment: The goals are to reduce or eliminate symptoms, decrease frequency and duration of gastroesophageal reflux, promote healing of injured mucosa, and prevent development of complications.

GENERAL APPROACH : Therapy is directed toward decreasing acidity of the refluxate, decreasing the gastric volume available to be refluxed, improving gastric emptying, increasing LES pressure, enhancing esophageal acid clearance, and protecting the esophageal mucosa.

• Treatment is determined by disease severity and includes the following: ✓ Lifestyle changes and patient-directed therapy with antacids and/or nonprescription acid suppression therapy (histamine 2–receptor antagonists [H2 RAs] and/or proton pump inhibitors [PPIs]) ✓ Pharmacologic treatment with prescription-strength acid suppression therapy ✓ Antireflux surgery.

PHARMACOLOGIC THERAPY

• Antacids provide immediate symptomatic relief for mild GERD and are often used concurrently with acid suppression therapies. Patients who require frequent use for chronic symptoms should receive prescription-strength acid suppression therapy instead.
• An antacid with alginic acid (Gaviscon) is not a potent acid-neutralizing agent and does not enhance LES pressure, but it does form a viscous solution that floats on the surface of gastric contents. This serves as a protective barrier for the esophagus against reflux of gastric contents and reduces frequency of reflux episodes.

PPIs (dexlansoprazole, esomeprazole, lansoprazole, omeprazole, pantoprazole, and rabeprazole) block gastric acid secretion by inhibiting hydrogen potassium adenosine triphosphatase in gastric parietal cells, resulting in profound and long lasting antisecretory effects.

Cap Esso (Esomeprazole)20/40mg PO OD 15-30 minutes before breakfast

Tab Panizox (Pantoprazole) 20/40mg PO OD 15-30 minutes before breakfast

Lansoprazole, esomeprazole, and pantoprazole are available in IV formulations for patients who cannot take oral medications, but they are not more effective than oral preparations and are significantly more expensive.

• Patients should take oral PPIs in the morning 15 to 30 minutes before breakfast or their largest meal of the day to maximize efficacy, because these agents inhibit only actively secreting proton pumps. Dexlansoprazole can be taken without regard to meals. If dosed twice daily, the second dose should be taken approximately 10 to 12 hours after the morning dose and prior to a meal or snack.