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Gastric contents |
| Gastric acid is the most important oesophageal irritant and there is a close relationship between acid exposure time and symptoms. |
| Defective gastric emptying |
| Gastric emptying is delayed in patients with gastro-oesophageal reflux disease. The reason for this is unknown. |
Increased intra-abdominal pressure
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| Dietary and environmental factors |
| Dietary fat, chocolate, alcohol and coffee relax the lower oesophageal sphincter and may provoke symptoms.
Systemic sclerosis After treatment for achalasia |
| Patient factors |
| Visceral sensitivity and patient vigilance play a role in determining symptom severity and consulting behaviour in individual patients |
Clinical features:
The major symptoms are heartburn and regurgitation, often provoked by bending, straining or lying down.
‘Waterbrash’, which is salivation due to reflex salivary gland stimulation as acid enters the gullet, is often present.
The patient is often overweight. Some patients are woken at night by choking as refluxed fluid irritates the larynx.
Others develop odynophagia or dysphagia.
‘Extra-oesophageal’
Atypical chest pain which may be severe can mimic angina and may be due to reflux-induced oesophageal spasm.
‘Acid laryngitis’ – Hoarseness of voice
Esophageal asthma
Recurrent chest infections, chronic cough
| ALARM SYMPTOMS IN GERD (Ref: Harrison) | |||||||
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Investigations:
| Investigation is advisable if
Patients present in middle or late age, Symptoms are atypical Complication is suspected Endoscopy It is the investigation of choice. This is performed to exclude other upper gastrointestinal diseases which can mimic gastro-oesophageal reflux, and to identify complications. A normal endoscopy in a patient with compatible symptoms should not preclude treatment for gastro-oesophageal reflux disease. |
| Twenty-four-hour pH monitoring
It is indicated if the diagnosis is unclear or surgical intervention is under consideration. This involves tethering a slim catheter with a terminal radiotelemetry pH-sensitive probe above the gastro-oesophageal junction. The intraluminal pH is recorded whilst the patient undergoes normal activities, and episodes of pain are noted and related to pH. A pH of less than 4 for more than 6-7% of the study time is diagnostic of reflux disease. In a few patients with difficult reflux, impedance testing can detect weakly acidic or alkaline reflux that is not revealed by standard pH testing. |
Bernstein test:
A thin tube is placed in middle of esophagus
Dilute HCL (0.I N) and normal saline is given alternatively
Patient is unaware which solution is given
If GERD is present then HCL will produce pain but not normal saline
Rarely done now a days
| Management |
| Lifestyle advice, including
Weight loss Avoidance of dietary items which the patient finds worsen symptoms Elevation of the bed head in those who experience nocturnal symptoms Avoidance of late meals and Giving up smoking PPIs are the treatment of choice. Symptoms usually resolve and oesophagitis heals in the majority of patients. Recurrence of symptoms is common when therapy is stopped and some patients require life-long treatment at the lowest acceptable dose. There is no evidence that H. pylori eradication has any therapeutic value. Proprietary antacids and alginates also provide symptomatic benefit. H2-receptor antagonist drugs also help symptoms without healing oesophagitis. |
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Surgery Patients who fail to respond to medical therapy, those who are unwilling to take long-term PPIs and those whose major symptom is severe regurgitation should be considered for laparoscopic anti-reflux surgery. Although heartburn and regurgitation are alleviated in most patients, a small minority develop complications such as inability to vomit and abdominal bloating (‘gas-bloat’ syndrome’). |
Complications:
Oesophagitis
Barrett’s oesophagus
| Anaemia |
| Iron deficiency anaemia occurs as a consequence of
Chronic, insidious blood loss from long-standing oesophagitis. ‘Cameron lesions’: Most patients have a large hiatus hernia and bleeding can occur from subtle erosions in the neck of the sac |
| Benign oesophageal stricture |
| Fibrous strictures develop as a consequence of long-standing oesophagitis. Most patients are elderly and have poor oesophageal peristaltic activity. They present with dysphagia which is worse for solids than for liquids. Bolus obstruction following ingestion of meat causes absolute dysphagia | |
| Gastric volvulus |
| Occasionally a massive intrathoracic hiatus hernia may twist upon itself, in either the organo-axial or the lateral axis, leading to a gastric volvulus. This leads to complete oesophageal or gastric obstruction and the patient presents with severe chest pain, vomiting and dysphagia. |