Gastroesophageal Reflux Disease
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- Changes of the esophageal mucosa resulting from reflux of gastric contents into the esophagus
- Often described as “heartburn,” “acid indigestion,” and “acid reflux”
Incidence: 5/1,000 person-years
- 10–20% in the United States
- 40% of adults in the United States have reflux symptoms.
- 50–85% of gastroesophageal reflux disease (GERD) patients have nonerosive reflux disease.
- Chronic GERD is a risk factor for Barrett esophagus.
- 10% of patients with chronic GERD have Barrett esophagus.
- Risk of adenocarcinoma without Barrett esophagus and no dysplasia: 0.1–0.5% per patient-year
- Risk of adenocarcinoma with Barrett esophagus and high-grade dysplasia: 6–19% per patient-year
- Pediatric population: Regurgitation occurs at least once a day in 2/3 of 4-month-old infants, decreasing to 21% at age 6 to 7 months, and 5% at 10 to 12 months.
Etiology and Pathophysiology
- The pattern and mechanism of reflux varies depending on the severity of disease.
- GERD begins when acidic stomach contents contact the squamous mucosal lining of the esophagus, at the esophagogastric junction (EGJ).
- Inappropriate transient lower esophageal sphincter (LES) relaxation. Foods that are spicy; acidic; and high in fat, caffeine, alcohol, tobacco, anticholinergic medications, nitrates, smooth muscle relaxants affect LES relaxation.
- Patients with severe GERD often have evidence of a hiatal hernia, which can (1):
- Trap acid in the hernia sac
- Impair acid emptying
- Increase retrograde acid flow rate
- Reduce the EGJ sphincter pressure
- Increase frequency of transient LES relaxations
Genetic heterogeneity has been associated with GERD.
- Hiatal hernia
- Alcohol use
- Tobacco use
- Decrease consumption of food and beverage triggers such as spicy, fatty foods, alcohol, and caffeine.
- Weight loss
- Avoid lying down after meals.
- Tobacco and alcohol cessation
- Elevate head of bed at night.
- Avoid meals close to bedtime.
- Infants: Use car seat for 2 to 3 hours after meals; thickened feedings
Commonly Associated Conditions
- Nonerosive esophagitis
- Erosive esophagitis
- Irritable bowel syndrome
- Peptic ulcer disease
- Extraesophageal reflux: aspiration, chronic cough, laryngitis, vocal cord granuloma, sinusitis, otitis media
- Hiatal hernia: acid pocket (zone of high acidity in the proximal stomach above the diaphragm) (2)[B]
- Peptic stricture: 10% of patients with GERD
- Barrett esophagus
- Esophageal adenocarcinoma