Acidity / GERD
Dr. Amit Miglani
Senior Gastroenterologist, Hepatologist & Endoscopist of Faridabad.
What is GERD ?
Gastroesophageal Reflux Disease ( GERD ) is characterised by reflux of the gastric contents into the esophagus. It results due to disruption of the esophagogastric junction due to some intrinsic or structural causes. Typically GERD results in heartburn or regurgitation, typically it can present with chronic cough, asthma, dental erosions, laryngitis, chest pain. GERD can be classified into non erosive reflux disease, erosive esophagitis. Most common of these is non erosive reflux disease followed by erosive esophagitis.
Etiology
Many factors have been identified such as Transient relaxation of lower esophageal sphincter , esophageal dysmotility which results in delayed esophageal clearance of acid, lower esophageal sphincter laxity ,hiatus hernia and delayed gastric emptying. Several other risk factors such as Obesity, smoking, pregnancy, connective tissue disorders , excess alcohol consumption and some drugs like NSAIDS, anticholinergic drugs, and calcium channel blockers have been associated with increased prevalence of GERD.
Pathophysiology
Impaired function of the lower esophageal sphincter and disturbed transient lower esophageal relaxation results in the retrograde movement of the gastric contents like gastric acid and pepsin to the esophageal mucosa which results in inflammation of the esophageal mucosa.
Hiatus hernia results in impaired contraction of the lower esophageal sphincter which results in regurgitation of gastric contents.
Impaired mucosal defence of the esophagus and reduced esophageal motility leads to prolonged exposure of the esophageal mucosa to gastric contents which results in mucosal damage and inflammation.
Presentation
Typically the patient presents with heartburn and regurgitation of food. Heartburn typically results in a retrosternal burning sensation radiating to the neck immediately after taking food and aggravated while lying down. Regurgitation results in retrograde passage of acidic gastric contents in the mouth and hypopharynx. Atypical symptoms include chest pain, hoarseness of voice, chronic cough, laryngitis, dental erosions, asthma.
EVALUATION
Typically the patients are diagnosed on the basis of classical history and response to antisecretory therapy. In the presence of alarm symptoms such as anemia, dysphagia, recurrent vomiting, odynophagia or hematemesis Upper GI Endoscopy should be done. Endoscopy can rule out esophageal strictures, ulcers, carcinoma esophagus, Barrett's esophagus or any peptic ulcer .If a patient is having underlying coronary artery disease should be evaluated for any cardiac event.
In medically refractory GERD and normal endoscopic findings should undergo esophageal ambulatory reflux monitoring which measures esophageal pH and impedance at the reflux event. It is an ph monitoring which can detect pathological acid exposures in the esophagus, number of acid exposure events, frequency of events and the symptomatic correlation.
TREATMENT
The goal of GERD treatment is to improve the symptoms and to prevent the complication in the form of peptic stricture, Barrett's esophagus and adenocarcinoma.
Lifestyle modifications and counselling are the cornerstone of GERD treatment. Weight loss in obese patients has been seen to improve symptoms. Elevation of the head end of bed, avoidance of spicy food, chocolate, citrus food and caffeine, don’t go to bed or lie down for at least 2 hours after taking meals , avoid wearing tight clothes , avoid forward bending
Antisecretory therapy in the form of PPI( commonly used are Omeprazole, pantoprazole , rabeprazole , esoprazole ) has been very effective in GERD management. PPI should be given in standard doses before the first meal of the day. Individuals not responding to the standard doses can be switched to twice daily dosing of PPI. Individuals with incomplete response to twice daily dosing and having more night time symptoms H2 antagonist can be added at bedtime.
Surgical therapy
Individuals who are refractory to medical therapy or have adverse effects to medical therapy, have large hiatus hernia or want to discontinue the medical therapy. Such individuals can undergo surgical therapy such as Nissen fundoplication which has been gold standard treatment however 15 to 20% of the patients develop postoperative dysphagia, bloating and belching. Before undergoing fundoplication esophageal manometry should be done to rule out underlying achalasia cardia and other motility disorders of esophagus. Bariatric surgery such as sleeve gastrectomy,Roux en Y gastric bypass surgery in obese patients helps in weight loss and improvement in GERD.
Endoscopic therapy
Recently various endoscopic therapy like GERDex procedure and Ablation therapy has been used in the treatment of GERD with Good Results.
