GERD is one of the most prevalent gastrointestinal disorders.

• Population-based studies show that up to 15% of individuals have heartburn at least once

a week and about 7% have heartburn daily.

• Symptoms are caused by the backflow of gastric acid and other gastric contents into the

esophagus due to incompetent barriers at the gastroesophageal junction.

• The total exposure of the esophagus to refluxed acid correlates with the potential for mucosal

damage

• If the refluxed material extends to the cervical esophagus and breaches the upper

sphincter, it can enter the pharynx, larynx, and trachea, causing chronic cough,

Bronchoconstriction, pharyngitis, laryngitis, or bronchitis.

Reflux Esophagitis

• Is a complication of reflux and develops when mucosal defenses are unable to counteract

the damage was done by acid, pepsin, and bile.

Clinical Features

• Regurgitation of sour material in the mouth and heartburn are the characteristic symptoms

of GERD.

• Angina-like or atypical chest pain occurs in some patients, while others experience no

heartburn or chest pain.

• Persistent dysphagia suggests the development of a peptic stricture.

• Most patients with peptic stricture have a history of several years of heartburn preceding

dysphagia.

• However, in one-third of patients, dysphagia is the presenting symptom.

• Rapidly progressive dysphagia and weight loss may indicate the development of

adenocarcinoma in Barrett's esophagus.

• Bleeding occurs due to mucosal erosions or Barrett's ulcer.

• Severe reflux may reach the pharynx and mouth and result in laryngitis, morning

hoarseness, and pulmonary aspiration. Recurrent pulmonary aspiration can cause

aspiration pneumonia, pulmonary fibrosis, or chronic asthma.

• By, In contrast, many patients with GERD remain asymptomatic or self-treated and do not

seek attention until severe complications occur.

Investigations

• Barium swallow – normal, stricture or ulcer

• Esophagoscopy

• Mucosal biopsy

• A therapeutic trial with a proton pump inhibitor (such as Omeprazole, 40 mg bid) for 1

the week provides strong support for the diagnosis of GERD.

Treatment

• The goals of treatment are to

Decrease gastroesophageal reflux

Render the refluxate harmless

Improve oesophageal clearance

Protect the oesophageal mucosa.

 

Uncomplicated GERD

• The management of uncomplicated cases generally includes

Weight reduction

Sleeping with the head of the bed elevated by about 4 to 6 in. with blocks

Elimination of factors that increase abdominal pressure

• Patients should

Not smoke

Avoid consuming fatty foods, coffee, chocolate, alcohol, mint, orange juice,

Avoid certain medications (such as anticholinergic drugs, calcium channel blockers,

and other smooth-muscle relaxants).

• They should also avoid ingesting large quantities of fluids with meals.

• In mild cases, lifestyle changes, and over-the-counter antisecretory agents may be

adequate.

• In moderate cases, H2 receptor blocking agents are effective in symptom relief for 6 to

12 weeks.

Cimetidine, 300 mg; ranitidine, 150 mg bid

Famotidine, 20 mg bid

Nizatidine 150 mg bid)

Erosive GERD

• Higher doses are necessary for healing erosive esophagitis, but proton pump inhibitors

(PPIs) are more effective in this setting.

• In cases resistant to H2 receptor blockers and severe cases, vigorous acid suppression

with a PPI is recommended.

• The PPIs are comparably effective: for 8 weeks can heal erosive esophagitis in up to 90%

of patients.

Omeprazole (40 mg/d)

Lansoprazole (30 mg/d)

• Reflux esophagitis requires prolonged therapy, for 3 to 6 months or longer if the disease

recurs quickly.

• After initial therapy, a lower maintenance dose of PPI is used. Side effects are minimal.

• Vitamin B12 absorption is compromised by the treatment.

Anti-reflux Surgery

• Should be considered for patients with resistant and complicated reflux esophagitis that

does not respond fully to medical therapy or for patients for whom long-term medical

therapy is not desirable.

Esophagogastroduodenoscopy (EGD)

• Is preferred in patients with odynophagia because it is a specific symptom of esophagitis.

• EGD is the main diagnostic tool used for esophagitis.

• This approach would reveal more diagnostic information (eg, inflammatory

characteristics, ability to obtain samples for pathological examination, cytological

examination, viral and bacterial cultures).

• Allows mucosal visualization.

• Wide variety of findings based on the underlying cause

REFERENCES;

•      Braunwald & Fauci (2001). Harrison’s principles of internal medicine 15th Ed.  Oxford: McGraw Hill

•      Davidson, S (2006). Principles and practice of medicine 20th Ed.  Churchill: Livingstone.

Kumar & Clark (2003) Textbook of clinical medicine. Churchill: Livingstone.

•      Douglas Model (2006): Making sense of Clinical Examination of the Adult patient. 1st Ed. Hodder Arnold

•      Longmore, M., Wilkinson, I., Baldwin, A., & Wallin, E. (2014). Oxford handbook of clinical medicine. Oxford

•      Macleod, J. (2009). Macleod's clinical examination. G. Douglas, E. F. Nicol, & C. E. Robertson (Eds.). Elsevier Health Sciences.

•      Nicholson N., (1999), Medicine of Non-communicable diseases in adults. AMREF

•      Stuart and Saunders (2004): Mental health Nursing principles and practice. 1st Ed. Mosby

•      Swash, M., & Glynn, M. (2011). Hutchison's clinical methods: An integrated approach to clinical practice.