Saturday, 5 May 2012

Acid Reflux Disease (GERD)

Acid Reflux Disease - or Gastroesophageal reflux disease (GERD) - is a symptom of mucosal trauma caused by stomach acid moving up from the stomach into the esophagus.

GERD can be caused by alterations in the barrier between the stomach and esophagus, including abnormal relaxation of the lower esophageal sphincter. It can also be caused by blocked expulsion of gastric reflux from the esophagus, or a hiatal hernia. GERD caused by these problems can be permanent or transient.

An alternative type of acid reflux, that causes respiratory and laryngeal signs and symptoms, is called Extraesophageal Reflux Disease (EERD), or Laryngopharyngeal Reflux (LPR). EERD. It is not likely to cause heartburn, and is infrequently referred to as "Silent Reflux."



Signs and Symptoms


The signs and symptoms of GERD can differ based on a number of criteria, including age and the underlying cause of the disease.

Adults


Common symptoms of GERD include:
  • Hearburn.
  • Regurgitation.
  • Dyphagia (trouble swallowing).
Less-common symptoms of GERD include:
  • Odynophagia (pain when swallowing).
  • Water brash (increase salivation).
  • Nausea.
  • Chest pain.
GERD can sometimes lead to injury of the esophagus, which can include:
  • Reflux oesphagitus - necrosis of the esophageal epthelium that causes ulcers near the junction between the stomach and the esophagus.
  • Esophageal strictures - narrowing of the esphagus due to reflux-induced inflammation
  • Barrett's Esophagus - intestinal metaplasia of the distal esphagus.
  • Esophageal adinocarcinoma - a very rare form of cancer.
Other atypical symptoms associated with GERD, with evidence showing a link with esophageal damage, include:
  • Chronic cough
  • Laryngitis (clearing of the throat, horseness)
  • Asthma 
  • Erosion of tooth enamel
  • Hypersensitivity and damage of the teeth
  • Sinusitis
  • Pharyngitis
  • Globus pharingeus/globus hystericus (feeling of choking, or feeling of objects in throat)
Children (in first year of childhood)


Background acid reflux is common and benign in children, especially during the first year of childhood. Differentiating between normal acid reflux, GERD and other illnesses presenting as chronic vomiting can be difficult. Symptoms may vary from those present in adults.

Children may present with one or many symptoms of GERD; no single symptom is universal to all children.

In children suffering with GERD, signs and symptoms may include:
  • Chronic vomiting
  • Passing of mucous
  • Coughing
  • Respiratory problems such as wheezing
  • Inconsolable crying
  • Refusing food/crying for food (such as refusing to breast feed, only to cry for it the moment the breast is removed)
  • Failure to gain adequate weight
  • Bad breath
  • Belching and burping

Diagnosis


Gold-standard diagnosis of GERD involves Esophageal pH Monitoring, the monitoring of the pH levels present in the esophagus using either single or dual pH sensors via a pH catheter, or wireless pH monitoring using a pH capsule. The tests will last 24 hours for single and dual sensors, and 48 hours for wireless monitoring.

Other techniques used for diagnosis of GERD and associated conditions include X-rays of the esophagus and stomach, esophageal manometry (which involves the insertion and slow withdrawal of a catheter into the patients esophagus and stomach), and esophagogastroduodenoscopy - or EGD - (which involves the insertion of an endoscope into the esophagus and stomach, under either topical or general anesthetic). These technique may also highlight other atypical problems associated with GERD. These techniques however are only used in severe cases of GERD, or if patients have not responded to the initial treatment via Esophageal pH Monitoring and standard medication.

Treatment


Treatment for GERD can include lifestyle alterations, medication or surgery depending on the severity and causes of the disease

Lifestyle

Certain foods and lifestyles are suspected to promote GERD, but investigations in this area have suggested that evidence for the majority of dietary interventions is anecdotal.

Weightloss has been shown to improve symptoms of GERD.

Sleeping on the left side of the body, as well as elevating the head of the bed during sleeping, has been shown to reduce nighttime reflux episodes in patients. The degree of elevation is important, with a minimum elevation of between 6-8 inches for the effects to be noticeable. It has also been suggested that patients should avoid eating for at least 2 hours before bed as this can cause or worsen symptoms of GERD.

Medication

Medication to treat GERD is among the most prescribed in the world.

Medication can include:
  • Proton pump inhibitors - these are sited as the most effective medication for treating GERD, and work by stopping acid secretion at the source of acid production, the proton pump.
  • Gastric H2 receptor blockers - whilst technically antihistamines, these drugs have been shown to be effective in treating GERD, reported to relieve complaints in 50% of GERD patients.
  • Antacids - taken before meals or after symptoms begin, they can reduce gastric acidity by increasing the pH.
  • Gaviscon - works like an antacid by increasing the pH, and also coats the mucosa and decreases reflux. It is reported to be the most effective non-prescription treatment for GERD.
  • Prokinetics - strengthen the lower esophageal sphincter (LES) and speeds up gastric emptying. Prokinetics are reported as having high side-effect profiles, with Cisapride - a member of this class - being withdrawn from markets for causing Long QT Syndrome (a syndrome that can lead to irregular heart beat disorders).
  • Sucralfate - useful as an adjunct as it helps prevent esophageal damage caused by GERD. It must be taken several tomes daily, and cannot be taken within 2 hours of meals or other medication.
  • Mosapride - this is used largely outside of the US as a therapy for GERD.
  • Baclofen - as a GABA agonist, Baclogen has been shown to decrease transient lower esophageal sphincter relaxations, which can clinically reduce episodes of GERD.
Medication may be used in a "step up" or "step down" approach (for example, moving from antacids, to histamine antagonists). 72% of patients have been shown to recover within 6 months when using a "step up" approach, compared to 70% when using a "step down" approach.

Surgery

In rare cases it may be necessary for the patient to undergo a Nissen fundpolication. This procedure involves the upper part of the stomach being wrapped around the lower esophagal sphincter in order to strengthen the sphincter and prevent further GERD. It can also be used to repair a hiatal hernia. It is often performed laparoscopically.

Recovery time for this type of surgery varies, but significant improvements in quality of life should occur within 3 months to 1 year.

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