Gastroesophageal reflux disease (GERD) Hunerdeep Gill #1018

GERD Often called reflux, heartburn It is the recurring backflow of gastric acid from the stomach into the esophagus Loosening of the lower esophageal sphincter (LES) Refluxed stomach acid touches the lining of the esophagus causing a burning sensation

The lower esophageal sphincter (LES) is a tight muscle at the bottom of the esophagus The LES is designed to relax when the food passes through the esophagus into the stomach Reflux can occur when the tightness of the LES decreases

LES Problem Caused High fat and carbohydrates in diet Alcohol consumption Tobacco products Carminatives (peppermint & spearmint) Acidic fruit juices & tomato-based foods Some medications (e.g. calcium channel blockers & nitrates) Forceful abdominal breathing

Symptoms A burning sensation in your chest (heartburn), sometimes spreading to the throat, along with a sour taste in your mouth Chest pain Difficulty swallowing (dysphagia) Dry cough Hoarseness or sore throat Regurgitation of food or sour liquid (acid reflux) Sensation of a lump in the throat

Risk Factors Obesity Hiatal hernia Pregnancy Smoking Dry mouth Asthma Diabetes Delayed stomach emptying Connective tissue disorders, such as scleroderma Zollinger-Ellison syndrome

Narrowing of the esophagus (esophageal stricture):   Narrowing of the esophagus (esophageal stricture):  Damage to cells in the lower esophagus from acid exposure leads to formation of scar tissue. The scar tissue narrows the food pathway, causing difficulty swallowing An open sore in the esophagus (esophageal ulcer): Stomach acid can severely erode tissues in the esophagus, causing an open sore to form. The esophageal ulcer may bleed, cause pain and make swallowing difficult Precancerous changes to the esophagus (Barrett's esophagus):  In Barrett's esophagus, the color and composition of the tissue lining the lower esophagus change. These changes are associated with an increased risk of esophageal cancer. The risk of cancer is low, but your doctor will likely recommend regular endoscopy exams to look for early warning signs of esophageal cancer (epithelial cells from squamous to intestinal columnar epithelium)

Treatment Antacids: H-2-receptor blockers: Proton pump inhibitors: that neutralize stomach acid, may provide quick relief. But antacids alone won't heal an inflamed esophagus damaged by stomach acid. Overuse of some antacids can cause side effects, such as diarrhea or constipation H-2-receptor blockers: these medications include cimetidine (Tagamet HB), famotidine (Pepcid AC), nizatidine (Axid AR) or ranitidine (Zantac 25, Zantac 75, Zantac 150). H-2-receptor blockers don't act as quickly as antacids, but they provide longer relief. Stronger versions of these medications are available in prescription form Proton pump inhibitors: block acid production and allow time for damaged esophageal tissue to heal. Over-the-counter proton pump inhibitors include lansoprazole (Prevacid 24 HR) and omeprazole (Prilosec OTC)

Surgery Surgery to reinforce the lower esophageal sphincter (Nissen fundoplication): Fundoplication: is the standard surgical treatment for GERD. This is were the upper part of the stomach is wrapped around the LES to strengthen the sphincter, prevent acid reflux, and repair a hiatal hernia patients can leave the hospital in 1 to 3 days and return to work in 2 to 3 weeks Procedure if medications aren't effective or if you're not a candidate for Nissen fundoplication; Surgery to create a barrier preventing the backup of stomach acid: A device (Esophyx) is inserted through the mouth into the stomach. The device is used to fold the tissue at the base of the stomach into a replacement for the sphincter valve, to keep stomach acid from washing into your esophagus A procedure to form scar tissue in the esophagus (Stretta procedure): This approach uses electrode energy to heat esophageal tissue. The heat creates scar tissue and damages the nerves that respond to refluxed acid. The scar tissue that forms as your esophagus heals helps to strengthen the muscles Recently approved: Surgery to strengthen the lower esophageal sphincter (Linx): The Linx device is a ring of tiny magnetic titanium beads that is wrapped around the junction of the stomach and esophagus. The magnetic attraction between the beads is strong enough to keep the opening between the two closed to refluxing acid, but weak enough so that food can pass through it. The new device has been approved by the Food and Drug Administration. It can be implanted using minimally invasive surgery methods

Preventive measures Maintain a healthy weight: Excess pounds put pressure on your abdomen, pushing up your stomach and causing acid to back up into your esophagus Avoid foods and drinks that trigger heartburn: Common triggers such as fatty or fried foods, tomato sauce, alcohol, chocolate, mint, garlic, onion, and caffeine may make heartburn worse. Eat smaller meals: Avoid overeating by eating smaller meals. Don't lie down after a meal. Wait at least three hours after eating before lying down or going to bed. Elevate the head of your bed: If you regularly experience heartburn at night or while trying to sleep, the bed should be raised by six to nine inches.. Don't smoke: Smoking decreases the lower esophageal sphincter's ability to function properly

GERD in Children Distinguishing between normal, physiologic reflux and GERD in children is important. Most infants with GER are happy and healthy even if they frequently spit up or vomit, and babies usually outgrow GER by their first birthday Reflux that continues past 1 year of age may be GERD. Studies show GERD is common and may be overlooked in infants and children. GERD can present as repeated regurgitation, nausea, heartburn, coughing, laryngitis, or respiratory problems like wheezing, asthma, or pneumonia. Infants and young children may demonstrate irritability or arching of the back, often during or immediately after feedings. Infants with GERD may refuse to feed and experience poor growth.

Case Study Edna Earl is a 62 year old female retired teacher who presents today complaining of severe epigastric pain when she lies down to sleep. She states that she has never had stomach problems prior to this. The pain usually is present as she lies down to sleep, and does not go away until she drinks buttermilk. She often wakes up with burning in her throat and epigastric area, and sometimes has an unpleasant bile taste in her mouth. Edna is well nourished, and appears her stated age of 62. She is 5’6’’ and weighs 138 lbs. Edna has HTN and hypothyroidism. Current medications include Lopressor 50 mg per day, and Synthroid daily. Edna states she sometimes has a glass of wine with her meal, and smokes 1/2-1 pack of cigarettes per day. VS BP 120/82, P 82, R 16, T 98.4.

References http://www.nlm.nih.gov/medlineplus/ency/article/000265.htm http://www.webmd.com/children/infants-children http://www.medicalnewstoday.com/articles/14085.php http://www.healthline.com/health/gerd/basics http://emedicine.medscape.com/article/176595-overview http://www.surgery.usc.edu/uppergi-general/gastroesophagealrefluxdisease-linx-risksbenefits.html