Gastroesophageal reflux
Gastroesophageal reflux: Excerpt from Professional Guide to Diseases (Eighth Edition)
Gastroesophageal reflux, also called gastroesophageal reflux disease (GERD), is the backflow of gastric or duodenal contents, or both, into the esophagus and past the lower esophageal sphincter (LES) without associated belching or vomiting. Reflux may cause symptoms or pathologic changes. Persistent reflux may cause reflux esophagitis (inflammation of the esophageal mucosa). Prognosis varies with the underlying cause.
Causes and incidence
The function of the LES — a high-pressure area in the lower esophagus, just above the stomach — is to prevent gastric contents from backing up into the esophagus. Normally, the LES creates pressure, closing the lower end of the esophagus, but relaxes after each swallow to allow food into the stomach. Reflux occurs when LES pressure is deficient or when pressure within the stomach exceeds LES pressure. (See Influences on LES pressure, page 690.)
Studies have shown that a patient with symptom-producing reflux can’t swallow often enough to create sufficient peristaltic amplitude to clear gastric acid from the lower esophagus. This results in prolonged periods of acidity in the esophagus when reflux occurs.
Predisposing factors include:
❑ pyloric surgery (alteration or removal of the pylorus), which allows reflux of bile or pancreatic juice
❑ long-term nasogastric (NG) intubation (more than 4 days)
❑ any agent that lowers LES pressure, such as food, alcohol, cigarettes; anticholinergics (atropine, belladonna, and propantheline); or other drugs (morphine, diazepam, calcium channel blockers, and meperidine)
❑ hiatal hernia with an incompetent sphincter
❑ any condition or position that increases intra-abdominal pressure, such as straining, bending, coughing, pregnancy, obesity, and recurrent or persistent vomiting.
About 25% to 40% of Americans experience symptomatic GERD at some point in their lives, while 7% to 10% of Americans experience symptoms on a daily basis. True incidence figures may be even higher because many people with GERD take over-the-counter remedies without reporting their symptoms.
Signs and symptoms
GERD doesn’t always cause symptoms, and in patients showing clinical effects, it isn’t always possible to confirm physiologic reflux. The most common feature of GERD is heartburn, which may become more severe with vigorous exercise, bending, or lying down, and may be relieved by antacids or sitting upright. The pain of esophageal spasm resulting from reflux esophagitis tends to be chronic and may mimic angina pectoris, radiating to the neck, jaws, and arms.
Other symptoms include odynophagia, which may be followed by a dull substernal ache from severe, long-term reflux; dysphagia from esophageal spasm, stricture, or esophagitis; and bleeding (bright red or dark brown). Rarely, nocturnal regurgitation wakens the patient with coughing, choking, and a mouthful of saliva. Reflux may be associated with hiatal hernia. Direct hiatal hernia becomes clinically significant only when reflux is confirmed.
Pulmonary symptoms result from reflux of gastric contents into the throat and subsequent aspiration; they include chronic pulmonary disease or nocturnal wheezing, bronchitis, asthma, morning hoarseness, and cough. In children, other signs consist of failure to thrive and forceful vomiting from esophageal irritation. Such vomiting sometimes causes aspiration pneumonia.
Diagnosis
CONFIRMING DIAGNOSIS After a careful history and physical examination, tests to confirm GERD include barium swallow fluoroscopy, esophageal pH probe, esophageal manometry, and esophagoscopy. In children, barium esophagography under fluoroscopic control can show reflux.
Recurrent reflux after age 6 weeks is abnormal. An acid perfusion (Bernstein) test can show that reflux is the cause of symptoms. Finally, endoscopy and biopsy allow visualization and confirmation of any pathologic changes in the mucosa.
Treatment
Effective management begins by teaching the patient to avoid factors that decrease LES pressure or cause esophageal irritation. The patient should eat a low-fat, high-fiber diet and avoid caffeine, tobacco, and carbonated beverages. He shouldn’t eat 2 hours before going to bed and should avoid tight clothing, elevate the head of the bed 6" to 8" (15 to 20 cm) and maintain a normal body weight. Promotility agents help increase LES sphincter tone and stimulate upper GI motility. Proton pump inhibitors and histamine-2 (H2) receptor antagonists help reduce gastric acidity. If possible, NG intubation shouldn’t be continued for more than 5 days because the tube interferes with sphincter integrity and allows reflux, especially when the patient lies flat.
Positional therapy is especially useful in infants and children who experience GERD without complications.
Surgery may be necessary to control severe and refractory symptoms, such as pulmonary aspiration, hemorrhage, obstruction, severe pain, perforation, an incompetent LES, or associated hiatal hernia. Surgical procedures that create an artificial closure at the gastroesophageal junction may be needed in some patients. These include a procedure that invaginates the esophagus into the stomach and procedures that create a gastric wraparound with or without fixation. The fundoplication procedure can be performed endoscopically. Also, vagotomy or pyloroplasty may be combined with an antireflux regimen to modify gastric contents.
Special considerations
Teach the patient what causes reflux, how to avoid reflux with an antireflux regimen (medication, diet, and positional therapy), and what symptoms to watch for and report.
❑ Instruct the patient to avoid circumstances that increase intra-abdominal pressure (such as bending, coughing, vigorous exercise, tight clothing, constipation, and obesity) as well as substances that reduce sphincter control (cigarettes, alcohol, fatty foods, and caffeine).
❑ Advise the patient to sit upright, particularly after meals, and to eat small, frequent meals. Tell him to avoid highly seasoned food, acidic juices, alcoholic drinks, bedtime snacks, and foods high in fat or carbohydrates, which reduce LES pressure. He should eat meals at least 2 to 3 hours before lying down.
❑ Tell the patient to take antacids, as ordered (usually 1 hour before or 3 hours after meals and at bedtime).
❑ Teach the patient correct preparation for diagnostic testing. For example, he shouldn’t eat for 6 to 8 hours before a barium swallow or endoscopy.
❑ After surgery using a thoracic approach, carefully watch and record chest tube drainage and the patient’s respiratory status. If needed, give chest physiotherapy and oxygen. Position the patient with an NG tube in semi-Fowler’s position to help prevent reflux. Offer reassurance and emotional support.
Pictures
Book Source Details
- Book Title: Professional Guide to Diseases (Eighth Edition)
- Author(s): Springhouse
- Year of Publication: 2005
- Copyright Details: Professional Guide to Diseases (Eighth Edition), Copyright © 2005 Lippincott Williams & Wilkins.
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Copyright notice for book excerpts: Copyright © 2008 Lippincott Williams & Wilkins. All rights reserved.
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