B24. Treatment of gastro-esophageal reflux, its clinical manifestation and etiology

From greek.doctor

Gastroesophageal reflux disease (GERD) (or gastro-oesophageal reflux disease in British English, but that's abbreviated GORD) is a common disease where gastric contents reflux into the oesophagus, causing symptoms like heartburn, regurgitation, and possible severe complications. It’s caused by excessive relaxation of the lower oesophageal sphincter, and is therefore sort of the opposite disorder of achalasia.

Etiology

Risk factors include those which decrease the tone of the LES and/or increase the pressure inside the stomach:

Classification

We distinguish GERD into one of three types:

  • Non-erosive reflux disease (NERD)
  • Erosive reflux disease (ERD), also called erosive oesophagitis
  • Complicated erosive reflux disease

In NERD, which accounts for 60% of cases, the gastroesophageal mucosa is visibly normal. In ERD, erosions are present on the mucosa. Complicated ERD is characterised by the presence of complications like ulcers, stenosis, or Barrett oesophagus.

Clinical features

The typical symptoms of GERD are heartburn and regurgitation. Atypical symptoms may occur if the regurgitation reaches the larynx, bronchi, or teeth, causing symptoms like hoarseness and coughing.

In complicated GERD the patient may have strictures or oesophagitis, which may cause dysphagia or odynophagia, or constant pain.

Diagnosis and evaluation

In most cases, patients don’t need to undergo procedures for the precise diagnosis. If a patient with typical symptoms presents without being at risk of complications, the patient can undergo a so-called PPI test. The patient is prescribed a PPI for 4 weeks, and if the symptoms improve, then the diagnosis of GERD is likely.

In cases where the diagnosis is uncertain, proper diagnostic modalities are necessary. There are many options:

Treatment

Treatment involves lifestyle changes such as smoking cessation, weight loss, not eating before bedtime, elevating the head in the bed.

In most cases, medical therapy is necessary. The standard treatment is PPIs. Alternatives include H2 receptor antagonists, antacids, and surface agents like sucralfate.

Preoperative evaluation

For people being evaluated for surgical treatment of GERD, it’s important to determine that it is actually GERD which causes the patient’s complaints. Patients should undergo upper endoscopy, pH testing, and oesophageal manometry.

Surgical treatment

Surgery is indicated for GERD when standard medical therapy is insufficient to treat the patient’s symptoms. The most commonly performed surgical procedure for GERD is laparoscopic fundoplication, most often the Nissen fundoplication. In Nissen fundoplication, the gastric fundus is wrapped around the lower oesophagus and secured with stitches. This creates a “cuff” around the lower oesophageal sphincter, which prevents reflux.

Complications