Gastroesophageal reflux disease (GERD)
Introduction
Definition and overview:
Gastroesophageal reflux disease (GERD) is a common
condition which the stomach contents move up into the
esophagus. Reflux may be a disease when it causes frequent
or severe symptoms or injuries. Reflux may cause damage
to the esophagus, pharynx or respiratory region.
Historical context:
Historically, GERD has developed as a disease from early descriptions of in in the
ancient context as a heartburn, to a very well understood condition in the
meantime. In the 20th century, advances in diagnosis and treatment were brought
with endoscopy, proton pump inhibitors, and improved diagnostic techniques like
pH monitoring and esophageal manometry.
Epidemiology:
GERD is a common condition that affects a substantial amount of the world’s
population. GERD affects about 10-20% of people in western countries regularly.
GERD’s prevalence in Asian countries used to be lower but has been rising in the
recent years. GERD can occur at any age of any gender, but it is more common in
adults, especially whose age is 40 and older and it is slightly more common in men
than women.
Etiology
Causes and risk factors:
GERD is caused by frequent acidic or nonacidic reflux content from the stomach.
When swallowing, a circular band shaped piece of muscle around the bottom of the
esophagus, called the lower esophageal
sphincter, relaxes to allow food and liquid
to flow into the stomach. Then the
sphincter closes again. If the sphincter
does not relax as is typical or it weakens,
stomach acid can flow back into the
esophagus. This constant backwash of
acid irritates the lining of the esophagus,
often causing it to become inflamed. The
following are some conditions that can
increase the risk of GERD: obesity
(which is known as excess body weight),
pregnancy in women, connective tissue disorder, delayed stomach emptying,
smoking, eating large meals late at night, eating fatty or fried foods, drinking
alcohol or coffee, and certain medicines like aspirin.
Genetic and environmental influences:
It may increase the possibility of exposure to GERD of a person when having a
family history of GERD or similar conditions like Barrett’s esophagus. Also, there
is specific genetic variants and inherited traits that may affect exposure to GERD.
Natural environments don’t have many influences on GERD, but some wrong
lifestyle habits may have an influence like excess body weight, smoking,
pregnancy, stress…etc.
Clinical Features
Signs and symptoms:
The main symptom of GERD is heartburn
which described often as a fiery and
burning feeling in the chest, and vomiting
sour or bitter liquid to the throat or the
mouth. Other symptoms of GERD are the
following: pain in the middle of the chest
which radiates to the back, difficulty in
swallowing, sore throat, coughing,
increased salivation, and shortness of
breath.
Disease stages and progression:
1- Mild GERD: it comes with infrequent heartburn, vomiting, and random chest
discomfort, usually after eating certain foods or lying down. It is often managed
with diet modification and avoiding trigger food.
2- Moderate GERD: more frequent heartburn and vomiting, may occur daily. To
treat this stage, in addition to lifestyle
changes, strong medications may be
suggested.
3- Severe GERD: Continuing, severe
symptoms, including intense heartburn,
vomiting, and pain. There may also be
complications like difficulty swallowing or
chronic cough. This stage requires
thorough evaluation, often with endoscopy
and tests like pH monitoring. Medications
are usually necessary, and surgery may be considered.
4- Complicated GERD: at this stage, GERD can cause some complications like:
Inflammation and damage to the esophageal lining, changes in the esophageal
lining, which increase the risk of esophageal cancer, narrowing of the esophagus
due to scar tissue, and open sores on the esophageal lining.
Complications:
After long periods of time, long-lasting inflammation in the esophagus can cause
esophagitis, which is an inflammation of a tissue in the esophagus, esophageal
stricture, which is narrowing of the esophagus, and Barrett esophagus, which is a
precancerous change to the esophagus.
Diagnosis
Diagnostic criteria:
The common symptoms that can occur to the patient are the following: heartburn,
regurgitation, chest pain, and chronic cough. Also, detailed history with some
lifestyle factors like smoking, alcohol consumption…etc. is essential for assessing
GERD.
Diagnostic tests and procedures:
- Visualizing esophageal damage and identifies complications like Barrett's
Esophagus.
- Measures acid reflux over 24-48 hours using a tube or wireless capsule.
- Assesses esophageal muscle contractions and LES function with a pressure-
sensing tube.
- Detecting both acid and non-acid reflux by measuring electrical impedance.
- Visualizes structural abnormalities like hiatal hernia using X-rays after ingesting
barium.
- Obtaining tissue samples during endoscopy to check for abnormalities.
Differential diagnosis:
The most important diseases to differentiate from GERD are the following:
- Peptic Ulcer disease has similar symptoms like epigastric pain and nausea.
- Esophageal motility disorders can cause dysphagia and chest pain.
- Esophageal cancer leads to symptoms like dysphagia and weight loss.
- Cardiac conditions cause chest pain with radiation.
Pathophysiology
Mechanisms of disease development:
GERD is developing through a combination of
factors which is the following:
- The LES, which is a ring of muscle at the
junction of the esophagus and stomach to
prevent stomach acid from refluxing into the
esophagus, becomes weakened or relaxed,
allowing acid to flow back into the esophagus.
- Increasing gastric acid production.
- Impaired esophageal motility can delay the clearance of acid, allowing it to
remain in contact with the esophageal lining for longer periods.
- Delayed gastric emptying which happens when the stomach empties too slowly.
Cellular and molecular changes:
The chronic acid exposure that occurs to GERD patients can cause epithelial
damage, inflammation, altered cellular signaling, increased permeability, oxidative
stress, and fibrosis.
Impact on body systems:
- Gastrointestinal system: GERD mainly affects the esophagus and acid exposure
can lead to complications. Also, medication used to treat GERD can affect gastric
acid levels and gut microbiota.
- Respiratory system: Acid reflux can lead to aspiration,
where stomach contents enter the airways. This can cause
chronic cough, laryngitis, asthma-like symptoms, or even
aspiration pneumonia. Moreover, when stomach acid
reaches the throat and voice box, it may cause symptoms
like hoarseness, throat clearing, and a sensation of a lump
in the throat.
- Immune system: Chronic inflammation from acid
exposure can lead to cellular changes in the esophagus,
increasing the risk of developing esophageal
adenocarcinoma, which is a type of cancer.
Management and Treatment
Medical and surgical treatments:
There are many surgical treatments for GERD but the most important are the
following:
- Nissen fundoplication: The most common surgical procedure for GERD, where
the top part of the stomach is wrapped around the lower esophagus to strengthen
the LES and prevent reflux.
- Partial fundoplication: A similar procedure that involves wrapping the stomach
around the esophagus only partially, which may be more appropriate for certain
patients.
- LINX device: A ring of magnetic beads is surgically placed around the LES. The
magnets are strong enough to keep the LES closed to prevent reflux but weak
enough to allow swallowing and belching.
- Stretta procedure: Uses radiofrequency energy to tighten the LES.
- Transoral incisionless fundoplication (TIF): A minimally invasive procedure that
creates a valve at the top of the stomach to prevent reflux.
Pharmacological therapies:
There are various medications to treat GERD but the most significant are the
following:
- Antacids: Provide quick relief by neutralizing stomach acid.
- H2 receptor blockers: Reduce acid production.
- Proton pump inhibitors (PPIs): More potent than H2 blockers, PPIs like
omeprazole and esomeprazole reduce acid production and heal the esophagus.
- Prokinetics: Enhance gastrointestinal motility and strengthen the lower
esophageal sphincter (LES), thus reducing acid reflux.
- Alginate-based therapies: Form a protective barrier that floats on top of the
stomach contents, preventing acid from refluxing into the esophagus.
- Cytoprotective agents: Protect the esophageal lining and promote healing.
Lifestyle and dietary modifications:
The dietary modifications for GERD patients
revolve around avoiding trigger foods like spicy
foods, citrus fruits, tomato-based products,
chocolate, mint, caffeine, alcohol, and fatty and
fried food. Also, a GERD patient should eat
smaller and frequent meals and prevent eating late
to reduce pressure on the stomach, which leads to
preventing acid reflux. In addition, chewing Food
thoroughly and eating slowly aids digestion. The
lifestyle modification includes, but not limited to,
the following: weight management, quit smoking,
avoid tight clothing, limit alcohol and caffeine,
staying hydrated, and elevating the head of the bed
to help preventing acid from flowing back to the
esophagus during sleeping.
Rehabilitation and supportive care:
Rehabilitation and supportive care for GERD involve a multi-disciplinary
approach, including nutritional counseling, physical therapy, psychological
support, speech therapy, education, medication management, and community
resources.
Prevention and Control
Primary, secondary, and tertiary prevention strategies:
Primary prevention focuses on lifestyle and dietary changes, like avoiding trigger
foods, keeping a healthy weight, and quitting smoking and drinking. Secondary
prevention involves early detection and regular monitoring, medications, and
continued lifestyle modifications. Tertiary prevention aims to manage and reduce
complications using intensive medical treatment, surgical interventions, and patient
education.
Public health interventions:
Public health interventions of GERD focus on
awareness, prevention, and handy treatment
options like the following:
- Awareness campaigns to educate people about
GERD symptoms, risk factors and the
importance of early detection. In addition to
promoting healthy eating, weight
management…etc.
- Making sure that individuals have access to
healthcare providers and access to medication.
- Applying guidelines that require clear labeling of foods that may trigger GERD
symptoms, such as those high in fat or caffeine.
- Conducting research to understand the prevalence, risk factors, and long-term
outcomes of GERD can help shape public health strategies. In addition to
gathering data on GERD cases, treatment outcomes, and healthcare access to
inform policy and healthcare planning.
Vaccination and screening programs:
For the meantime there is no discovered vaccination available for GERD as it is
not a result of a virus or bacterium. Nevertheless, screening programs can play a
very important role in early detection and managing GERD.
Prognosis
Disease outcomes and survival rates:
With the most of patients with GERD, the condition is not life threatening,
especially when managed with medications and lifestyle changes. Patients with
Barrett's esophagus face an increased risk of developing esophageal
adenocarcinoma, though this risk remains relatively low. The survival rate for
esophageal adenocarcinoma varies widely; when diagnosed at an early stage, the
five-year survival rate can be significantly higher. However, the prognosis tends to
be poor if the cancer is detected at a later stage due to its aggressive nature.
Surgical interventions, such as fundoplication, can be highly effective in
preventing reflux and associated complications, potentially improving long-term
outcomes. Ongoing management and monitoring are crucial, especially for those
with Barrett's esophagus, to detect any precancerous changes early and intervene
promptly.
Factors influencing prognosis:
- Patients with more severe and frequent symptoms tend to have a poorer prognosis
due to the higher likelihood of developing complications like esophagitis, Barrett's
esophagus, or esophageal stricture.
- Poor response to standard treatments can indicate more severe disease or the
presence of complicated factors.
- Development of complications.
- Smoking, alcohol consumption, and excess body weight can worsen symptoms.
Quality of life:
GERD significantly affects many aspects of life like physical, emotional, and
social well-being. Some symptoms of GERD like heartburn and regurgitation can
affect daily activities and sleep, which may delay social interactions and work
performance quality.
Current Research and Future Directions
Recent advances and discoveries:
In 2024, researchers focused on enhancing diagnostic
precision and developing innovative therapeutic strategies.
Furthermore, new approaches include exploring the
effectiveness of advanced acid suppression therapies and
addressing esophageal motility disorders more precisely.
Research has also stressed the importance of understanding
the pathophysiology of GERD, including the roles of
esophageal mucosal reliability and acid exposure.
Ongoing clinical trials:
- Mayo Clinic is leading multiple studies like
evaluating AI-based diagnosis of GERD using
voice analysis, and examining the
effectiveness of new treatments in addition to
other trials include exploring the impact of
diaphragmatic breathing on reflux symptoms
and assessing the outcomes of anti-reflux
surgeries.
- National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK)
supports a range of studies on GERD, involving studies on how diet affects
symptoms, new diagnostic approaches, and treatments. Also, they look at the risk
factors of GERD’s complications such as Barrett’s esophagus and esophageal
cancer.
Future research needs:
The world need some future research on GERD for example: understanding
genetic and molecular factors and the role of microbiome. Also, developing non-
aggressive diagnostic tools for early detection. Studying the progression to
Barrett's esophagus and esophageal cancer, in addition to the long-term impact on
quality of life is only so important.
Case Studies
Example cases:
- Case one:
A 52-year-old woman was referred to gastroenterology practice for a history of
gastroesophageal reflux disease. The patient claims to have had heartburn
symptoms for at least five years. Her symptoms responded to over-the-counter
medications such as antacid tablets and liquids, but they grew so frequent that she
sought medical attention from her primary care physician. Later, she reported
minor acid reflux at least twice a week. She does not have any other chronic
medical issues and does not use any other drugs. Her social background includes
severe alcohol usage for 20 years, which she discontinued after being diagnosed
with liver illness four years ago. There is no family history of gastrointestinal
cancer in her family.
- Case two:
A 52-year-old man is referred to your gastroenterology practice for a history of
gastroesophageal reflux disease (GERD). The patient reports a long history of
heartburn symptoms, dating back at least 5 years. His symptoms were responsive
to over-the-counter remedies including antacid tablets and liquids, but eventually
became such a regular occurrence that he sought medical care from his primary
care physician. He was initially prescribed an H2 blocker, which was incompletely
effective, so he started proton pump inhibitor therapy. He currently takes 20mg of
omeprazole daily which is effective, but notes that if he misses a dose, he
sometimes experiences heartburn. He denies dysphagia, nausea or vomiting, blood
in his stool, or unintentional weight loss. He has no other chronic medical
conditions and takes no other medications. He is a nonsmoker who drinks alcohol
in moderation and has no family history of gastrointestinal cancer.
