Gastrointestinal Tract
GERD
Gastroesophageal reflux disease (GERD), gastro-oesophageal reflux disease (GORD), gastric reflux disease, or acid reflux disease is defined as chronic symptoms or mucosal damage produced by the abnormal reflux in the esophagus.
This is commonly due to transient or permanent changes in the barrier between the esophagus and the stomach. This can be due to incompetence of the lower esophageal sphincter, transient lower esophageal sphincter relaxation, impaired expulsion of gastric reflux from the esophagus, or a hiatal hernia. Respiratory and laryngeal manifestations of GERD are commonly referred to as extraesophageal reflux disease (EERD).
Signs and symptoms
Adults
The most-common symptoms of GERD are:
- Heartburn
- Regurgitation
- Trouble swallowing (dysphagia)
Less-common symptoms include:
- Pain with swallowing (odynophagia)
- Excessive salivation (this is common during heartburn, as saliva is generally slightly basic and is the body's natural response to heartburn, acting similarly to an antacid)
- Nausea
- Chest pain
GERD sometimes causes injury of the esophagus. These injuries may include:
- Reflux esophagitis—necrosis of esophageal epithelium causing ulcers near the junction of the stomach and esophagus.
- Esophageal strictures—the persistent narrowing of the esophagus caused by reflux-induced inflammation.
- Barrett's esophagus—metaplasia (changes of the epithelial cells from squamous to columnar epithelium) of the distal esophagus.
- Esophageal adenocarcinoma—a rare form of cancer.
Several other atypical symptoms are associated with GERD, but there is good evidence for causation only when they are accompanied by esophageal injury. These symptoms are:
- Chronic cough
- Laryngitis (hoarseness, throat clearing)
- Asthma
- Erosion of dental enamel
- Dentine hypersensitivity
- Sinusitis and damaged teeth
Some people have proposed that symptoms such as pharyngitis, sinusitis, recurrent ear infections, and idiopathic pulmonary fibrosis are due to GERD; however, a causative role has not been established.
Children
Common symptoms of Pediatric Reflux
- Irritability and pain, sometimes screaming suddenly when asleep. Constant or sudden crying or “colic” like symptoms. Babies can be inconsolable especially when laid down flat
- Poor sleep habits typically with arching their necks and back during or after feeding
- Excessive possetting or vomiting
- Frequent burping or frequent hiccups
- Excessive dribbling or running nose
- Swallowing problems, gagging and choking
- Frequent ear infections or sinus congestion
- Babies are often very gassy and extremely difficult to “burp” after feeds
- Refusing feeds or frequent feeds for comfort
- Night time coughing, extreme cases of acid reflux can cause apnoea and respiratory problems such as asthma, bronchitis and pneumonia if stomach contents are inhaled
- Bad breath – smelling acidy
- Rancid/acid smelling diapers with loose stool. Bowel movements can be very frequent or babies can be constipated
Medications
A number of drugs are approved to treat GERD, and are among the most-often-prescribed forms of medication in most Western countries.
- Proton pump inhibitors (such as omeprazole, pantoprazole, lansoprazole, and rabeprazole) are the most effective in reducing gastric acid secretion. These drugs stop acid secretion at the source of acid production, i.e., the proton pump.
- Gastric H2 receptor blockers (such as ranitidine, famotidine and cimetidine) can reduce gastric secretion of acid. These drugs are technically antihistamines. They relieve complaints in about 50% of all GERD patients. Compared to placebo (which also is associated with symptom improvement), they have a number needed to treat of eight (8).
- Antacids before meals or symptomatically after symptoms begin can reduce gastric acidity (increase pH).
- Alginic acid (Gaviscon) may coat the mucosa as well as increase pH and decrease reflux. A meta-analysis of randomized controlled trials suggests alginic acid may be the most effective of non-prescription treatments with a number needed to treat of four.
- Prokinetics strengthen the lower esophageal sphincter (LES) and speed up gastric emptying. Cisapride, a member of this class, was withdrawn from the market for causing Long QT syndrome. Reglan (metoclopramide) is a prokinetic with significant side effects called Tardive Dyskinesia/Dystonia. The United States Food and Drug Administration issued a Black Box Warning about Reglan in January 2009.
- Sucralfate (Carafate) is also useful as an adjunct in helping to heal and prevent esophageal damage caused by GERD, however it must be taken several times daily and at least two (2) hours apart from meals and medications.
- Mosapride citrate is a 5-HT4 receptor agonist used outside the United States largely as a therapy for GERD and dyspepsia.
Clinical trials which compare GERD treatments head-to-head provide physicians with critical information. Unfortunately most pharmaceutical-company sponsored studies are conducted versus placebo and not an active control. However, the DIAMOND has shown rough equivalence of efficacy between a "step-up" approach to therapy (antacids, followed by histamine antagonists, followed by PPIs) and a "step-down" approach (the reverse). The primary endpoint of the study was treatment success after 6 months, and was achieved for 70% of patients in "step-down" versus 72% of patients in "step-up."
