di Ambrogio Giulia e Cacciabue Paola
DEFINITION
GERD is the retrograde flow of gastric juice (gastric acid) and/or duodenal contents (bile acids; pancreatic juice) into the distal esophagus, commonly due to incompetence of the lower esophageal sphinter (LES).
EPIDEMIOLOGY
GERD involves 10% of adult population (75% of all the esophageal patology) with a marked increase over 40 years. We are witnessing a growing overall trend for a greater need and ease of inspection of the upper digestive tract, but especially for effective dissemination of GERD as a consequence of modernity: lifestyle, wrong dietary and behavioral rules, stress conditions resulting from social organization and working conditions.
In infants it is a physiological phenomenon that appears in the first 10 months after birth and disappears by itself after a few months. It is because the esophagus in the newborn is not yet fully developed.
SYMPTOMS
The most-common symptoms of GERD are:
- Heartburn (a burning pain behind the breastbone). Sometimes the pain even extends to the neck, throat and face.
- 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)
- Sore throat and hoarseness
- Sinusitis
- Nausea
- Chest pain
DIAGNOSIS
Useful investigations may include:
PATHOGENESIS
It is determined by malfunctioning lower esophageal sphincter (LES), which consists of an asymmetrical thickening of smooth muscle fibers in the final stretch of the esophageal body which continue without interruption into the muscles of the stomach; LES is distinguished from adjacent parts to the tonic and phasic baseline activities of relaxation . The basal tone of LES is due to myogenic activity, modulated by neurohormonal excitatory and inhibitory influences. Neurotransmitters of the excitatory nerves are composed predominantly of acetylcholine and substance P, those of the inhibitors nerves are nitric oxide (NO) and vasoactive intestinal peptide (VIP).
The triggers of GERD are:
- Helicobacter Pylori
- Decrease in the tone of the cardia (LES)
- Foods : fatty foods, nicotine, caffeine, citrus fruits, alcohol
- Stenosis which causes prolonged stagnation of the bolus in the stomach
- Dyskinesias(movement disorders) that slow the normal emptying of the same
- Hiatal hernia
- Abundant meals
- Increase in gastric pressure such as obesity and pregnancy
- Zollinger-Ellison syndrome which can be present with increased gastric acidity due to gastrin production
- Hypercalcemia, which can increase gastrin production , leading to increased acidity
- Scleroderma and systemic sclerosis, which can feature esophageal dysmotility
- Types of drugs that interfere with lower esophageal sphincter function include those that have anticholinergic effects (such as many antihistamines and some antidepressants), calcium channel blockers, progesterone, and nitrates.
COMPLICATIONS
- Esophagitis may cause bleeding that is usually slight but can be massive.
- The blood may be vomited up or may pass through the digestive tract, resulting in the passage of dark, tarry stools (melena) or bright red blood, if the bleeding is heavy enough.
- Esophageal ulcers, which are open sores on the lining of the esophagus, can result from repeated reflux.
- Narrowing (stricture) of the esophagus from reflux makes swallowing solid foods increasingly more difficult. Narrowing of the airways can cause shortness of breath and wheezing.
- Discoloration of the enamel due to an erosive action of the acids.
- Barrett's esophagus: with prolonged irritation of the lower part of the esophagus from repeated reflux, the normal lining of the esophagus (squamous epithelium)is replaced by an intestinal-type lining (columnar epithelium).The secretory columnar epithelium may be more able to withstand the erosive action of the gastric secretions; however, this metaplasia confers an increased risk of adenocarcinoma.
PREVENTION AND TREATMENT
- Relief is often found by raising the head of the bed, raising the upper body with pillows, or sleeping sitting up.When a person is standing or sitting, gravity helps to prevent the reflux of stomach contents into the esophagus, which explains why reflux can worsen when a person is lying down..
- Eating a big meal causes excess stomach acid production, and attacks can be minimized by eating small frequent meals instead of large meals, especially for dinner.
- To minimize attacks, a sufferer may benefit from avoiding certain foods that stimulate excess acid secretion and/or relax the opening between the stomach and esophagus. Acidic fruit or juice, fatty foods, pretzels, coffee, tea, onions, peppermint, chocolate, or highly spiced foods are to be avoided, especially shortly before bedtime.
- Tight clothing around the abdomen can also increase the risk of heartburn because it puts pressure on the stomach, which can cause the food and acids in the stomach to reflux to the lower esophageal sphincter.
- Avoidance of smoking.
- Weight reduction in overweight or obese people.
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, esomeprazole, pantoprazole, lansoprazole, and rabeprazole) are the most effective in reducing gastric acid secretion.
- 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.
- Antacids before meals or symptomatically after symptoms begin can reduce gastric acidity (increase pH).
- Alginic acids (Gaviscon) may coat the mucosa as well as increase pH and decrease reflux.
- Prokinetics strengthen the lower esophageal sphincter (LES) and speed up gastric emptying.
Surgery
Surgery is an option for people whose symptoms are unresponsive to drugs or for people who have esophagitis that persists even after symptoms are relieved. In addition, surgery may be the preferred treatment for people who do not like the prospect of having to take drugs for many years.
The standard surgical treatment is the Nissen fundoplication: in this procedure the upper part of the stomach is wrapped around the lower esophageal sphincter (LES) to strengthen the sphincter and prevent acid reflux and to repair a hiatal hernia. The procedure is often done laparoscopically (minimally invasive procedure).
