Author:
Yanina A.Purim-Shem-Tov
Description
- Spectrum of pathology in which gastric reflux causes symptoms and damage to esophageal mucosa
- Reflux esophagitis vs. nonerosive reflux disease
- Prevalence in North America is 18.1-27.8%
Etiology
- Incompetent reflux barrier allowing increase in frequency and duration of gastric contents into esophagus
- Lower esophageal sphincter (LES):
- Main antireflux barrier
- Crural diaphragm attachment (diaphragmatic sphincter)
- Contributes to pressure barrier at gastroesophageal junction
- Esophageal acid clearance via peristalsis and esophageal mucosal resistance are additional barriers
- Most healthy individuals have brief episodes of reflux without symptoms
- Transient lower esophageal sphincter relaxations (TLESRs):
- Occur with higher frequency in gastroesophageal reflux disease (GERD) patients
- Exposed esophageal mucosa becomes acidified and with time necroses
- Decreased LES tone:
- Delayed gastric emptying, increased body mass, and gastric distention contribute to reflux
- Hiatal hernias associated with GERD:
- Significance varies in any given individual
- Most persons with hiatal hernias do not have clinically evident reflux disease
- Acid secretion is same in those with or without GERD
- Associated medical conditions: Pregnancy, chronic hiccups, cerebral palsy, Down syndrome, autoimmune diseases, diabetes mellitus (DM), hypothyroidism
Signs and Symptoms
- Esophageal manifestations:
- Heartburn (or pyrosis)
- Regurgitation
- Dysphagia
- Extraesophageal manifestations:
- Bronchospasm
- Laryngitis
- Chronic cough
History
- Typical signs and symptoms:
- Heartburn (pyrosis):
- Retrosternal burning pain
- Radiates from epigastrium through chest to neck and throat
- Dysphagia:
- Dysphagia suggests esophageal spasm or stricture
- Odynophagia:
- Odynophagia suggests ulcerative esophagitis
- Regurgitation
- Water brash
- Belching
- Esophageal strictures, bleeding
- Barrett esophagus (esophageal carcinoma)
- Early satiety, nausea, anorexia, weight loss
- Symptoms worse with recumbence or bending over
- Symptoms usually relieved with antacids, although temporarily
- Atypical signs and symptoms:
- Noncardiac chest pain
- Asthma
- Persistent cough, hiccups
- Hoarseness
- Pharyngeal/laryngeal ulcers and carcinoma
- Frequent throat clearing
- Recurrent pneumonitis
- Nocturnal choking
- Upper GI tract bleeding
Physical Exam
- Nonspecific, but may have some epigastric tenderness
- Symptoms worsen with placing patient flat on the bed or Trendelenburg position
Pediatric Considerations |
- Regurgitation is common in infants:
- Incidence decreases from twice daily in 50% of those age 2 mo to 1% of 1-yr-olds
- Signs:
- Frequent vomiting, irritability, cough, crying, and malaise
- Arching the body (hyperextension) at feeding and refusals of feedings
- Failure to thrive
- Formula intolerance
- Sepsis
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Essential Workup
- Differentiate GERD from more emergent conditions such as ischemic heart pain, esophageal perforation, or aortic pathology
- Obtain typical history
- Perform thorough physical exam: Vital signs, head, ears, eyes, nose, throat (HEENT), chest and abdominal exams
Diagnostic Tests & Interpretation
- No gold stand ard
- ECG for cardiac etiology
Lab
- CBC:
- Chronic anemia from esophagitis
- Stool testing for occult bleeding
Imaging
- No routine imaging in ED
- CXR:
- Evidence of esophageal perforation, hiatal hernia, aortic disease
Diagnostic Procedures/Surgery
- Diagnostic trial of antacid:
- Those with persistent symptoms should be referred for endoscopy
- 90% of GERD patients respond to proton pump inhibitor (PPI) therapy
- Barium esophagram for prominent dysphagia
- Esophageal pH monitoring:
- Correlate symptoms to acid reflux
- Esophageal manometry (poor sensitivity):
- Evaluate LES resting pressure and esophageal peristaltic contractions
- Esophagogastroduodenoscopy (EGD):
- Detects reflux esophagitis and complications (Barrett esophagus, hiatal hernia, stricture, ulcers, malignancy)
Differential Diagnosis
- Ischemic heart disease
- Asthma
- Peptic ulcer disease
- Gastritis
- Hepatitis/pancreatitis
- Esophageal perforation
- Esophageal foreign body
- Esophageal infection
- Cholecystitis/cholelithiasis
- Mesenteric ischemia
Prehospital
- Esophageal pain may mimic angina
- Airway may need active control secondary to vomiting
Initial Stabilization/Therapy
- ABCs need to be evaluated
- IV fluid resuscitation for blood loss or shock
ED Treatment/Procedures
- Symptomatic relief:
- Antacids
- Antacids with viscous lidocaine
- Sublingual nitroglycerine for esophageal spasm
- Analgesics
- Lifestyle modifications:
- Avoid late-night or heavy/fatty meals
- Minimize time in supine position after eating
- Elevation of head of bed
- Weight loss
- Eliminate smoking and alcohol intake
- Avoid direct esophageal irritants such as citric juices and coffee
- Avoid foods that decrease LES pressures such as fatty foods, chocolate, and coffee
- Avoid drugs that lower LES tone
- PPIs:
- More potent long-acting inhibitors of gastric acid secretion than H2-blockers
- Faster healing than other drug therapies
- More efficacious in severe GERD and frank esophagitis
- H2-blockers:
- Effective for mild to moderate disease
- Severe disease requires greater dosage than that used for peptic ulcer disease
- Antacids (aluminum hydroxide/magnesium carbonate/simethicone):
- Treatment of mild and infrequent reflux symptoms
- Not effective for healing esophagitis
- Alginic acid slurry floats on surface of gastric contents, providing mechanical barrier
- Sucralfate:
- Binds to exposed proteins on surface of injured mucosa to form protective barrier
- May also directly stimulate mucosal repair
- Metoclopramide (prokinetic drug):
- Improves peristalsis
- Accelerates gastric emptying
- Increases LES pressure
- Drugs that modify TLESR
- Endoscopic therapy:
- Suturing (plication), thermal injury, chemical injection
- Antireflux surgery (goal: Increase LES pressure):
- Chronic reflux, younger patients, nonhealing ulceration, severe bleeding
- Fundoplication can be more effective than medical therapy in selected cases
- Currently newer incisionless procedure called transoral incisionless fundoplication available
Pregnancy Prophylaxis |
- Reflux present in 30-50% of pregnancies
- Increased intra-abdominal pressure, hormonal fluctuations lead to increased TLESRs
- EGD reserved for severe presentations
- H2-blockers - first-line therapy (longer safety record)
- PPIs - limited safety history in pregnancy
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Medication
- Aluminum hydroxide/magnesium carbonate/simethicone: 30 mL + viscous lidocaine 2%, 10 mL, PO q6h
- Cimetidine: 400 mg PO b.i.d, 300 mg IM/IV q6-8h
- Nizatidine: 150 mg PO b.i.d
- Ranitidine: 150 mg (peds: 5-10 mg/kg q12h) PO b.i.d or 300 mg PO at bedtime
- Famotidine: 20 mg PO/IV b.i.d (peds: 0.5-1 mg/kg/d div. q8-12h, max 40 mg/d)
- Esomeprazole: 20-40 mg PO daily
- Lansoprazole: 15-30 mg daily
- Omeprazole: 20-40 mg PO daily
- Pantoprazole: 40 mg PO/IV daily
- Rabeprazole: 20 mg PO daily
- Metoclopramide: 10-15 mg PO/IV/IM q6h before meals and nightly at bedtime
- Sucralfate: 1 g PO 1 hr before meals and nightly at bedtime
First Line
- Lifestyle modifications:
- Head of bed elevation
- Dietary modification
- Refraining from assuming a supine position after meals
- Avoidance of tight-fitting garments
- Promotion of salivation by either chewing gum
- Restriction of alcohol use
- Reduction of obesity
- Acid-suppressive medications:
- Treatment of H. pylori infections (see “Peptic Ulcer Disease”/“Gastritis”)
Second Line
- Prokinetic drugs (bethanechol, metoclopramide)
- Drugs that inhibit TLESRs (baclofen)
Disposition
Admission Criteria
- Significant esophageal bleeding
- Uncontrolled reactive asthma
- Dehydration
- Starvation and failure to thrive
Discharge Criteria
Uncomplicated GERD: Refer to patient's primary care physician (PCP) or gastroenterologist for further evaluation
Issues for Referral
Extraesophageal manifestations such as asthma, laryngitis
Follow-up Recommendations
Gastroenterologist for endoscopy in patients who require continuous maintenance medical therapy to rule out Barrett esophagus
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