Gastroesophageal reflux disease (GERD) is defined as the passage of gastric contents into the food pipe causing troublesome symptoms of heartburn and regurgitation. It is one of the most common gastrointestinal disorders. The prevalence of GERD varies between 10-20 % in the various populations. In India, its prevalence ranges from 7.6 to 30%, being < 10% in most population studies.
Some degree of reflux is physiological, meaning it happens in normal individuals, is short-lived, asymptomatic and mostly occurs after food. Pathological reflux is associated with symptoms, occurs during sleep and is associated with abnormal findings on endoscopy.
Risk factors for GERD
- Hiatus hernia
- Connective tissue disorders like scleroderma
- Conditions associated with delayed emptying of the stomach
Factors that aggravate GERD
- Drinking alcohol, coffee or carbonated drinks
- Eating large meals or late-night meals
- Eating fatty foods, mint, citrus fruits
Classical symptoms of GERD are heartburn and regurgitation. Heartburn is described as a burning sensation in the retrosternal area which is considered troublesome if mild symptoms occur two or more days a week or severe symptoms occur more than once a week. Regurgitation is flow of refluxed gastric content into the mouth which contains stomach acidic content with undigested food material. Other symptoms include chest pain, difficulty swallowing, chronic cough, foreign body sensation in the throat, change in voice and nausea. Advanced disease can lead to complications like esophageal stricture, Barrett’s esophagus which is a precursor for esophageal malignancy. Any patient with the onset of these symptoms at the age of 55-60 years or greater, low hemoglobin, associated gastrointestinal bleeding in form of blood vomiting or blood in the stool, loss of appetite, weight loss, difficulty swallowing or persistent vomiting should be evaluated further to make early diagnosis and treatment should be given accordingly.
Diagnosis can be made based on clinical symptoms in patients with classical symptoms of heartburn and regurgitation. In patients with atypical symptoms, refractory symptoms or symptoms of advanced disease further evaluation is required. Upper GI endoscopy is the initial diagnostic test that can be easily done and is a readily available OPD-based procedure in which a tube with an upfront attached camera is passed into the food pipe and stomach. Upper GI endoscopy helps in detecting the presence of esophageal ulcers or erosions, hiatus hernia, esophageal stricture, changes of Barrett’s esophagus or malignancy and biopsies can be taken in the same sitting if required. Some patients need further evaluation in form of ambulatory esophageal pH monitoring with impedance which requires placing a transnasal catheter or a wireless capsule in a distal food pipe and measuring pH during reflux episodes and correlating with symptoms. Sometimes esophageal high-resolution manometry is required to rule out underlying motility disorder. These tests also help in differentiating GERD from other diseases of food pipe like pill esophagitis, eosinophilic esophagitis, infectious esophagitis, esophageal webs and esophageal motility disorders.
Management approach depends on the frequency and severity of symptoms and endoscopy findings. Treatment consists of lifestyle and dietary changes which include small frequent meals, avoiding excessive spicy and fatty meals, avoiding lying down position for 2-3 hours after meals, elevating head end while lying down, decreasing stress and avoiding smoking, alcohol and tobacco. Use of carbonated drinks, excessive tea, coffee and chocolate is discouraged. Use of tight-fitting clothes is discouraged. Patients who are overweight or obese are advised to reduce weight and do regular exercise. Drugs like proton pump inhibitors and H2 receptor antagonists which decrease acid secretion in the stomach are useful along with other antacids. Drugs that increase gastric motility and decrease lower esophageal sphincter relaxation are useful. Patient with underlying stress and anxiety needs attention and treatment is given accordingly. Patients with recurrent symptoms need intermittent doses of these antacids for the shortest possible duration along with reinforcement of lifestyle and dietary modifications. Patients with symptoms not responding to the above-mentioned treatment or advanced disease with complications need endoscopic or surgical intervention wherein the lower esophageal sphincter is tightened to reduce the frequency and severity of acid reflux.