Gastroesophageal reflux disease

Background

Posterior view of the position and relation of the esophagus in the cervical region and in the posterior mediastinum.

Layers of the GI track: the mucosa, submucosa, muscularis, and serosa.

Esophagus anatomy and nomenclature based on two systems.

• Abbreviation: GERD
• Definition: a highly variable chronic condition that is characterized by periodic episodes of backward flow of the gastric contents into the esophagus due to improper functioning of a sphincter at the lower end of the esophagus
  • Usually accompanied by "heartburn" symptoms and histopathologic changes in the esophagus
• Affects up to 20% of population
• Assume chest pain is cardiac origin until proven otherwise

Causes

• Decreased pressure of lower esophageal sphincter
  • High-fat food
  • Nicotine
  • Ethanol
  • Caffeine
  • Medications (mintrates, calcium-channel blockers, anticholinergics, progesterone/estrogen)
  • Pregnancy
• Decreased esophageal motility
  • Achalasia
  • Scleroderma
  • Diabetes
• Prolonged gastric emptying
  • Anticholinergics
  • Outlet obstruction
  • Diabetic gastroparesis
• High-fat food

Clinical Features

Severe tooth erosion in GERD

Typical

• Pain and discomfort with or right after meals
  • typically described as burning pain
  • often worse when lying flat
• +/-Dysphagia

Atypical

• Chest pain with features similar to ACS:
  • Exertional, associated with diaphoresis, nausea/vomiting, radiating to arm
• Asthma
• Pneumonia
• Hoarseness
• Aspiration

Pediatric

• Reflux is physiologic in infants
• Pathologic only if it causes complications, such as:
  • Failure to thrive/weight loss
  • Esophagitis
  • Respiratory disease: refractory asthma, recurrent pneumonia, apnea
  • BRUE

Differential Diagnosis

Epigastric Pain

• Gastroesophageal reflux disease (GERD)
• Peptic ulcer disease with or without perforation
  • Zollinger-Ellison syndrome
• Gastritis
• Pancreatitis
• Gallbladder disease
  • Acute cholecystitis
  • Cholangitis
  • Symptomatic cholelithiasis
  • Acalculous cholecystitis
• Myocardial Ischemia
• Splenic Infarctionenlargement/rupture/aneurysm
• Pericarditis/Myocarditis
• Aortic dissection
• Hepatitis
• Pyelonephritis
• Pneumonia
• Pyogenic liver abscess
• Fitz-Hugh-Curtis Syndrome
• Hepatomegaly due to CHF
• Bowel obstruction
• SMA syndrome
• Pulmonary embolism
• Bezoar
• Ingested foreign body

Management

Endoscopic image showing narrowing of the esophagus near the junction with the stomach, a complication of chronic gastroesophageal reflux disease that can cause dysphagia.

• Avoid GERD exacerbating agents (ETOH, caffeine, nicotine, chocolate, fatty foods)
• Sleep with head of bed elevated
• Avoid eating within 3hr of sleep
• PPI, H2 blocker, bismuth subsalicylate

Infants

• Small frequent feeds, avoid semi-supine position (e.g. carseat, carrier) right after feeds
  • medications only if significant complications

Disposition

• Home (outpatient treatment)

See Also

• Abdominal Pain