Gastroesophageal reflux disease (GERD)
The esophagus is about 27cm in length, is hollow, with mucosa, submucosa and muscularis layers, but without a serosal layer. Mucosa is stratified squamous that transitions to columnar epithelium at gastroesophageal junction. The upper ⅓ is skeletal muscle, the lower ⅔ is smooth muscle. Within the layers of muscle is the myenteric plexus.
Gastroesophageal reflux disease develops when the reflux of the stomach contents into the esophagus causes complications. The lower esophageal sphincter usually prevents reflux, however disruption to this can cause GERD. Reflux can occur in normal individuals, in such cases the gastric contents are cleared by peristaltic functioning neutralization thanks to saliva. This reflux (in healthy individuals) usually occurs in the absence of a swallow because of a vagally mediated reflux. In GERD patients, transient relaxation of the lower esophageal sphincter, or a low resting sphincter pressure causes the regurgitation.
Image: “GastroEsophageal Reflux Disease (GERD)” by BruceBlaus, CC BY-SA 4.0, via Wikimedia Commons.
A hiatal hernia increases risks of GERD as it means the effects of the diaphragm on closing the sphincter are lessened. Similarly, those with an unbuffered acid pocket in the gastric cardia (that escape the meal) can be the source of postprandial reflux. Signs and symptoms of GERD occur when defective epithelium comes into contact with regurgitated acid.
Classic symptoms are heartburn and acid regurgitation with chest pain, dysphagia and odynophagia. Additionally, we can see cough, laryngitis, asthma and dental erosion.
When symptoms are alleviated thanks to treatment (such as (antisecretory therapy) no additional evaluation is needed. An endoscopy is only required if the individual fails to respond within a month, or if additional symptoms such as anemia are present. Endoscopy is also valuable in detection of Barrett’s esophagus (below).
Treatment
- Certain foods may provoke symptoms (e.g. alcohol, coffee, spicy food, late meals), at first step, avoid these
- There is a close relationship between weight and GERD, so weightloss is also a good form of treatment
- Inhibition of gastric secretion is the cornerstone of pharmaceutical treatment
- Proton pump inhibitors
- Omeprazole, lansoprazole, rabeprazole, pantoprazole
- Take before breakfast once per day
- Note - Omeprazole + H.pylori = increased risk of atrophic gastritis
- H2-antagonists can be added in severe cases
- Cimetidine, Ranitidine (withdrawn in 2020), Famotidine, Nizatidine
Little people can suffer Gastroesophageal reflux (GOR), the uncontrolled passage of gastric contents into the esophagus. It is common in healthy infants and even more common in premature ones!