Gastroesophageal reflux disease(GERD)

Gastroesophageal reflux disease (American English and Canadian English) or Gastro-oesophageal reflux disease (British English, Hiberno-English, Australian English, New Zealand English, South African English) and abbreviated to either GERD or GORD is defined as chronic symptoms or mucosal damage produced by the abnormal reflux in the esophagus.

This is commonly due to transient or permanent changes in the barrier between the esophagus and the stomach. This can be due to incompetence of the cardia, transient cardia relaxation, impaired expulsion of gastric reflux from the esophagus, or a hiatus hernia.



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Symptoms
Adults

Heartburn is the major symptom of acid in the esophagus, characterized by burning discomfort behind the breastbone (sternum). Findings in GERD include esophagitis (reflux esophagitis) — inflammatory changes in the esophageal lining (mucosa) —, strictures, difficulty swallowing (dysphagia), and chronic chest pain. Patients may have only one of those symptoms. Typical GERD symptoms include cough, hoarseness, voice changes, chronic ear ache, burning chest pains, nausea or sinusitis. GERD complications include stricture formation, Barrett's esophagus, esophageal spasms, esophageal ulcers, and possibly even lead to esophageal cancer, especially in adults over 60 years old.

Occasional heartburn is common but does not necessarily mean one has GERD. Patients with heartburn symptoms more than once a week are at risk of developing GERD. A hiatal hernia is usually asymptomatic, but the presence of a hiatal hernia is a risk factor for developing GERD.

Children

GERD may be difficult to detect in infants and children. Symptoms may vary from typical adult symptoms. GERD in children may cause repeated vomiting, effortless spitting up, coughing, and other respiratory problems. Inconsolable crying, failure to gain adequate weight, refusing food, bad breath, and belching or burping are also common. Children may have one symptom or many — no single symptom is universal in all children with GERD.

It is estimated that of the approximately 4 million babies born in the U.S. each year, up to 35% of them may have difficulties with reflux in the first few months of their life. Most of those children will outgrow their reflux by their first birthday. However, a small but significant number of them will not outgrow the condition.

Babies' immature digestive systems are usually the cause, and most infants stop having acid reflux by the time they reach their first birthday. Some children do not outgrow acid reflux, however, and continue to have it into their teen years. Children who have had heartburn that does not seem to go away, or any other GERD symptoms for a while, should talk to their parents and visit their doctor.


Diagnosis
A detailed history taking is vital to the diagnosis. Useful investigations may include barium swallow X-rays, esophageal manometry, 24-hour esophageal pH monitoring and Esophagogastroduodenoscopy (EGD). In general, an EGD is done when the patient does not respond well to treatment, or has alarm symptoms including: dysphagia, anemia, blood in the stool (detected chemically), wheezing, weight loss, or voice changes. Some physicians advocate once-in-a-lifetime endoscopy for patients with longstanding GERD, to evaluate the possible presence of Barrett's esophagus, a precursor lesion for esophageal adenocarcinoma.

Esophagogastroduodenoscopy (EGD) (a form of endoscopy) involves insertion of a thin scope through the mouth and throat into the esophagus and stomach (often while the patient is sedated) in order to assess the internal surfaces of the esophagus, stomach, and duodenum.

Biopsies can be performed during gastroscopy and these may show:

  • Edema and basal hyperplasia (non-specific inflammatory changes)
  • Lymphocytic inflammation (non-specific)
  • Neutrophilic inflammation (usually due to reflux or Helicobacter gastritis)
  • Eosinophilic inflammation (usually due to reflux)
  • Goblet cell intestinal metaplasia or Barretts esophagus.
  • Elongation of the papillae
  • Thinning of the squamous cell layer
  • Dysplasia or pre-cancer.
  • Carcinoma.

Reflux changes may be non-erosive in nature, leading to the entity non-erosive reflux disease.

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