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Gastro-esophageal reflux disease (GERO)

 


Gastro-esophageal reflux disease(GERO) 

Overview GE reflux is generally a result of transient relaxation of the lower esophageal sphincter (LES). The transient relaxation is a vagally mediated reflex, which is the physiologic mechanism of belching. Transient relaxations occur at increased frequency with gastric distension and in the upright position. Hiatal hernia is risk factor for factor for GERD. LES pressure is increased by motilin, acetylcholine, and possibly gastrin. Therefore, drugs that increase these mediators tend to decrease reflux. LES pressure is decreased by progesterone (pregnancy increases GE reflux), chocolate, smoking, and some medications, especially those with anticholinergic properties. 

Suspect GE reflux disease (GERD) in patients with a persistent, nonproductive cough, especially with hoarseness, continual clearing of the throat, and a feeling of fullness in the throat. This cough is commonly worse at night when the patient is supine. 

Most non-cardiac chest pains (70%) are caused by GERD! Most other GI-related chest pains are due to motility disorders. Note: These pains are not necessarily associated with pyrosis (heartburn) or dysphagia.

Extraesophageal manifestations of GERD: 

  • Nocturnal cough 
  • Frequent sore throat 
  • Hoarseness, laryngitis, 
  • Loss of dental enamel 
  • Exacerbation of asthma 
  • VCD (vocal cord dysfunction)
GERD is associated with two respiratory disorders: asthma and VCD. Some asthma patients, even without symptoms of GERD, have improvement of their asthma symptoms with GERD treatment. In the workup of GERD, always ask about asthma symptoms-especially those occurring at night. Note: A recent study showed that treatment of asymptomatic GERD in patients with severe asthma did not improve asthma control.

Do not assume asthma is the culprit in patients who complain of nocturnal symptoms. VCD is spasm of the vocal cords with associated inspiratory stridor. Patients will tell you that they are wheezing at night and may not really know if it is inspiratory or expiratory. Pulmonary function testing may be necessary to help distinguish vocal cord dysfunction from asthma. VCD is not always due to GERO; it is more typically seen in young adults who engage in competitive sports and is thought to be a stress reaction. About I 0% of exercise-induced "asthma" is now thought to be misdiagnosed VCD.

Increased body mass index (BMI) is associated with increased incidence of both GERO and asthma. Complications: esophageal ulcers, stricture, bleeding, and Barrett esophagus.

Diagnosis of GERO 
If the patient has only the classic symptoms of heartburn without alarm signals, the diagnostic workup starts with a therapeutic trial of PPis-EGD is indicated only if this trial fails.
Alarm signals in GERO indicating the need for EGO: 
  1. Nausea/Emesis 
  2. Blood in the stool 
  3. Family history of PUD 
  4. Weight loss 
  5. Anorexia 
  6. Iron deficiency anemia 
  7. Abnormal physical exam 
  8. Long duration of frequent symptoms, especially in Caucasian males > 50 years old 
  9. Failure to respond to full doses of a PP! 
  10. Dysphagia/Odynophagia 

EGO also is done if you suspect Barrett esophagus. 
If the patient has obstructive symptoms, you can do a barium swallow before endoscopy. 

Note: 62% of patients with GERO symptoms have a normal esophagus. This is termed nonerosive reflux disease or NERD!.

Treatment 
General measures. Many patients with reflux symptoms (∼50%) can be treated successfully with simple antacids, loss of weight, and raising the end of the bed at night. Precipitating factors should be avoided, and chocolate consumption and cessation of smoking. These measures are simple to say yet difficult to carry out, but are useful in mild cases. Medication that potentiates reflux, e.g. antimuscarinics, calcium channel blockers and bisphosphonates, should be stopped if possible.

 

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