Gastroesophageal reux disease (GERD) is symptoms or mucosal damage that result from abnormal reux of gastric contents into

the esophagus.

GERD can be divided into three distinct categories: (1) Erosive esophagitis (2) Non-erosive reux disease (3) Barretts esophagus

(1) Erosive esophagitis occurs when the esophagus is repeatedly exposed to reuxed material for prolonged periods . The inammation that occurs progresses to erosions of the squamous epithelium.

(2) Non-erosive reux disease, also referred to as symptomatic GERD or endoscopynegative reux disease:

it is associated with severe reux symptoms with normal endoscopic ndings.

(3) Barretts esophagus is a complication of GERD characterized by replacement of the normal squamous epithelial lining of the esophagus by specialized columnar-type epithelium. - Occur in patients with a long history (years) of symptomatic reux . - Barretts esophagus is a risk factor for developing adenocarcinoma of the esophagus.

EPIDEMIOLOGY AND ETIOLOGY

- GERD is prevalent in patients of all ages.

- Mortality associated with GERD is rare.

- The true prevalence and incidence of GERD are unknown because many patients do not seek medical treatment, and there is no gold standard for diagnosing the disease. - The prevalence of erosive esophagitis increases in adults older than 40 years of age - Non-erosive reux disease may begin approximately a decade sooner.

- No major difference in incidence between men and women except for its association with pregnancy.

- Non-erosive reux disease seen more in females.

- Barretts esophagus occurs more frequently in males

Pathophysiology The retrograde movement of acid or other noxious substances from the stomach into the esophagus is a major factor in the development of GERD. - Associated with defective lower esophageal sphincter pressure or function. - Other factors: problems in esophageal clearance, mucosal resistance, gastric emptying, epidermal growth factor, and salivary buffering. - Aggressive factors that may promote esophageal damage upon reux into the esophagus include : gastric acid, pepsin, bile acids, and pancreatic enzymes.

Lower Esophageal Sphincter Pressure

- The sphincter is normally in a tonic, contracted state state, preventing the reux of gastric material from the stomach. It relaxes on swallowing to permit the free passage of food Into the stomach.
First mechanism: reux may occur after spontaneous transient lower esophageal sphincter relaxations that are not associated with swallowing, This relaxation can be caused by Esophageal distention, vomiting, belching, and retching. - Transient decrease in sphincter pressure is responsible for approximately 65% of the reux episodes in patients with GERD.

Second Mechanism: Reux may occur after transient increases in intraabdominal pressure (stress reux). such as that occurring during straining, bending over, coughing, eating, or a Valsalva maneuver. Third Mechanism: the lower esophageal sphincter may be atonic, thus permitting free reux. Although transient relaxations are more likely to occur when there is normal lower esophageal sphincter pressure.

Anatomic Factors Hiatal hernia is a primary etiology for GERD and esophagitis. Because it can disturb the lower esophageal sphincter pressure, but the reux may or may not simultaneously occur. Esophageal Clearance In GERD there are normal amounts of acid, but the acid produced spends too much time in contact with the esophageal mucosa. The esophagus is cleared by primary peristalsis in response to swallowing, or by secondary peristalsis in response to esophageal distention and gravitational effects. - Saliva contains bicarbonate that buffers the gastric material on the surface of the esophagus, to maintain a neutral intra-esophageal pH Therefore, esophageal damage due to reux occurs more often in the elderly and patients with xerostomia.

Mucosal Resistance

The esophageal mucosa and submucosa consist of mucus-secreting glands that contain bicarbonate. Bicarbonate moving from the blood to the lumen can neutralize acidic reuxate in the esophagus. When the mucosa is repeatedly exposed to the reuxate in GERD, or if there is a defect in the normal mucosal defenses, hydrogen ions diffuse into the mucosa, leading to the cellular acidication and necrosis that ultimately cause esophagitis.

Gastric Emptying Delayed gastric emptying can lead to increased gastric volume and contribute to reux. Factors that increase gastric volume and/or decrease gastric emptying, such as smoking and high-fat meals, are often associated with gastroesophageal reflux. This partially explains the prevalence of postprandial gastroesophageal reux.

Composition of Reuxate Duodenogastric reux esophagitis or alkaline esophagitis refers to esophagitis induced by the reux of bilious and pancreatic uid. Although bile acids have both a direct irritant effect on the esophageal mucosa and an indirect effect of increasing hydrogen ion permeability of the mucosa. symptoms are more often related to acid reux than to bile reux. The percentage of time that esophageal pH is below 4 is greater for patients with severe disease than for those with mild disease.

Clinical Presentation of GERD Typical Symptoms Heartburn is the hallmark symptom of GERD (a substernal sensation of warmth or burning rising up from the abdomen that may radiate to the neck). It may be waxing and waning in character. Regurgitation is also very common. Symptoms may be worse after a fatty meal, when bending over, or when lying in a recumbent position. Other symptoms include water brash (hypersalivation) and belching.

Atypical Symptoms Non-allergic asthma, chronic cough, hoarseness, pharyngitis, chest pain, and dental erosions. In some cases, these symptoms may be the only ones present, making it more difficult to recognize GERD as the cause, especially when endoscopic studies are normal. Complicated Symptoms These include continual pain, dysphagia (difficulty swallowing), odynophagia (painful swallowing), bleeding, unexplained weight loss, and choking. These symptoms may be indicative of complications of GERD such as Barretts esophagus, esophageal strictures, or esophageal cancer.

Complications of GERD
Recurrent reux symptoms that are not adequately treated may lead to Barretts esophagus and may be an independent risk factor for esophageal adeno-carcinoma. Esophageal strictures The use of non-steroidal anti-inammatory drugs or aspirin is an additional risk factor that may contribute to the development or worsening of esophageal strictures.

Esophageal stricture

Esophageal cancer

Diagnosis of GERD
Presenting symptoms and associated risk factors. Patients presenting with uncomplicated, typical symptoms of reux (heartburn and regurgitation) do not usually require invasive esophageal evaluation. Specic diagnostic tests may be warranted in patients not responding to empiric (prescription) therapy, those with complicated or alarm symptoms (e.g., weight loss or dysphagia).

Upper gastrointestinal endoscopy is the preferred diagnostic test for assessing the mucosa for esophagitis and Barretts esophagus. It enables visualization and biopsy of the esophageal mucosa. Endoscopy should be considered. The PillcamTM ESO allows for visualization of the esophagus via a camera-containing capsule that is swallowed by the patient. The entire procedure takes less than 15 minutes and can be done in the physicians office. 24-Hour ambulatory pH monitoring may be the only way to objectively prove that symptoms are reux-related in patients with atypical symptoms or non-erosive reux disease. The empiric use of a standard-dose (or double-dose) PPI as a therapeutic trial may be used in diagnosing GERD. This approach is less expensive, more convenient, and more readily available than ambulatory pH monitoring. Esophageal manometry involves placing a multi-lumen tube into the stomach. Pressures are measured as the tube is pulled back across the lower esophageal sphincter, esophagus. Barium radiography involves the ingestion of barium followed by x-rays of the esophagus. It is more cost effective than endoscopy but is no longer recommended for routine diagnosis of GERD. Barium radiography lacks the sensitivity and specicity needed to determine the presence of mucosal injury, and it cannot distinguish between Barretts esophagus and esophagitis.