gastroesophageal reflux disease

gastroesophageal

[gas″tro-ĕ-sof″ah-je´al] pertaining to the stomach and esophagus.gastroesophageal reflux disease (GERD) any of various conditions resulting from reflux" >gastroesophageal reflux, ranging in seriousness from mild to life-threatening; principal characteristics are heartburn and regurgitation. When there is damage to the esophageal epithelium, it is known as esophagitis" >reflux esophagitis.

gastroesophageal reflux disease (GERD),

a syndrome due to structural or functional incompetence of the lower esophageal sphincter (LES), which permits retrograde flow of acidic gastric juice into the esophagus.

Although the underlying abnormality in GERD is apparently inborn and irreversible, the incidence of symptomatic disease increases with age. In addition to reflux, most cases involve disordered gastric motility and delayed gastric emptying. Symptoms include recurring epigastric and retrosternal distress, usually described as heartburn, along with varying degrees of belching, nausea, gagging, cough, or hoarseness. Almost 50% of adults in the U.S. report experiencing these symptoms at least once a month, and almost 20% experience them at least once a week. GERD is increasingly recognized as a cause of throat irritation and chronic cough. The incidence of GERD among adults with asthma may be as high as 80%. The disorder is more common in men. The likelihood of symptomatic reflux is increased by obesity, pregnancy, cigarette smoking, diabetes mellitus, scleroderma, and other connective tissue diseases. Symptoms can be induced by recumbency, strenuous exercise, heavy lifting, smoking, eating large meals, or consuming alcohol, chocolate, fatty foods, and drugs such as theophylline, calcium channel blockers, and anticholinergic agents. Acid reflux can cause peptic esophagitis, ulcer formation, esophageal stricture, or metaplastic change in esophageal squamous epithelium, called Barrett esophagus, which can progress to carcinoma. Diagnosis of GERD is by history, esophageal pH monitoring, radiologic study showing reflux of swallowed barium, and endoscopy to identify ulceration or stricture and permit biopsy to rule out malignancy. Treatment includes avoidance of known aggravating factors and administration of antacids, H₂ antagonists, prokinetic agents, and proton pump inhibitors. Surgical procedures to inhibit reflux mechanically, particularly Nissen fundoplication, can improve symptoms in severe disease but have not been shown to prevent carcinoma in patients with GERD and Barrett esophagus. Fewer than one half of patients who have had surgery remain symptom free without antisecretory medicine. Gastroesophageal reflux, with passive regurgitation of feedings, occurs in about 50% of healthy infants but seldom persists beyond 1 year of age.

gastroesophageal reflux disease

n. Abbr. GERD A chronic condition in which the lower esophageal sphincter allows gastric acids to reflux into the esophagus, causing heartburn, acid indigestion, and possible injury to the esophageal lining.

gas·tro·e·soph·a·ge·al re·flux dis·ease

(GERD) (gas'trō-ĕ-sof'ă-jē'ăl rē'flŭks di-zēz') A syndrome of chronic or recurrent epigastric or retrosternal pain, accompanied by varying degrees of belching, nausea, cough, or hoarseness, due to reflux of acid gastric juice into the lower esophagus; results from malfunction of the lower esophageal sphincter (LES) and disordered gastric motility; may lead to peptic esophagitis, ulceration, stricture, or Barrett esophagus.
Synonym(s): gastro-oesophageal reflux disease.

Gastroesophageal reflux disease (GERD)

A disorder of the lower end of the esophagus, caused by stomach acid flowing backward into the esophagus and irritating the tissues.Mentioned in: Indigestion

Gastroesophageal Reflux Disease

DRG Category:	328
Mean LOS:	3.3 days
Description:	SURGICAL: Stomach, Esophageal, and Duodenal Procedure Without CC or Major CC
DRG Category:	391
Mean LOS:	5.1 days
Description:	MEDICAL: Esophagitis, Gastroenteritis, and Miscellaneous Digestive Disorders With Major CC

Gastroesophageal reflux disease (GERD) is a syndrome caused by esophageal reflux, or the backward flow of gastroesophageal contents into the esophagus. It is a common syndrome that is experienced by up to 40% of people at some point in their lives. GERD occurs because of inappropriate relaxation of the lower esophageal sphincter (LES) in response to an unknown stimulus. Reflux occurs in most adults, but if it occurs regularly, the esophagus cannot resist the irritating effects of gastric acid and pepsin because the mucosal barrier of the esophagus breaks down. Without this protection, tissue injury, inflammation, hyperemia, and even erosion occur.

As healing occurs, the cells that replace the normal squamous cell epithelium may be more resistant to reflux but may also be a premalignant tissue that can lead to adenocarcinoma. Repeated exposure may also lead to fibrosis and scarring, which can cause esophageal stricture to occur. Stricture leads to difficulty in swallowing. Chronic reflux is often associated with hiatus hernia.

Barrett’s esophagus is a condition thought to be caused by the chronic reflux of gastric acid into the esophagus. It occurs when squamous epithelium of the esophagus is replaced by intestinal columnar epithelium, a situation that may lead to adenocarcinoma. Barrett’s esophagus is present in approximately 10% to 15% of patients with GERD.

Causes

The causes of GERD are not well understood. Many patients with GERD have normal resting LES pressure and produce normal amounts of gastric acid. Possible explanations for GERD include delays in gastric emptying, changes in LES control with aging, and obesity. Environmental and physical factors that lower tone and contractility of the LES include diet (fatty foods, peppermint, alcohol, caffeine, chocolate) and drugs (nicotine, beta-adrenergic blockers, nitrates, theophylline, anticholinergic drugs).

Genetic considerations

Family history appears to be a significant risk factor for GERD. Twin concordance has been shown to be 42% among identical twins and only 26% between nonidentical twins. Barrett’s esophagus most likely has a genetic component as well because its incidence associated with GERD is highly variable.

Gender, ethnic/racial, and life span considerations

GERD occurs at any age but is most common in people over age 50. It occurs in both men and women, and it is a common disorder that affects as much as one-third of the total population. Although white males are more at risk for Barrett’s esophagus and adenocarcinoma than other populations, no gender or racial/ethnic considerations are reported for other types of gastroesophageal reflux.

Global health considerations

While the global prevalence of GERD is unknown, heartburn is a common problem in North America and Western Europe, with approximately 7% of the population reporting daily symptoms.

Assessment

History

Elicit a history of contributing factors, including the regular consumption of fatty foods, caffeinated beverages, chocolate, nicotine, alcohol, or peppermint. Take a drug history to determine if the patient has been taking drugs that may contribute to GERD: beta-adrenergic blockers, calcium channel blockers, nitrates, theophylline, diazepam, anticholinergic drugs, estrogen, and progesterone.

Little relationship appears to occur between the severity of symptoms and the degree of esophagitis. Some patients have minimal evidence of esophagitis, whereas others with severe, chronic inflammation may have no symptoms until stricture occurs. Patients may describe the characteristic symptom of heartburn (also known as pyrosis or dyspepsia). The discomfort is often a substernal or retrosternal pain that radiates upward to the neck, jaw, or back. Patients describe a worsening pain when they bend over, strain, or lie flat. With severe inflammation, discomfort occurs after each meal and lasts for up to 2 hours. Patients may describe coughing, hoarseness, or wheezing at night.

Patients may also report regurgitation, with a sensation of warm fluid traveling upward to the throat and leaving a bitter, sour taste in the mouth. Other symptoms may include difficulty swallowing (dysphagia) and painful swallowing (odynophagia) during eating, as well as eructation, flatulence, or bloating after eating.

Physical examination

The most common symptoms are heartburn, regurgitation, and dysphagia. Generally, the patient’s physical appearance is unchanged by GERD. On rare occasions, some patients may experience unexplained weight loss.

Psychosocial

Psychosocial assessment should include assessment of the degree of stress the person experiences and the strategies she or he uses to cope with stress.

Diagnostic highlights

Test	Normal Result	Abnormality With Condition	Explanation
Esophageal pH monitoring	> 5	< 5	Presence of gastric contents in the esophagus decreases pH
Esophageal manometry	Congruent esophageal pressures bilaterally; competent LES	Abnormal contractions and peristalsis; incompetent LES; low resting pressure of LES	Multilumen esophageal catheter introduced through mouth; used to measure esophageal pressures during a variety of swallowing maneuvers

Other Tests: Esophagogastroduodenoscopy, barium esophagogram, scintigraphy, barium esophagogram, Bernstein’s test (acidic solution infused into stomach causing heartburn in patients with GERD)

Primary nursing diagnosis

Diagnosis

Pain related to esophageal reflux and esophageal inflammation

Outcomes

Comfort level; Pain control behavior; Pain level; Symptom control behavior; Symptom severity

Interventions

Medication administration; Medication management; Pain management; Positioning; Environmental management: Comfort; Nutritional monitoring; Weight management

Planning and implementation

Collaborative

Although diet therapy alone can manage symptoms in some patients, most patients can have their GERD managed pharmacologically. Dietary modifications that may decrease symptoms include reducing intake of fatty foods, caffeinated beverages, chocolate, nicotine, alcohol, and peppermint. Reducing the intake of spicy and acidic foods lets esophageal healing occur during times of acute inflammation. Encourage the patient to eat five to six small meals during the day rather than large meals. Ingestion of large amounts of food increases gastric pressure and thereby increases esophageal reflux. Both weight loss and smoking-cessation programs are also important for any patients who have problems with obesity and tobacco use.

Surgical procedures to relieve reflux are generally reserved for those otherwise healthy patients who have not responded to medications. Three major surgical procedures are used: Nissen fundoplication (surgeon wraps fundus of the stomach around esophagus to anchor the LES area below the diaphragm), Hill’s repair (anchors gastroesophageal junction to the median arcuate ligament), and Belsey’s repair (transthoracic approach with a fundic wrap around the distal esophagus).

Pharmacologic highlights

Medication or Drug Class	Dosage	Description	Rationale
Antacids	Usually 30 mL between meals and as needed PO	Aluminum or magnesium salts	Neutralize gastric acid and relieve heartburn
Proton pump inhibitors (thought to be more effective) or H2 receptor antagonists	Varies with drug; routes vary	Decrease gastric acid production; omeprazole, lansoprazole, cimetidine, ranitidine, famotidine, nizatidine	Proton pump inhibitors are the most powerful medications available; used when GERD is well documented; proton pump inhibitors block final step in the H+ ion secretion by the parietal cell, have few adverse effects, and are well tolerated
Cisapride	10–20 mg PO qid before meals and at bedtime	Gastrointestinal (GI) stimulant	Increases LES pressure and improves esophageal clearance and gastric emptying
Metoclopramide	10 mg PO tid before meals	GI stimulant	Improves gastric emptying and increases LES pressure
Sulcrafate	1 g PO qid	Antiulcer	Forms a protective adhesive gel over areas of injury or inflammation

Independent

Many patients experience nighttime reflux because of the recumbent position and infrequent swallowing. Changing the patient’s position by elevating the head of the bed during sleep may mitigate symptoms. Place 6-inch blocks under the head of the bed or place a wedge under the mattress to enhance nocturnal acid clearance. Encourage the patient to avoid food for 3 hours before going to sleep and advise the patient to eat slowly and chew food thoroughly. Encourage patients to avoid large meals.

Lifestyle modifications are important in the management of GERD. Lifestyle changes to reduce intra-abdominal pressure may be helpful to relieve symptoms. Encourage the patient to avoid the following: restrictive clothing, lifting heavy objects, straining, working in a bent-over position, and stooping. Support the patient’s efforts to stop smoking, lose weight, and reduce stress. Encourage them to avoid alcohol, chocolate, coffee, citrus fruit, and tomatoes. Make appropriate referrals to the dietitian to provide the knowledge essential for weight control.

Evidence-Based Practice and Health Policy

Jansson, C., Wallander, M.A., Johansson, S., Johnsen, R., & Hveem, K. (2010). Stressful psychosocial factors and symptoms of gastroesophageal reflux disease: A population-based study in Norway. Scandinavian Journal of Gastroenterology, 45(1), 21–29.

A population-based, cross-sectional case-control study among 3,153 individuals reporting severe GERD symptoms and 40,210 individuals without symptoms revealed significant associations between workplace experiences and symptomatology risk.
Those who reported high demands at work were twice as likely to report severe GERD compared to those who reported low demands (95% CI, 1.4 to 2.8; p < 0.001).
The individuals who reported low decisional authority were 1.4 times more likely to report severe GERD than those who reported high decision authority (95% CI, 1 to 1.9; p = 0.03).

Documentation guidelines

Discomfort: Timing, character, location, duration, precipitating factors
Nutrition: Food and fluid intake; understanding of dietary restriction and weight reduction for each meal; daily weight measurement
Medication management: Understanding drug therapy, response to medications
Response to nighttime positioning: Progress of changing position of head of the bed at night, tolerance to position change

Discharge and home healthcare guidelines

Teach the patient how to maintain adequate nutrition and hydration and to manage medications. Make sure the patient and family understand all aspects of the treatment regimen. Review dietary limitations, recommendations to reduce weight and cut out tobacco, and dosage and side effects of all medications. Make sure the patient understands the need to change position at nighttime and that he or she has the supplies required to do so.

gas·tro·e·soph·a·ge·al re·flux dis·ease

(GERD) (gas'trō-ĕ-sof'ǎ-jē'-ăl rē'flŭks di-zēz') A syndrome of chronic or recurrent epigastric or retrosternal pain, accompanied by varying degrees of belching, nausea, cough, or hoarseness, due to reflux of acid gastric juice into the lower esophagus; results from malfunction of the lower esophageal sphincter (LES) and disordered gastric motility.
Synonym(s): gastro-oesophageal reflux disease.

Patient discussion about gastroesophageal reflux disease

Q. Baby with Gastro esophageal Reflux... I have a baby with Gastro esophageal Reflux Disease, should I worry that she will have autism? I want to clarify my doubt to be more overcautious. Kindly guide me!

Q. how do you deal with a mild case of acid reflux A. You can start with life style changes: if you have symptoms during the night, you can try to elevate the head of your bed. You can try to avoid foods that induce reflux: fatty foods, chocolate, peppermint, and excessive alcohol. Cola, red wine, and orange juice are very acidic, so it would be wise to avoid them too, In addition to these, you can try to use a diary to reveal which kind of food causes symptoms and avoid it.
Try to refrain from lying down immediately after a meal, or eating just before bedtime. Overweight is a risk factor for reflux, so if it's relevant weight reduction is also recommended.
If you feel heartburn, you may chew in order to increase salivation and thus alleviate the symptoms. Smoking has a negative effect on salivation, so smoking cessation is also recommended.
And that's before we even mentioned OTC drugs...

Q. is there anything to cure G.E.R.D. instead of taking pills daily? A. there is no known way to "cure" but it can be manageable. there's a somewhat new procedure -An endoscope. Using this scope, doctors can treat the lower part of the esophagus to improve how it works. These nonsurgical procedures are somewhat new. There is not enough scientific evidence yet to talk about how well they work.
here is a nice tutorial about it:
http://www.nlm.nih.gov/medlineplus/tutorials/uppergiendoscopy/htm/lesson.htm
and of course you can avoid some types of food and habits (sorry...long and tasty list...):
http://heartburn.about.com/cs/dietfood/a/heartburnfoods3.htm

More discussions about gastroesophageal reflux disease