Gastroesophageal Reflux Disease - Disorders of the Esophagus

GASTROESOPHAGEAL REFLUX DISEASE

Some degree of gastroesophageal reflux (back-flow of gastric or duodenal contents into the esophagus) is normal in both adults and children. Excessive reflux may occur because of an incompetent lower esophageal sphincter, pyloric stenosis, or a motility disorder. The incidence of reflux seems to increase with aging.

Clinical Manifestations

Symptoms of gastroesophageal reflux disease (GERD) may include pyrosis (burning sensation in the esophagus), dyspepsia (indiges-tion), regurgitation, dysphagia or odynophagia (difficulty swal-lowing, pain on swallowing), hypersalivation, and esophagitis. The symptoms may mimic those of a heart attack. The patient’s history aids in obtaining an accurate diagnosis.

Assessment and Diagnostic Findings

Diagnostic testing may include an endoscopy or barium swallow to evaluate damage to the esophageal mucosa. Ambulatory 12- to 36-hour esophageal pH monitoring is used to evaluate the degree of acid reflux. Bilirubin monitoring (Bilitec) is used to measure bile reflux patterns. Exposure to bile can cause mucosal damage (Aronson, 2000; Stein et al., 1999).

Management

Management begins with teaching the patient to avoid situations that decrease lower esophageal sphincter pressure or cause esophageal irritation. The patient is instructed to eat a low-fat diet; to avoid caffeine, tobacco, beer, milk, foods containing peppermint or spearmint, and carbonated beverages; to avoid eating or drink-ing 2 hours before bedtime; to maintain normal body weight; to avoid tight-fitting clothes; to elevate the head of the bed on 6- to 8-inch (15- to 20-cm) blocks; and to elevate the upper body on pil-lows. If reflux persists, the patient may be given medications such as antacids or histamine receptor blockers. Proton pump inhibitors (medications that decrease the release of gastric acid, such as lanso-prazole [Prevacid] or rabeprazole [Aciphex]) may be used; however, there is concern that these products may increase intragastric bac-terial growth and the risk for infection. In addition, the patient may receive prokinetic agents, which accelerate gastric emptying. These agents include bethanechol (Urecholine), domperidone (Motil-ium), and metoclopramide (Reglan). Metoclopramide has central nervous system complications with long-term use. The use of pectin-based products is now being studied (Aronson, 2000).

If medical management is unsuccessful, surgical intervention may be necessary. Surgical management involves a fundoplica-tion (wrapping of a portion of the gastric fundus around the sphincter area of the esophagus). Fundoplication may be per-formed by laparoscopy.