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| Gastroesophageal Reflux Disease |
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| Definition |
Is defined as chronic symptoms or mucosal damage
produced by the abnormal reflux of gastric contents
into 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
lower esophageal sphincter (LES), transient LES
relaxation, impaired expulsion of gastric reflux
from the esophagus, or association with a hiatal
hernia.
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Symptoms |
Adults
a.Heartburn ( burning discomfort behind the
breastbone (sternum)).
b.Esophagitis (reflux esophagitis) (nflammatory
changes in the esophageal lining (mucosa) )
c.Difficulty swallowing (dysphagia), and chronic
chest pain.
Atypical symptoms of GERD include
cough, hoarseness,
changes of the voice, chronic ear ache, acute sharp
chest pains, or
sinusitis.
Children
GERD in children may cause repeated vomiting,
effortless spitting up, coughing, and other
respiratory problems. Inconsolable crying, failure
to gain adequate weight, refusing food and bad
breath are also common. Children may have one
symptom or many — no single symptom is universally
present in all children with GERD.It is it estimated
that of the approximately 8 million babies born in
the U.S. each year, upwards of 35% of them may have
difficulties with reflux in the first few months of
their life. A majority 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.
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| 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
changes in the voice. Some physicians advocate once
in a lifetime endoscopy for patients with
longstanding GERD, to evaluate for the presence of
Barrett's esophagus, a precursor lesion for
esophageal adenocarcinoma.Esophagogastroduodenoscopy
(EGD) (a form of endoscopy) involves the 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 surface
of the esophagus, stomach and duodenum.
►Biopsies can be performed during gastroscopy and
these may show
Edema and basal hyperplasia (non-specific
inflammatory changes)
►Neutrophilic inflammation (usually either reflux or
Helicobacter gastritis)
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►Lymphocytic inflammation (non-specific) |
►Elongation of the papillae
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►Eosinophilic inflammation (usually due to reflux) |
►Thinning of the squamous cell layer
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►Dysplasia or
pre-cancer |
►Carcinoma |
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►Goblet cell intestinal
metaplasia or Barretts esophagus |
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| Pathophysiology |
Having GERD indicates
incompetence of the lower esophageal sphincter.
Increased acidity or production of gastric acid can
contribute to the problem, as can obesity,
tight-fitting clothes and pregnancy. It is also
thought that yeast infections of the digestive tract
can cause GERD-like symptoms.Another paradoxical
cause of GERD-like symptoms is not enough stomach
acid (hypochlorhydria). The valve that empties the
stomach into the intestines is triggered by acidity.
If there is not enough acid, this valve does not
open and the stomach contents are churned up into
the esophagus. There is still enough acidity to
cause irritation to the esophagus.
Factors that can contribute to GERD areHiatus
hernia, which increases the likelihood of GERD due
to mechanical and motility factors.
Zollinger-Ellison syndrome, which can be present
with increased gastric acidity due to gastrin
production.
Hypercalcemia, which can increase gastrin
production, leading to increased acidity.
Scleroderma and systemic sclerosis, which can
feature esophageal dysmotility.
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| Treatment |
| The rubric "lifestyle
modifications" is the term physicians use when
recommending non-pharmaceutical treatments for GERD.
A 2006 review suggested that evidence for most
dietary interventions is anecdotal; only weight loss
and elevating the head of the bed .
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| Foods |
Certain foods and
lifestyle are considered to promote gastroesophageal
reflux:
►Coffee, alcohol, calcium supplements, and excessive
amounts of Vitamin C supplements are stimulants of
gastric acid secretion. Taking these before bedtime
especially can promote evening reflux. Calcium
containing antacids are in this group.
►Foods high in fats and smoking reduce lower
esophageal sphincter competence, so avoiding these
tends to help, as well. Fat also delays emptying of
the stomach.
►Having more but smaller meals also reduces the risk
of GERD, as it means there is less food in the
stomach at any one time.
So;Avoid:
| ►Eating for 2 hours before bedtime |
►Soft drinks that contain caffeine
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| ►Chocolate and peppermint
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►Spicy foods
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| ►Acidic foods like oranges and tomatoes(okay
when fresh.) |
►Cruciferous vegetables: onions, cabbage,
cauliflower, broccoli, Brussel sprouts
milk and milk-based products contain calcium and
fat, so should be avoided before bedtime. |
| ►Food for 2 hours before bedtime and not
lying down after a meal are frequently recommended
lifestyle modifications. |
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| Positional therapy |
"Positional
therapy":
Elevation to the head
of the bed is the next-easiest to implement. If one
implements pharmacologic therapy in combination with
food avoidance before bedtime and elevation of the
head of the bed over 95% of patients will have
complete relief. Additional conservative measures
can be considered if there is incomplete relief.
Another approach is to advise all conservative
measures to maximize response.
Elevating the head of the bed can be accomplished by
using blocks as noted above or with other items:
plastic or wooden bed risers which support bed posts
or legs, a bed wedge pillow, or an inflatable
mattress lifter that fits in between mattress and
box spring. The height of the elevation is critical
and must be at a minimum of 6 to 8 inches (15 to 20
cm) in order to be at least minimally effective in
hindering the backflow of gastric fluids. It should
be noted that some innerspring mattresses do not
work well when inclined and tend to cause back pain
thus foam based mattresses are to be preferred.
Moreover, some use higher degrees of incline than
provided by the commonly suggested 6 to 8 inches (15
to 20 cm) and claim greater success.
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| Drug treatment |
A number of drugs are
registered for the treatment of GERD, and they are
among the most-often-prescribed forms of medication
in most Western countries. They can be used in
combination with other drugs, although some antacids
can impede the function of other medications:
Antacids before meals or symptomatically after
symptoms begin can reduce gastric acidity (increase
the pH). Alginic acid may coat the mucosa as well as
increase the pH and decrease reflux.
Gastric H2 receptor blockers such as ranitidine e.g.
Ranitak or
famotidine e.g.
Famotak can reduce gastric secretion of acid.
These drugs are technically antihistamines. They
relieve complaints in about 50% of all GERD
patients.
Proton pump inhibitors such as omeprazole e.g.
Omepak are the
most effective in reducing gastric acid secretion,
as they stop the secretion of acid at the source of
acid production, i.e. the proton pump. To maximize
effectiveness of this medication the drug should be
taken a half hour before meals.
Prokinetics strengthen the LES and speed up gastric
emptying. Cisapride, a member of this class, was
withdrawn from the market for causing Long QT
syndrome.
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| Surgical treatment |
The standard surgical
treatment, sometimes preferred over longtime use of
medication, is the Nissen fundoplication. The upper
part of the stomach is wrapped around the LES to
strengthen the sphincter and prevent acid reflux and
to repair a hiatal hernia. The procedure is often
done laparoscopically.
An obsolete treatment is vagotomy ("highly selective
vagotomy"), the surgical removal of vagus nerve
branches that innervate the stomach lining. This
treatment has been largely replaced by medication.
Other treatments:
In 2000, the U.S. Food and Drug Administration (FDA)
approved two endoscopic devices to treat chronic
heartburn. One system, Endocinch, puts stitches in
the LES to create little pleats that help strengthen
the muscle. Another, the Stretta Procedure, uses
electrodes to apply radio frequency energy to the
LES. The long term outcomes of both procedures
compared to a Nissen fundoplication are still being
determined.
Subsequently the NDO Surgical Plicator was FDA
cleared for the endoscopic treatment of GERD. The
Plicator creates a plication, or fold, of tissue
near the gastroesophageal junction, and fixates the
plication with a suture-based implant. The Plicator
is currently marketed by NDO Surgical, Inc. Another
treatment which involved injection of a solution
that is injected during endoscopy into the lower
esophageal wall was available for approximately one
year ending in late 2005. It was marketed under the
name Enteryx. It was removed from the market due to
several reports of complications from misplaced
injections.
Retrieved from "http://en.wikipedia.org/
http://www.barrettsinfo.com
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