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Gastroesophageal Reflux Disease, Complications of GERD and Barrett’s oesophagus

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Gastroesophageal Reflux Disease (GERD) is a chronic digestive condition where stomach acid or bile frequently flows back into the esophagus, irritating its lining. This reflux occurs due to a weakened or dysfunctional lower esophageal sphincter (LES), the muscle that normally prevents stomach contents from moving upward.

Gastroesophageal Reflux Disease

Symptoms or complications resulting from the reflux of gastric contents into the esophagus or beyond, into the oral cavity (including larynx) or lung.” The acidic nature of the refluxed gastric contents (and pepsin) is predominantly responsible for the esophageal mucosal damage and development of reflux oesophagitis. However, the presence of bile in reflux contents is increasingly thought to contribute to reflux disease in a subset of cases (Bile refluxate contains bile acids and trypsin).

Phenotypic presentations of GERD

  1. Erosive esophagitis (EE),
  2. Non erosive reflux disease (NERD).
  3. Barrett’s esophagus.

Physiologic Vs Pathologic GERD

  • Physiologic GERD: Postprandial, Asymptomatic, short-lived episodes of reflux, and No nocturnal symptoms.
  • Pathologic GERD: Occurs at any time, symptomatic, Mucosal injury, and nocturnal symptoms.
Gastroesophageal Reflux Disease

Gastroesophageal Reflux Disease

Epidemiology:

frequency of GERD symptoms in US adult population:

  • 44% have heartburn at least once a month.
  • 14% of Americans have symptoms weekly.
  • 7% of Americans have symptoms daily.

The majority of patients with GERD don’t seek medical attention.

Important Reasons to Diagnose and Treat GERD

  • Negative impact on health-related quality of life.
  • Risk factor for esophageal adenocarcinoma.

Anti-Reflux system

1. Clearance mechanism:

  • Chemical: Swallowed saliva (Lubrication and neutralization).
  • Mechanical: antegrade oesophageal peristalsis.

2. Mucosal integrity: mucosal rosette (prominent mucosal folds at gastro-oesophageal junction.

3. Lower oesophageal sphincter (LOS) competence.

  • Intrinsic LOS pressure.
  • total length of LOS.
  • intra-abdominal length of LOS.

4. Normal gastric motility/emptying.

5. Other:

  • Angle of His (‘Nap valve mechanism).
  • Crural fibres of the diaphragm (pinchcock’ action) mainly the right crus.
  • Phrenoesophogeal ligament.

Etiology and pathophysiology of GERD

Symptomatic reflux occurs when these anti-reflux mechanisms become impaired.

1. Primary causes

1. Poor/abnormal LES function

  • Decreased LES pressure.
  • Decreased total LES length (<2-3 cm).
  • Decreased intra-abdominal LES length(<1-2 cm).

2. Transient LES relaxations (Factors relaxing the LES)

  • Food: Citrus fruits, chocolate, drinks with caffeine, fatty and fried foods, garlic, onions, menthol, spicy foods, tomato-based foods, and sauce.
  • Pregnancy.
  • Drugs such as oral contraceptive pills (OCP).
  • Smoking and Obesity.

3. Loss of angle of His

4. large para oesophageal hernia (eg Sliding hiatus hernia) can cause slowed emptying due to obstruction or altered motility.

5. Diaphragmatic crural defect.

6. Loss of mucosal rosette (e.g. due to inflammation).

2. Secondary causes

1. Poor oesophageal clearance

  1. Poor esophageal motility: common in the elderly population, or pts with achalasia, stroke, or collagen disease as scleroderma.
  2. Decreased saliva production.

2. factors related to stomach

  1. Excess gastric acid production
  2. delayed gastric emptying: due to anatomic obstruction of gastric outlet as in pyloric stenosis or due to neuromuscular dysfunction as in gastroparesis elderly or diabetic.
  3. Excess duodeno-gastric reflux.

Clinical Presentations of GERD:

1. Classic GERD symptoms

Heartburn (pyrosis): retro-sternal burning discomfort (Postprandial, aggravated by a change in position “when lying down or bending over” and Prompt relief by antacids.

Regurgitation: the effortless return of gastric contents (bitter, acidic fluid) into the pharynx when lying down or bending over without nausea, retching, or abdominal contraction, unlike vomiting which is an active process associated with abdominal contraction.

2. Extraesophageal (Atypical) manifestations of GERD

1. Pulmonary: Asthma, aspiration pneumonia, chronic bronchitis, and pulmonary fibrosis.

2. ENT:

1. Laryngopharyngeal manifestations

  • Laryngitis (Edema & hyperemia of the larynx) and pharyngitis.
  • Vocal cord erythema, polyps, granulomas, and ulcers.
  • Hyperemia and lymphoid hyperplasia of the posterior pharynx.
  • Interarytenyoid changes and subglottic stenosis.
  • Laryngeal cancer.

2. Sinusitis

3. Chronic cough and globus sensation.

4. Hoarseness and Dysphonia

3. other: Chest pain and dental erosion

Complicated GERD:

Symptoms of Complicated GERD:

  1. ‎Dysphagia: difficulty swallowing: food sticks or hangs up‬‎.
  2. Odynophagia retrosternal pain with swallowing.
  3. Bleeding (rare): melena, hematemesis or occult leading to anemia.

Complications of GERD

  • Erosive/ulcerative esophagitis.
  • Motility disorder of the oesophagus.
  • Esophageal (peptic) stricture.
  • Shortening of oesophagus →sliding HH.
  • Barrett’s esophagus.
  • Adenocarcinoma.

Barrett’s oesophagus:

  • Replacement of the normal squamous epithelium of the lower oesophagus by metaplastic columnar epithelium due to long-standing reflux (then dysplasia).‎
  • Premalignant (10% risk of adenocarcinoma).
  • For diagnosis, intestinal metaplasia must be identified histologically (goblet cells).
  • Treatment is a combination of acid suppression and lifelong endoscopic surveillance. Anti-reflux surgery may have a role.

Benign (Peptic) Strictures:

  • These occur in inadequately treated patients.
  • They present with dysphagia and endoscopy is essential to exclude malignancy.
  • Treatment is by endoscopic dilatation followed by either long-term proton-pump inhibitors (PPI) or anti-reflux surgery to prevent recurrence.

Differential Diagnosis

  • Gallstones
  • Gastric lesion: gastritis, peptic ulcer, cancer stomach.
  • Oesophageal lesion: Achalasia, cancer, stricture.
  • Coronary heart disease.

Diagnostic Evaluation

If classic symptoms of heartburn and regurgitation exist in the absence of alarm symptoms the diagnosis of GERD can be made clinically and treatment can be initiated.

Alarm Signs/Symptoms

  • Dysphagia.
  • Odynophagia.
  • GI bleeding.
  • Iron deficiency anemia.
  • Early satiety.
  • Vomiting.
  • Weight loss.

When to Perform Diagnostic Tests

  • Uncertain diagnosis.
  • Atypical symptoms.
  • Symptoms associated with complications.
  • Inadequate response to therapy.
  • Recurrent symptoms Prior to anti-reflux surgery.

Diagnostic Tests for GERD

  • Barium swallow.
  • Endoscopy.
  • Ambulatory pH monitoring.
  • Esophageal manometry.

Barium Swallow

Limitations

Detailed mucosal exam for erosive esophagitis, Barrett’s esophagus.

Useful first diagnostic test for patients with dysphagia

  • Stricture (location, length).
  • Mass (location, length).
  • Bird’s beak.
  • Hiatal hernia (size, type).
  • Short oesophagus.

Endoscopy

Indications for endoscopy

  • Alarm symptoms.
  • Empiric therapy failure.
  • Preoperative evaluation.

Detection of Barrett’s esophagus

Endoscopic examination

  • Endoscopic examination of the upper GIT is the mainstay investigation for GERD, allowing direct visualization of the lining of the oesophagus and stomach.
  • Biopsies can be taken from the mucosa to facilitate histological examination of the tissues.

The endoscopic findings in GERD

Range from normal to erosions and ulcerations Based on the presence or absence of mucosal changes, GERD is classified into 2 groups:

  • Nonerosive reflux disease (NERD), and
  • Erosive oesophagitis is a mucosal break “An area of slough or erythema with a sharp line of demarcation from adjacent normal mucosa”.

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