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Gastroesophageal reflux disease (GERD) causes,diagnosis and treatment

Definition of GERD :

 Reflux of gastric contents into the esophagus which allows prolonged contact of these contents with the lower esophageal mucosa. It is the most common disorder of the esophagus.

Causes and Pathogenesis of GERD 

(failure of antireflux mechanisms)
1. The resting lower esophageal sphincter (LOS) is low and fails to increase when lying flat .
2. Decrease esophageal clearance of acid due to poor esophageal peristalsis.
3. Delayed gastric emptying.
4. Hiatus hernia may impair the pinchcock mechanism of the diaphragm.
5. The lower esophageal sphincter tone fails to increase when intra abdominal pressure is increased by tight clothes or pregnancy .

Factors associated with increased reflux :

- Obesity                 - Fat, peppermint
- Pregnancy             - Chocolate
- Coffee (Caffeine)  - Smoking
- Anticholinergics    - Ca channel blockers
- Nitrates                   - Hiatus hernia

How to diagnose GERD ?

a. Clinical Picture :
1. Heart burn: It is the most cardinal symptom of GERD, it is due to direct stimulation of the hypersensitive esophageal mucosa.

2. Chest pain: similar to angina (due to reflux or esophageal spasm).

3. Odynophagia: (painful swallowing).
4. Dysphagia: due to disturbed motility or structure.

5. GIT bleeding, Iron deficiency anaemia (esophagitis).
6. Pulmonary: cough, aspiration pneumonia may occur.

b. Investigations :
GERD is a clinical diagnosis and many patients can be treated without investigations .
- Endoscopy. to confirm the presence of esophagitis.
- 24 hour intra-luminal pH monitoring of the esophagus.
- Esophageal manometry.
- Barium study: It may show a hiatus hernia.

Complications of GERD :

1. Stricture of esophagus.
2. Esophageal ulceration.
3. Barrett's esophagus: columnar metaplasia of the lower esophagus.It is a premalignant leading to adenocarcinoma.
4. Reflux induced laryngitis.

Treatment of Gastro-Esophageal reflux disease (GERD)

I. Simple Lifestyle measures :

50% of patients can be treated by:
- Cessation of smoking, loss of weight and simple antacids.
- Avoid alcohol, fatty meals & drugs e.g. nitrates.
- Avoid heavy meals especially before sleep.
- Raising the head of the bed at night.
- Avoid any other precipitating factor.

II. Pharmacological therapy 

1. Drugs that reduce gastric acidity :
Prolonged therapy is usually needed .
- Antacids: Mg trisilicate and aluminium hydroxide, also alginate containing antacids forming a gel with gastric contents reducing reflux.
- H2 blockers: Ranitidine (Zantac (300mg at bed time) .
- Proton pump inhibitors: Omeprazole (20-40mg/day),Lanzoprazole (30mg/day) or pantoprazole (20- 40mg/day). They inhibit the gastric hydrogen-potassium ATPase .

2. Drugs that increase esophageal peristalsis and LOS pressure ( Prokinetic) :
- Cisapride (Prepulsid): not available now!? It leads to arrythmia.
- Metoclopramide or Domperidone.

III. Surgery :

Nissen fundoplication (antireflux surgery) is performed laparoscopically
for severe cases with repair of hernia if present. The gastric fundus is warraped around the abdominal oesophagus.


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