Gastroesophageal Reflux Disease

Gastroesophageal Reflux Disease

A 32-year-old man comes to the emergency department for substernal chest pain of 2 hours’ duration. He says that he sometimes gets this pain while lying in bed at night. He is otherwise free of symptoms, except for a nonproductive cough that he has had for the past month or so. His physical examination is unremarkable. His ECG is normal. He is given sublingual nitroglycerin and notes that his chest discomfort is worsened.

Pathogenesis. Gastroesophageal reflux disease, or GERD, is caused by the abnormal flow of the acid gastric contents backward from the stomach up into the esophagus. The lower esophageal sphincter (LES) is not a true anatomic sphincter; you can’t find it in a cadaver. The LES is cre- ated by the different response of the smooth muscle cells in the distal esophagus.

A number of factors can cause decreased tone or loosening of this sphincter, such as nicotine, alcohol, caffeine, peppermint, chocolate, and anticholinergics. We also know that calcium-channel blocking agents and nitrates also lower the sphincter pressure. When the tone of the LES decreases, acid is more likely to reflux backward into the esophagus, particularly when the patient is lying flat. GERD can still occur in the absence of these precipitating factors and can often simply be idiopathic in origin.

Clinical Presentation. Dyspepsia or epigastric pain can be caused by GERD, ulcer disease, pan- creatitis, gastritis, and nonulcer dyspepsia. GERD can be differentiated from the others by the presence of a sore throat; a bad, metal-like taste in the mouth; hoarseness; and cough and wheez- ing. In addition, GERD is the one most likely to be associated with pain in the substernal area.

Diagnosis. Specific diagnostic testing is not necessary when the patient’s symptoms are those described in the clinical presentation. In clear cases of epigastric pain going under the sternum and associated with a respiratory complaint or a bad taste in the mouth, therapy should be initiated immediately with antisecretory medications, such as proton-pump inhibitors (PPIs).  The most accurate diagnostic test is a 24-hour pH monitor, but this is only necessary when the patient’s presentation is equivocal in nature and the diagnosis is not clear. An electrode is placed several centimeters above the gastroesophageal junction, and a determination is made of what the average pH is in that area. Normal endoscopy does not exclude reflux disease.

Treatment. Therapy for GERD is primarily with PPIs, all of which are essentially equal in effi- cacy. Omeprazole, esomeprazole, lansoprazole, pantoprazole, and rabeprazole will all reliably increase the pH of the gastric contents to a level above 4.0. Do motility studies prior to surgery to avoid iatrogenic dysphagia.

A small number of persons, usually <5%, will not respond to PPIs and will need to undergo surgery to tighten the sphincter. Traditionally, this has been a Nissen fundoplication, which is done laparoscopically. Another method is simply placing a circular purse-string suture in the LES to tighten it