Managing Gastroesophageal Reflux Disease
Anne P.Y. Ch'ien
Janet Secrest
Rebekah S. Corey
Sherry W. Ray
http://www.nursingcenter.com/library...icle_ID=270877


The Nurse Practitioner: The American Journal of Primary Health Care
May 2002
Volume 27 Number 5
Pages 36 - 53





Abstract

A common condition, gastroesophageal reflux disease (GERD) involves the reflux of gastric contents into the esophagus. GERD may contribute to asthma, noncardiac chest pain, and other problems. This article presents trends in GERD management, including pathophysiology, diagnosis, and treatment. The authors also explore lifestyle modifications, pharmacologic therapy, and gastroenterology referral.



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Many people with gastroesophageal reflux disease (GERD) believe erroneously that their heartburn is an unavoidable inconvenience of eating certain foods. Because of symptom prevalence, patients often don't report symptoms to clinicians. Using lifestyle modifications and pharmacologic therapy, you can improve GERD patients' quality of life and reduce the prevalence of serious complications.

GERD presents a collection of unpleasant clinical symptoms and histologic alterations resulting from the chronic, excessive backflow of gastric contents (refluxate) into the esophagus. Among other manifestations, GERD may cause frequent or daily heartburn and esophageal injury. 1

With heartburn and regurgitation as its cardinal symptoms, this common ailment affects both health and quality of life. Some suggest that GERD may impair quality of life more than untreated hypertension, duodenal ulcers, or mild heart failure. 1 , 2

GERD has several physical and psychosocial consequences. Because stress and certain foods may exacerbate discomfort, some patients may avoid social situations involving meals or high levels of stress. 3 Because GERD causes increased discomfort when a patient is supine, it also can result in altered rest and sleep patterns.

Besides these quality-of-life issues, inadequately treated reflux can lead to serious complications. Barrett's esophagus, for instance, occurs when chronic acid exposure causes the squamous epithelial lining to be replaced by metaplastic columnar epithelium, a precursor to adenocarcinoma of the esophagus. 1 , 2 , 4 Once Barrett's esophagus develops, the usual treatment modalities for GERD may not prevent progression to cancer. 2

Although clinicians seldom associate GERD with mortality, GERD sufferers have an increased rate of esophageal ulcers and stricture formation. 1 , 2 Additionally, when surrounding tissues are chronically exposed to refluxate, extraesophageal injury can occur. This is known as extraesophageal GERD. 1

Several extraesophageal symptoms may relate to GERD (see Table 1 , "Symptoms Associated with GERD"), although the exact mechanisms of the relationships remain unclear. 2 , 5-15 In a survey of people with GERD symptoms occurring at least weekly, researchers noted that patients with heartburn and regurgitation reported such atypical GERD symptoms about 85% of the time. 15 This seems to support the suggestion that GERD contributes to extraesophageal symptoms in some patients, and that a relationship exists between uncontrolled acid reflux and its related morbidity in the primary care patient population.


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Table 1 Symptoms Associated with GERD


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Epidemiology:
The American College of Gastroenterology reports that more than 60 million Americans experience acid indigestion at least once a month. 16 Some researchers have suggested that as many as 20% of those reporting acid reflux experience weekly symptoms, while many others experience daily symptoms. 15 The International Foundation for Functional Gastrointestinal Disorders reports that GERD affects an estimated 5% to 7% of the global population. 17 Perhaps this is a conservative estimate, as many more cases may go unreported.

Certain groups of patients may be particularly prone to acid reflux symptoms. GERD seems to be a common, although often self-limiting, condition in infants younger than age 12 months, and occasionally occurs in the older pediatric population. 18 , 19 Additionally, older adults may have an increased risk for GERD complications because of prolonged esophageal acid exposure over many years. Additionally, higher frequency of hiatal hernia, decreased saliva volume, or drugs that reduce lower esophageal sphincter (LES) pressure may contribute to GERD in older adults. 20

Several additional risk factors for GERD exist. Increased acid secretion, altered esophageal buffering, esophageal motility disorder, hiatal hernia, obesity, spinal cord injury, and gastroparesis may predispose patients to reflux. 2 , 21-23 Those with Zollinger-Ellison syndrome, thyroid disease, diabetes, scleroderma, or mixed connective disorders may develop esophageal motility dysfunction and impaired peristalsis that hinder acid clearance. 24 , 25

Reflux also can occur when circumstances such as pregnancy, obesity, frequent prone positioning, or chronic constipation increase intra-abdominal pressure. 23 , 26 Patients who smoke or take certain medications may experience increased reflux as well (see Table 2 , "Drugs That May Worsen Reflux Symptoms"). 21 Additionally, patients who take pills over time may be subject to "pill esophagitis," particularly when they take medications that irritate the esophagus. 25


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Table 2 Drugs That May Worsen Reflux Symptoms


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Despite the high incidence of GERD, its etiology remains poorly defined. Researchers identified an autosomal dominant hereditary pattern when studying five families that had multiple members with severe pediatric GERD. 27 The prevalence of GERD in the study subjects appeared to relate to a specific chromosome (13q14), suggesting a possible genetic tendency for familial occurrence of GERD.

Because of GERD prevalence, those experiencing it may not think of it as serious. In fact, many patients use over-the-counter (OTC) drugs before seeking clinician assistance. 17 In a survey, researchers found that only 5.4% (47) of those who reported GERD symptoms (n = 869) had visited a health care provider for their symptoms. 15

Patients who don't seek medical attention are undertreated or undiagnosed. 17 For patients who seek assistance, treatment options involve both lifestyle modifications and the use of pharmacologic therapy.

Pathophysiology:
Most individuals experience a small amount of physiologic reflux. Experts consider such a reflux normal when it occurs no more than 5.5% of the time. 28 In the majority of GERD patients, the pathology's cause isn't acid overproduction but length and frequency of esophageal acid exposure. 1

When properly functioning, various physical characteristics help prevent excessive reflux. In the wall of the normal esophagus, mucous-secreting glands secrete bicarbonate, which neutralizes gastric acid and helps protect the esophagus.

At the pharyngoesophageal junction, the upper esophageal sphincter (UES) serves as the main barrier in preventing laryngopharyngeal reflux. 29 At the esophagus's distal end, the lower esophageal sphincter is an area of smooth muscle that works with the diaphragm to provide a mechanical barrier to reflux.

Additionally, contractile motions in the esophagus move substances out of the esophageal tract. These clearance mechanisms determine the length of time that esophageal tissues are exposed to refluxate, which, in turn, influences mucosal integrity. 13 , 21 , 30

Persons with GERD may have an alteration in any of these intrinsic mechanisms, and, as a result, experience reflux symptoms. 21 One generally accepted cause of esophageal mucosal damage involves contact with hydrochloric acid in gastric juice. 31 To a lesser degree, bile acids and pancreatic enzymes may also play some part in the cellular insult that occurs with GERD, as acid and duodenogastroesophageal reflux occur simultaneously in the majority of reflux episodes. 32

At a pH of less than 2.0, diffusion potential develops at the esophagus's surface epithelial cells and increased cellular permeability permits hydrogen ions to penetrate through intracellular spaces. 31 As hydrogen ions reach sensory nerve endings deeper in the epithelium, the heartburn sensation occurs. 31 , 33

Additionally, hydrogen ion penetration into the cell may cause the cell to lose its ability to regulate its own volume, resulting in cell lysis and an inflammatory response. Because acidic pH decreases cell restitution and proliferation, the rate of cell death may exceed the rate of healthy cell production, and erosions may develop. 21 , 31

Over time, patients who have chronic GERD could develop scarring of the esophagus that impairs esophageal motility and causes fibrosis. 25 Eventually, the chronic inflammatory process may lead to the replacement of squamous epithelial cells by columnar-type epithelium, the premalignant cellular changes known as Barrett's esophagus. 1 , 2 , 34

Diagnosis: Early and Accurate
Because of the potential complications of GERD and its effect on quality of life, patients need early and accurate diagnoses. Clinical presentation and medical history present the most useful diagnostic tools. 1 These include characteristics, onset, frequency, duration, and progression of symptoms, as well as medications, diet, and activity history. 35 Body weight, fecal occult blood test, and physical assessment are also important for diagnosis. 36

The American College of Gastroenterology states that patients experiencing heartburn two or more times a week likely have GERD. 37 Heartburn is a retrosternal burning pain in the epigastric area, neck, throat, or occasionally the back. 20 Typically, the patient with GERD may complain of frequent postprandial or nocturnal heartburn. 38 One researcher describes frequent heartburn as specific for GERD and usually diagnostic. 8 One exception involves the heartburn-like symptoms in achalasia, which are caused by esophageal stasis from outflow obstruction. Here, fermentation of undigested food in the esophagus, coupled with local inflammation, creates a heartburn sensation. 8

Besides heartburn, regurgitation is another highly specific finding for GERD. Regurgitation is the movement of gastric contents into the esophagus without vomiting. 29 The patient may describe a sudden acidic taste or a "sour" or "hot" belch. 38 When these symptoms occur together with typical characteristics, you can establish a GERD diagnosis and treat many patients empirically without further testing. 8

Mimicking GERD

The chest pain some experience with GERD presents similar to angina, making its differentiation from cardiac disease somewhat challenging but essential. 20 Generally, pain that is esophageal rather than cardiac in nature includes symptoms such as heartburn or regurgitation, which worsen after meals and after lying down. Antacids may relieve the symptoms without deleterious cardiovascular effects. 39 Because of the seriousness of cardiopulmonary disease, diagnose chest discomfort as noncardiac only after a thorough cardiac workup. 11

Several additional differential diagnoses may mimic GERD, including biliary tract disease, obstruction, esophageal or gastric cancer, gastroparesis, infectious esophagitis, nonsteroidal anti-inflammatory drug-related gastritis, and peptic ulcer disease. 40 , 41 Differential diagnoses in infants also include food intolerance, gastroenteritis or other infection, anatomic anomalies, obstruction, masses, metabolic disorders, and pyloric stenosis. 18 , 19 Older children and adolescents have a presentation similar to adults, although they may not describe their discomfort as heartburn or reflux.

Reserve diagnostic testing for those with atypical or persistent symptoms who don't respond to empiric antireflux therapy after 7 to 10 days. 38 One exception involves the older adult patient, who, because of possible cumulative injury from years of reflux, may need early referral to a gastroenterologist for endoscopy, even if symptoms are milder than those of young individuals with newer disease onset. 20 Because acid suppression doesn't insure prevention of GERD complications, consider severity and length of esophageal exposure to acid when assessing for complications.

Under certain circumstances, consider invasive diagnostic testing by a gastroenterologist. These circumstances include lack of response to therapy, warning signs indicative of GERD complications (such as dysphagia, odynophagia, unexplained anemia, unintentional weight loss, noncardiac chest pain, early satiety, frequent vomiting, or gastroesophageal bleeding ), chronic or refractory symptoms in a patient at risk for Barrett's esophagus, or the need for continuous chronic therapy. 8 , 21 , 30

Consider patients chronic or refractory to therapy when symptoms are unrelieved or mucosal lesions don't heal after 12 weeks of therapy. 42 , 43 Indications for referring a pediatric patient include failure to thrive, therapy failure after 2 to 3 months, age 18 months or older with hiatal hernia, and respiratory or gastrointestinal complications. 19 , 40

Subtle Complications

Certain GERD complications may have a subtle presentation. Ask patients whether they have difficulty swallowing solids such as meat, vegetables with skins, and bread products. Sometimes, patients alter eating habits to avoid symptoms (chewing longer, cutting food into smaller pieces, toasting breads, and avoiding certain foods) without realizing their symptoms of esophageal disease. 39

Note that patients, particularly infants and children, with extraesophageal manifestations such as reflux laryngitis or asthma may not always complain of heartburn. 29 Patients with undiagnosed GERD-related respiratory problems may present with chronic cough. Some indications of GERD-related asthma include absence of allergic component, adult onset, nocturnal cough, obesity, poor response to asthma therapy, and asthma attack following heartburn or regurgitation. 39 The most common symptoms of laryngopharyngeal reflux include sensation of a lump in the throat (globus sensation), dysphonia, constant throat clearing, cough, cervical dysphagia, halitosis, pharyngeal tightness, otalgia, and hypersalivation. 28 , 29

To differentiate diagnoses, inquire about any history of gastrointestinal or respiratory disease, tobacco use, allergic-type symptoms, and new environmental conditions that could help explain symptoms. 9

To further evaluate symptoms, laboratory tests such as a complete blood count with differential and chemistry profile may be appropriate. 35 For patients with continued GERD symptoms, evaluation may include barium radiography (upper GI) or referral for endoscopy, ambulatory pH monitoring, esophageal manometry, or provocative testing (for example, the Bernstein test). 2 , 11 , 30 , 44 , 45

Some researchers have suggested that a 2- to 3-month trial of proton pump inhibitors may offer a less expensive and more comfortable option for diagnosis. 39 , 46 This option, however, requires further scientific evaluation.

Managing GERD:
Because of GERD's chronic nature, disease management requires a lifelong process even after bringing symptoms under control. The patient will need follow-up, support, and education to assist with issues of daily living and adherence to pharmacologic therapy. 17

Initial therapy for mild GERD begins with lifestyle modifications, which should continue throughout therapy. 2 , 8 , 21 , 30 Generally, dietary recommendations include avoiding certain foods that may increase esophageal reflux, such as chocolate, alcohol, cola, peppermint, fatty or spicy foods, citrus fruit and juice, coffee, onions, and garlic. 2 , 21 , 25 , 30 , 47

Experts also recommend interventions to prevent increased pressure against the LES: elevating the head of the bed by 6 to 10 inches, losing weight as appropriate, avoiding large meals, and avoiding lying down within 3 hours of a meal. 2 , 11 , 20 , 22 , 48-51 While reclining, patients should avoid lying on their right side because this may increase reflux. 26

Discourage smoking because it may increase aerophagia, belching, and acid exposure, and diminish the salivary base. 25 Some patients experience more reflux with vigorous exercise, so advise patients to avoid such activity within 1 hour of eating.

You can play a key role in educating and supporting patients regarding lifestyle modifications, including adjustments in diet, weight management, sleep position, activities, and smoking cessation. Participation in lifestyle modifications allows patients and their caregivers to have more active roles in care and may promote a greater sense of disease control.

Pediatric Approaches

The approach to managing pediatric patients with GERD differs slightly but still involves educating the caregiver or patient about lifestyle modifications and pharmacologic therapy (see Table 3 , "Managing Uncomplicated GERD in Children"). 19 , 29 Pediatric patients may need weekly visits to assess weight and feeding. 19 , 35


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Table 3 Managing Uncomplicated GERD in Children


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Infants with uncomplicated GERD who are otherwise healthy typically have repetitive regurgitation without failure to thrive or respiratory compromise. In this situation, reassure parents that the infant will likely grow out of it.

For pediatric patients, GERD management begins with conservative therapy to limit increased intra-abdominal pressure by avoiding prone position or vigorous play after meals. 40 Management also involves decreasing gastric volume and increasing the density of stomach contents with small, frequent meals.

Thickening feedings may result in fewer episodes of emesis and irritability, but may also promote "silent" reflux that takes longer to clear from the esophagus. Thus, thickened formulas may be contraindicated in infants with GERD-related pulmonary events.

Pharmacologic Measures

Besides lifestyle modifications, pharmacologic therapy may help control GERD symptoms (see Table 4 , "Drugs Used for GERD Management"). Widely available, OTC antacids buffer the pH of gastric fluid. Histamine 2 receptor antagonists decrease acid production by inhibiting histamine stimulation of the parietal cell and are available OTC or in higher prescription strengths.


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Table 4 Drugs Used for GERD Management


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Proton pump inhibitors suppress acid secretion by inhibiting the hydrogen/potassium adenosinetriphosphatase pump at the parietal cell. Besides acid suppression, promotility agents help control GERD by enhancing esophageal clearance and gastric emptying. The mucosal protectant agent sucralfate aids in mucosal healing by reducing direct tissue exposure to acid, although its use in uncomplicated GERD is limited. 1 , 52

Initially, patients often try OTC medications for GERD symptoms. OTC acid suppressants are appropriate for initial patient-directed therapy because they offer more effective heartburn relief over placebo. 30

Not all patients, however, find that self-care measures control their symptoms. Expert opinion states clinicians should offer empirical therapy for GERD to patients with disease-consistent symptoms. Further, you should also assume a GERD diagnosis in patients who respond well to therapy. 30

Acid suppression presents the mainstay of pharmacologic management of GERD. 8 , 30 , 46 One option involves step-up therapy in which standard or even OTC dosing of an H 2 blocker and antacids are started and titrated up for symptom control. 51

Initial treatment for young adults with uncomplicated disease usually consists of 6- to 12-week trials of H 2 blockers, with emphasis on lifestyle and dietary modifications. 2 , 25 , 53 In the literature, researchers agree on the use of acid suppressors without endoscopic assessment for uncomplicated GERD in the younger patient, indicating that short courses of H 2 blockers or proton pump inhibitors can be given safely. 21 , 46

Some health plans, however, require using proton pump inhibitors only after less expensive medications fail to control symptoms. Additionally, some suggest that you obtain a gastroenterology consult if symptoms persist after trying a second medication for 6 to 8 weeks. 35 Gastroenterologists may treat patients with complex GI problems with combination therapy that includes an acid suppressor, a prokinetic, or a mucosal protectant. 1 , 52

A second pharmacologic option in the management of GERD involves step-down therapy. In this case, a once- or twice-daily proton pump inhibitor is the initial treatment, with therapy titrated to the lowest form of acid suppression that controls symptoms. 30 , 51 With this plan, OTC agents may eventually manage the mildest symptoms.

Evaluating Progress:
After initiating acid-suppressive measures, schedule follow-up visits at 1 to 2 weeks, at 6 to 8 weeks, and at 3 months, depending on the patient's condition. 36 , 54 Evaluate progress by subjective parameters, such as improvement in heartburn complaints or other esophageal symptoms, frequency of asthma or laryngitis episodes, and use of asthma rescue medications. Objective indicators of improvement for asthma include serial spirometric studies or the patient's log of peak airflow recordings. 11

If the patient's symptoms are controlled, therapy usually continues for about 8 weeks. Once symptoms resolve, attempt downward titration of medications. 8 , 36 One researcher noted that patients with more severe GERD have symptom relapse 80% of the time after therapy discontinuation. 8 Other researchers suggest that patients may need maintenance therapy to prevent such recurrences. 46

The ultimate goals of GERD therapy involve complete symptom relief, healing of esophageal injury, and prevention of complications. 8 , 21 Maintenance therapy should consist of the least costly, most convenient, and effective drugs for patients.

If patients fail to respond to therapy, refer them to a gastroenterology specialist. Patients with severe, chronic esophagitis or Barrett's esophagus may need surgical consultation for reflux surgery after attempts to maximize medical therapy. 43 Some possible reasons for surgery include the need for continuous or increasing drug therapy accompanied by young age, financial burden, nonadherence with drug therapy, severe duodenogastroesophageal reflux, ongoing respiratory symptoms, or patient preference for surgery. 8 , 46 , 55 , 56

Whether open or laproscopic, the principle goal of surgery is to close any hiatal hernia and to restore an antireflux barrier by recreating a sufficient pressure gradient in the distal esophagus. 46 Some clinicians, however, have suggested that patients who don't respond to maximum medical therapy and those with atypical chest pain resulting from GERD are less likely to benefit from surgical intervention. 8 , 42 , 56

ACKNOWLEDGMENT:
The authors thank Richard Krause, MD, FACG (The Center for Digestive Disorders and Clinical Research) for sharing his thoughtful insight and clinical expertise during the writing of this article.

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