Gastroesophageal Reflux Disease
Adult-Gerontology Acute Care Practice Guidelines
Definition
A.Gastric reflux that irritates and erodes the lining of the esophagus.
Incidence
A.60% of adult population experience gastroesophageal reflux disease (GERD) of some type.
B.Affects up to 10 million adults in the United States on a daily basis.
C.Many people experience heartburn two to three times per week.
Pathogenesis
A.The esophagus contracts to propel food into the stomach via peristalsis.
B.A circular ring of muscle called the lower esophageal sphincter (LES) relaxes to allow food to enter the stomach, then contracts to avoid regurgitation of food or acid into the esophagus.
C.When the LES is weak due to stomach distention, acid can wash up into the esophagus.
D.Most episodes of heartburn occur shortly after meals.
E.Functional or mechanical problem of LES is the most common cause of GERD.
F.Transient relaxation of LES can be caused by food (coffee, alcohol, chocolate, meals heavy in fat), medications (beta agonists, nitrates, calcium channel blockers, anticholinergics), hormones, and nicotine.
Predisposing Factors
A.Obesity.
B.Smoking.
C.Pregnancy.
D.Certain medications.
E.Peptic ulcers.
F.Hiatal hernia.
G.Diabetes (due to associated gastroparesis).
H.Asthma (chronic, continuous coughing may contribute).
I.Connective tissue disorders.
J.Zollinger–Ellison syndrome.
Subjective Data
A.Common complaints/symptoms.
1.Heartburn or burning sensation after eating.
2.Nausea or vomiting.
3.Difficulty or pain when swallowing.
4.Regurgitation.
5.Hoarseness from irritation of the vocal cords.
6.Difficulty breathing.
B.Common/typical scenario.
1.Most patients will complain of burning sensation or discomfort that occurs after eating or when lying supine or bending over.
C.Family and social history.
1.Smoking.
2.Lifestyle.
3.Diet.
D.Review of systems.
1.Head, ear, eyes, nose, and throat (HEENT): Laryngitis, dysphagia, hoarseness, teeth decay, ear infections.
2.Respiratory: Chronic cough, new or worsening asthma.
3.Cardiac: Burning sensations behind breastbone.
Physical Examination
A.HEENT: Evaluate throat for redness or irritation, look for enamel decay of the teeth, evaluate ears for possible infections if warranted.
B.Respiratory: Listen for wheezing or decreased lung sounds.
C.Cardiac: Evaluate for palpitations, murmurs, or a rapidor slow heart rate.
Diagnostic Tests
A.Diagnosis of GERD can be made upon symptoms and response to treatment alone.
B.If a patient presents with chest pain or the diagnosis of GERD is not clear, then one or more of the following tests may be ordered.
1.Endoscopy: Evaluate for damage to the lining of the esophagus, stomach, and small intestine.
2.24-hour esophageal pH study: Measure frequency of acid reflux.
3.Esophageal manometry: Evaluate functioning of LES.
Differential Diagnosis
A.Gastritis.
B.Esophagitis.
C.Irritable bowel syndrome.
D.Peptic ulcer disease.
E.Hiatal hernia.
F.Gallstones.
G.Coronary atherosclerosis.
Evaluation and Management Plan
A.General plan.
1.Stepwise approach.
a.Control symptoms.
b.Heal esophagitis.
c.Prevent recurrence and complications of GERD.
2.Start with lifestyle modification and control of gastric acid secretion with medical therapy.
a.Weight loss.
b.Eat small, frequent meals.
c.Avoid foods that trigger reflux such as alcohol, chocolate, tomato-based products, caffeine.
d.Avoid lying down for 3 hours after a meal.
e.Avoid bending or stooping for 3 hours after a meal.
3.Surgery may be indicated in the following cases.
a.Symptoms not controlled with proton pump inhibitor (PPI) therapy.
b.Presence of Barrett esophagus.
c.Extraesophageal symptoms.
d.Young patients.
e.Poor compliance.
f.Patients with cardiac conduction defects.
B.Patient/family teaching points.
1.Stop smoking.
2.Reduce or eliminate alcohol intake.
3.Weight loss will improve symptoms.
4.Avoid tight fitting clothing.
5.Chew gum or use oral lozenges to increase saliva production.
6.If your symptoms are not controlled or last a long time, report this to your provider.
7.Chest pain can also be cardiac in nature; if the pain radiates to the jaw, left shoulder, or arm, be sure to seek medical attention immediately.
C.Pharmacotherapy.
1.Antacids can be taken after each meal and before bedtime.
2.H2 Receptor antagonists: First-line agent for mild to moderate symptoms.
3.Proton pump inhibitors.
a.Most powerful medications.
b.Most commonly reported adverse reactions.
i.Sore throat.
ii.Flatulence.
iii.Constipation.
c.Superior to H2 receptor antagonists.
4.Prokinetics.
a.Improve motility of esophagus.
b.Somewhat effective in patients only with mild symptoms.
c.May have long-term serious or potentially fatal complications.
D.Discharge instructions.
1.Follow patient teaching points upon discharge for best results.
2.Lifestyle changes and medical therapy should resolve GERD symptoms within 4 weeks and esophagitis in 8 weeks.
3.Complications of untreated GERD include:
a.Ulcers that can cause bleeding.
b.Strictures of esophagus.
c.Lung and throat problems.
d.Barrett’s esophagus.
e.Esophageal cancer.
Follow-Up
A.As per your provider or if symptoms are not controlled.
Consultation/Referral
A.If symptoms are not controlled with one PPI.
B.If symptoms do not confirm diagnosis or another problem is potentially causing symptoms.
Special/Geriatric Considerations
A.GERD can occur in pregnancy because of normal weight gain and hormone changes that allow muscles in the esophagus to relax more easily and frequently.
B.As the uterus expands, particularly in the third trimester, pressure builds up in the stomach, which may cause food and acid to regurgitate into the esophagus.
1.Antacids are first-line agents in pregnancy but may not be sufficient.
2.Histamine blockers and proton pump inhibitors are also approved for treatment of GERD during pregnancy.
Bibliography
El-Serag, H. B. (2007). Time trends of gastroesophageal reflux disease: A systematic review. Clinical Gastroenterology and Hepatology, 5(1), 17–26. doi:10.1016/j.cgh.2006.09.016
Giannini, E. G., Zentilin, P., Dulbecco, P., Vigneri, S., Scarlata, P., & Savarino, V. (2008). Management strategy for patients with gastroesophageal reflux disease: A comparison between empirical treatment with esomeprazole and endoscopy-oriented treatment. American Journal of Gastroenterology, 103(2), 267–275. Retrieved from https://journals.lww.com/ajg/Abstract/2008/02000/Management_Strategy_for_Patients_With.4.aspx
Grant, A. M., Cotton, S. C., Boachie, C., Ramsay, C. R., Krukowski, Z. H., Heading, R. C., & Campbell, M. K. (2013). Minimal access surgery compared with medical management for gastro-oesophageal reflux disease: Five year follow-up of a randomised controlled trial (REFLUX). BMJ, 346, f1908. doi:10.1136/bmj.f1908
Hampel, H., Abraham, N. S., & El-Serag, H. B. (2005). Meta-analysis: Obesity and the risk for gastroesophageal reflux disease and its complications. Annals of Internal Medicine, 143(3), 199–211. doi:10.7326/0003-4819-143-3-200508020-00006
Oor, J. E., Roks, D. J., Ünlü, C., & Hazebroek, E. J. (2016). Laparoscopic sleeve gastrectomy and gastroesophageal reflux disease: A systematic review and meta-analysis. American Journal of Surgery, 211(1), 250–267. doi:10.1016/j.amjsurg.2015.05.031