• About 1/3 of reflux patients have erosive, 2/3 have non-erosive reflux.
• GERD is the most common disease of the esophagus.
Pathogenesis
The main event is that the acid, pepsin and bile in the refluxing material come into contact with the esophageal mucosa and cause damage and symptoms.
• Normally, there is an anatomical and functional barrier between the esophagus and the stomach that prevents reflux. Factors that disrupt this barrier lead to the formation of GERD.
Inappropriate relaxation of the lower esophageal sphincter (LES) (most important and common cause}
Reduction in LES pressure
hiatal hernia
Decreased/delayed esophageal clearance (most important in the occurrence of reflux esophagitis)
Prolongation of gastric emptying time
increased stomach acid
Decreased esophageal mucosal resistance
Reflux of mucous injuring material (acid, pepsin, bile)
Causes that increase intra-abdominal pressure (obesity, tight-fitting clothes, ascites, pregnancy)
• Increase in abdominal pressure during pregnancy, changes in hormone balance and weight gain facilitate reflux.
• The frequency of reflux increases after esophageal surgeries.
Clinic
• Esophageal symptoms
The most important and most common symptom is retrosternal burning (pyrosis}.
Regurgitation, angina-like chest pain, or difficulty swallowing may be felt.
• Extra esophageal symptoms
Chronic laryngitis, pharyngitis, bronchitis, sinusitis, chronic cough, gingival erosions, asthma-like picture, pneumonia, pulmonary fibrosis and other pulmonary complications may develop, especially due to aspiration during sleep.
Cardiac arrhythmias, bronchospasm, and cough may be seen with the vasovagal reflex.
Among these, the relationship between cough, laryngitis, asthma-like picture and dental erosions with reflux has been shown more clearly.
Approach
• In a patient with typical symptoms, the diagnosis of GERD can be made with a well-received history.
Approximately half of the patients have a history of typical epigastric burning and regurgitation, and empirical treatment can be initiated directly in patients who do not have findings suggestive of a more serious pathology such as dysphagia, weight loss, anemia, and vomiting.
• Patients with atypical symptoms or who do not respond to empirical therapy (4-8 weeks) should be investigated for other possible diseases.
• Endoscopy should be performed for differential diagnosis and to demonstrate a possible Barrett's metaplasia, especially in patients with warning symptoms such as dysphagia, weight loss, anemia, or with long-term (> 5-10 years) pyrosis.
Diagnosis
• History: It is sufficient for the diagnosis of reflux in most patients.
• PPI test: It is helpful in the diagnosis if the symptoms respond to double dose PPI (proton pump inhibitor) treatment for 5-7 days and recur when the drug is discontinued.
• Esophageal pH measurement and impedance monitoring: It is the most valuable method for demonstrating GERD.
• Endoscopy {± biopsy): It is required for the definitive diagnosis of reflux-related esophagitis and Barret's metaplasia.
• Manometry is required to show or rule out a possible accompanying motility disorder in patients who will undergo surgery.
Treatment:
GERD treatment should be planned according to the factors that play a role in the pathogenesis.
• Medical treatment
General precautions in the treatment of GERD:
Raising the head of the bed ( ~20 cm)
Avoiding forward bending movements
Quitting smoking and alcohol consumption
Losing excess weight, not gaining weight
Not going to bed until 3 hours after a meal
Avoiding tight and tight clothing
Reducing the amount of fat in meals
Eating 3 regular meals and avoiding overeating in one meal
Avoiding foods that increase symptoms (spices, tea, coffee, soda, tomatoes, chocolate)
Avoidance of drugs that relax the lower esophageal sphincter and increase reflux (anticholinergic, theophylline, benzodiazepine, calcium channel blocker, nitrate, etc.).
GERD pharmacological treatment:
- Drugs that reduce acidity: Simple antacids, H2-receptor antagonists, proton pump inhibitors (the most effective drugs in the treatment)
- Prokinetic agents: Metoclopramide and domperidone increase lower esophageal sphincter pressure and gastric motility.
- Mucosal protective agents: Alginate, sucralfate, misoprostol
• The duration of medical treatment in GERD should be between 8-12 weeks. Long-term maintenance therapy is required in patients at high risk of relapse (moderate and advanced esophagitis).
• In long-term use of PPI; Iron deficiency, Vit B12 deficiency, excessive bacterial growth and pneumonia in the elderly, C. difficile colitis, calcium absorption impairment and related bone fractures have been reported.
• Laparoscopic fundoplication is the most common invasive procedure in the treatment of resistant reflux.
Complications
• The most important complications of GERD are bleeding due to chronic esophagitis and peptic stricture and the development of Barrett's esophagus (Barrett's metaplasia).
• Barrett's esophagus; It describes the transformation of the lower end squamous epithelium of the esophagus into columnar epithelium containing goblet cells (intestinal metaplasia).
• In the presence of long-term GERD, Barret's esophagus can transform into adenocarcinoma:
Chronic reflux Barret metaplasia Low-grade dysplasia High-grade dysplasia Carcinoma in situ Adenocancer
For this reason, patients who develop Barrett's metaplasia are periodically monitored endoscopically and a biopsy is taken at each endoscopy and the presence of dysplasia is investigated.
" In patients without dysplasia, endoscopic monitoring and biopsy are continued every 3 years.
If dysplasia is detected, it is confirmed with a second pathologist:
- Patients with low-grade dysplasia are followed up for 6-12 months endoscopically. Local ablation therapy can be applied in selected cases.
- Patients with high degree of dysplasia should be treated with local ablation therapies, endoscopic mucosal resection or surgical resection.
- Carcinoma in-situ or adenocarcinomas confined to the mucosa are evaluated for endoscopic mucosal resection or surgical treatment.
PPI therapy or reflux surgery has not been shown to reduce the risk of cancer in a patient with Barrett's metaplasia.
Obesity, male gender, > 60 years, bile reflux increases the risk of developing Barrett's metaplasia.