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Gastroesophageal reflux refers to a backflow of stomach contents into the esophagus.
The esophagus is the muscular tube that carries food from the throat to the stomach. Food is carried along the esophagus by waves of contraction and relaxation of its muscular walls (peristalsis). The part of the esophagus closest to the stomach is surrounded by a sphincter (circular muscle capable of opening and closing). During peristalsis, the lower esophageal sphincter relaxes, allowing food to enter the stomach. In the resting state, this sphincter is closed, preventing backflow (reflux) of stomach contents into the esophagus. However, a drop in pressure in the lower esophagus or a weakening of the sphincter muscle can permit a backflow of powerful stomach acids into the esophagus. While the lining of the stomach protects it from the effects of its own acids, the esophagus lacks this protective lining. A backflow of stomach acid into the esophagus can cause pain, inflammation (esophagitis), and damage. The degree of inflammation depends on the acidity of the stomach contents and the amount of stomach acid refluxed into the esophagus.
Certain foods or circumstances also increase the risk of reflux. Exercising or bending over after a large meal can pressure the sphincter and allow stomach acid to flow back into the esophagus. When an individual is lying down, gravity contributes to reflux. The intake of certain types of food and drink, smoking, and certain medications can lead to acid indigestion. Reflux can also be caused by anything that increases abdominal pressure such as clothing or belts too tight around the waist. Reflux may occur in association with pregnancy or obesity.
Reflux is also associated with hiatal hernia. The esophagus enters the stomach just after passing through a band of muscle called the diaphragm. In a hiatal hernia, the opening (hiatus) in the diaphragm through which the esophagus passes is enlarged. This allows the lower esophagus and upper part of the stomach that normally stay beneath the diaphragm to slide through the hiatus and move above the diaphragm into the chest cavity. This makes it difficult for the sphincter to work correctly, partially because the angle between the esophagus and stomach (gastroesophageal angle) is changed.
The relationship between Helicobacter pylori (H. pylori) infection and gastroesophageal reflux disease (GERD) is not well known. Gastritis secondary to H. pylori infection may protect against GERD based on geographic and ethnic distributions of GERD.
Risk: Individuals who are overweight, pregnant, use alcohol or caffeine, overeat fatty or spicy foods, or who smoke cigarettes have an increased risk of gastroesophageal reflux.
White males have increased risk for Barrett's esophagus and adenocarcinoma than other populations and males develop esophagitis between 2 and 3 times more frequently than females; prevalence of GERD increases after the age of 40 years (Patti). Incidence and Prevalence: Prevalence of gastroesophageal reflux is about 7% of the population in the US, although this number may be under reported, as many individuals control reflux with over-the-counter medication (Patti). |
Source: Medical Disability Advisor
| History: The most common symptom of gastroesophageal reflux is heartburn, a burning pain in the lower chest usually below the sternum. The pain may range from mild to so severe that it mimics a heart attack (myocardial infarction). Gastroesophageal reflux, however, is not related to the heart.
The pain typically occurs 30 to 60 minutes after eating and is often precipitated by other common symptoms of reflux. These include a reflex increase in salivation (water brash) and backward flow of stomach contents into the mouth (regurgitation). Inhalation (aspiration) of regurgitated material can occur especially during sleep. This may result in respiratory symptoms such as hoarseness, wheezing, cough, and difficulty breathing. Difficulty swallowing (dysphagia) is often a symptom of complicated reflux disease. Painful swallowing (odynophagia) may indicate esophageal inflammation or an ulcer. Physical exam: The diagnosis is usually suspected from the history; however, in some individuals it may be necessary to rule out a cardiac source of pain (myocardial infarction, angina pectoris) and other gastrointestinal disease. Tests: The healthcare provider may order an upper gastrointestinal x-ray and/or a direct examination of the esophagus (endoscopy) through a flexible fiberoptic tube (NG tube). An upper gastrointestinal (GI) series (barium x-ray of the upper gastrointestinal tract) can detect ulcers or narrowing of the esophagus.
Regardless of x-ray or endoscopic findings, proof that the symptoms are caused from acid reflux is best obtained through a tissue sample (biopsy) and microscopic examination.
When symptoms are not typical, special studies may be required to make the diagnosis. The simplest of these tests is the Bernstein acid perfusion test. In this test, a specific concentration of hydrochloric acid is instilled into the esophagus. If the individual's pain is reproduced by this procedure and relieved by instillation of saline solution, it is an indication that acid reflux is the cause of the pain. In some cases, ambulatory pH monitoring may be helpful. By continuously monitoring the degree of acidity (pH) of the esophagus for up to 24 hours, the individual's daily pattern of reflux and its relationship to symptom occurrence can be documented.
Pressure measurement (esophageal manometry) at the lower esophageal sphincter can indicate sphincter strength and abnormal functioning.
Radioisotope scans are sometimes done to demonstrate reflux. A reflux scan is less sensitive than 24-hour pH monitoring; however, it can help document aspiration of regurgitated material. |
Source: Medical Disability Advisor
| Treatment of symptomatic reflux may be considered in several phases. Phase I consists of general measures, Phase II is medical treatment, and Phase III is surgical intervention.
Phase I measures include strategies that mechanically decrease abdominal pressure and that modify intake of known aggravating substances. Weight loss may make a difference for overweight people. Tight clothing and belts should be avoided. Meals should be small and frequent. Reclining should be avoided for at least 2 hours after meals. Gravity may help relieve symptoms if the head of the bed is raised or more then one pillow is used when reclining. Substances that increase symptoms should be avoided such as alcohol, tobacco, caffeine, acidic foods and drink (e.g., citrus and tomatoes), fats, chocolates, and peppermint.
Medications should be reviewed since certain medications (anticholinergic drugs, calcium channel blockers) can decrease lower esophageal sphincter tone. Others such as potassium supplements and certain antibiotics may be irritating to the esophagus. Medication such as cimetidine or ranitidine can reduce stomach acidity. The acid neutralizing effect of antacids may also be helpful when taken after meals and at bedtime. However, this relief is only short-term.
When the above measures are unsuccessful in controlling symptoms, histamine (H2) antagonists are introduced in Phase II treatment. By blocking receptors, these medications decrease the secretion of gastric acid. If the response is incomplete, cholinergic drugs or other motility promoting (prokinetic) agents may be added. These medications increase esophageal and gastric movement (motility), increase lower esophageal sphincter tone, and promote gastric emptying. Medication to protect the mucous lining may also be tried. While uncomplicated disease usually responds well to Phase I therapy, complications generally require Phase II treatment.
If severe reflux esophagitis is present, a proton pump inhibitor medication may be tried. This medication directly blocks the secretion of acid (ions or protons) by the stomach. Although the medication often produces complete healing in 4 to 8 weeks, most individuals have recurrence of symptoms after the drug is discontinued.
Antireflux surgery or Phase III is indicated when symptoms persist or recur despite conservative treatment. A weakened esophageal sphincter can be surgically strengthened. A hiatal hernia can be reduced by surgically returning the stomach and esophagus to their normal position in the abdominal cavity. The hiatal opening is then secured with sutures. Another procedure called fundoplication creates a high-pressure area in the lower esophagus by surgically wrapping the fundus of the stomach around the distal esophagus, preventing reflux. |
Source: Medical Disability Advisor
| The clinical course of gastroesophageal reflux varies. While some symptoms resolve, others may be resistant to therapy. Most individuals with mild disease will continue to experience symptoms of varying degrees and frequency. When symptoms are severe or resistant to treatment, surgery may be required. |
Source: Medical Disability Advisor
| Complications include vomiting, aspiration, hoarseness, chronic cough, asthma, recurrent disease, and choking sensations. A small percentage of the individuals with severe reflux esophagitis develop narrowing or constriction of the esophagus (peptic stricture). Barrett's esophagus is a precancerous condition involving changes in the esophageal lining due to damage from persistent acid reflux; this condition may occur in those with peptic strictures.
Complications may also include painful swallowing (odynophagia) and noncardiac chest pain that may indicate the development of ulcers. Anticholinergic drugs commonly used for asthma increase the tendency of the lower esophageal sphincter to leak and may lengthen disability. |
Source: Medical Disability Advisor
| Restrictions or accommodations are not normally necessary. |
Source: Medical Disability Advisor
| If an individual fails to recover within the expected maximum duration period, the reader may wish to consider the following questions to better understand the specifics of an individual's medical case. Regarding diagnosis:
- Has diagnosis of gastroesophageal reflux been confirmed?
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Was diagnosis confirmed by esophagoscopy, biopsy, upper gastrointestinal (GI) series, and/or Bernstein acid test?
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Have conditions with similar symptoms been ruled out?
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Have associated causes or conditions that may aggravate the condition been identified?
Regarding treatment:
- Has individual been instructed in lifestyle and diet modifications, including losing weight, abstaining from alcohol, tobacco, caffeine, acidic and fatty foods, and wearing nonrestrictive clothing? Is individual complying with recommended changes? What can be done to enhance compliance?
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Have medications taken for other conditions been reviewed? Can any that may contribute to reflux be replaced or eliminated?
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Is use of histamine (H2) antagonists, cholinergics, or a proton pump inhibitor medication effectively controlling symptoms?
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If symptoms were severe or resistant to treatment, was surgery required?
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Which of the following procedures was performed or is scheduled to be performed: surgical strengthening of the esophageal sphincter; correction of a hiatal hernia; or a fundoplication to create a high-pressure area in the lower esophagus?
Regarding prognosis:
- Do symptoms persist despite medical treatment? How severe are the symptoms?
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Would individual benefit from counseling to assist with lifestyle and diet changes?
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Would individual benefit from evaluation by a gastroenterologist specialist?
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If individual underwent surgery, was it successful?
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Has individual experienced any complications associated with the gastroesophageal reflux or the surgical intervention?
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Are complications being effectively addressed in the overall treatment plan?
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Source: Medical Disability Advisor
| Patti, Marco, and Urs Diener. "Gastroesophageal Reflux Disease." eMedicine. Eds. John Gunn Lee, et al. 3 Sep. 2004. Medscape. 29 Oct. 2004 <http://emedicine.com/med/topic857.htm>. |
Source: Medical Disability Advisor
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