Gastroesophageal Reflux Disease: Practice Essentials, Background, Anatomy (original) (raw)

Practice Essentials

Gastroesophageal reflux disease occurs when the amount of gastric juice that refluxes into the esophagus exceeds the normal limit, causing symptoms with or without associated esophageal mucosal injury (ie, esophagitis; see the image below).

Gastroesophageal Reflux Disease. This image demonstrates peptic esophagitis.

Signs and symptoms

Typical esophageal symptoms include the following:

Heartburn
Regurgitation
Dysphagia

Abnormal reflux can cause atypical (extraesophageal) symptoms, such as the following:

Coughing and/or wheezing
Hoarseness, sore throat
Otitis media
Noncardiac chest pain
Enamel erosion or other dental manifestations

A history of nausea, vomiting, or regurgitation should alert the physician to evaluate for delayed gastric emptying.

See Presentation for more detail.

Diagnosis

Testing

The following studies are used to evaluate patients with suspected gastroesophageal reflux disease:

Upper gastrointestinal endoscopy/esophagogastroduodenoscopy: Mandatory
Esophageal manometry: Mandatory
Ambulatory 24-hour pH monitoring: Criterion standard in establishing a diagnosis of gastroesophageal reflux disease

Imaging studies

Upper gastrointestinal contrast-enhanced studies are the initial radiologic procedure of choice in the workup gastroesophageal reflux disease. Plain chest radiographic findings are not useful in the evaluation of this condition, but they are helpful in assessing the pulmonary status and basic anatomy. Chest images may also demonstrate a large hiatal hernia, but small hernias can be easily missed.

Currently, no role exists for computed tomography scanning, magnetic resonance imaging, or ultrasonography in the routine evaluation of patients with reflux disease.

See Workup for more detail.

Management

Treatment of gastroesophageal reflux disease involves a stepwise approach. The goals are to control symptoms, to heal esophagitis, and to prevent recurrent esophagitis or other complications. The treatment is based on lifestyle modifications and control of gastric acid secretion through medical therapy with antacids or proton pump inhibitors or surgical treatment with corrective antireflux surgery. [1, 2, 3, 4, 5, 6]

Nonpharmacotherapy

Lifestyle modifications used in the management of gastroesophageal reflux disease include the following:

Losing weight (if overweight)
Avoiding alcohol, chocolate, citrus juice, and tomato-based products
Avoiding peppermint, coffee, and possibly the onion family [7]
Eating small, frequent meals rather than large meals
Waiting 3 hours after a meal to lie down
Refraining from ingesting food (except liquids) within 3 hours of bedtime
Elevating the head of the bed by 8 inches
Avoiding bending or stooping positions

Pharmacotherapy

The following medications are used in the management of gastroesophageal reflux disease:

H2 receptor antagonists (eg, cimetidine, famotidine, nizatidine)
Proton pump inhibitors (eg, omeprazole, lansoprazole, rabeprazole, esomeprazole, pantoprazole)
Potassium-competitive acid blockers (eg, vonoprazan)
Prokinetic agents (eg, metoclopramide)
Antacids (eg, aluminum hydroxide, magnesium hydroxide)

Surgical options

Transthoracic and transabdominal fundoplications are performed for gastroesophageal reflux disease, including partial (anterior or posterior) and circumferential wraps. Open and laparoscopic techniques may be used.

Placement of a device to augment the lower esophageal sphincter is another surgical option.

Indications for fundoplication include the following:

Patients with symptoms that are not completely controlled by proton pump inhibitors
Patients with well-controlled reflux disease who desire definitive, one-time treatment
The presence of Barrett esophagus
The presence of extraesophageal manifestations
Young patients
Poor patient compliance with medications
Postmenopausal women with osteoporosis
Patients with cardiac conduction defects
Cost of medical therapy

See Treatment and Medication for more detail.

Background

Gastroesophageal reflux is a normal physiologic phenomenon experienced intermittently by most people, particularly after a meal. Gastroesophageal reflux disease (GERD) occurs when the amount of gastric juice that refluxes into the esophagus exceeds the normal limit, causing symptoms with or without associated esophageal mucosal injury (ie, esophagitis).

A study by Richter and a Gallup Organization National Survey estimated that 25%-40% of healthy adult Americans experience symptomatic GERD, most commonly manifested clinically by pyrosis (heartburn), at least once a month. Furthermore, approximately 7%-10% of the adult population in the United States experiences such symptoms on a daily basis. [8, 9] (See Epidemiology.)

In most persons with GERD, endogenous defense mechanisms either limit the amount of noxious material that is introduced into the esophagus or rapidly clear the material from the esophagus so that symptoms and esophageal mucosal irritation are minimized. Examples of the defense mechanisms include actions of the lower esophageal sphincter (LES) and normal esophageal motility. When the defense mechanisms are defective or become overwhelmed so that the esophagus is bathed in acid or bile and acid-containing fluid for prolonged periods, GERD can be said to exist. (See Pathophysiology.)

Patients with GERD can exhibit various symptoms, both typical and atypical. Typical symptoms include heartburn, regurgitation, and dysphagia. Atypical symptoms include noncardiac chest pain, asthma, pneumonia, hoarseness, and aspiration. [10, 11] Patients typically have numerous daily episodes of symptomatic reflux, including pyrosis, water brash or sour taste in the mouth, nighttime coughing or aspiration, pneumonia or pneumonitis, bronchospasm, and laryngitis and voice changes, including hoarseness. In addition, objective evidence of esophageal damage can be seen on esophagogastroduodenoscopy as manifested by the incremental grades of esophagitis discussed below. (See Presentation.)

Laboratory tests are seldom useful in establishing a diagnosis of GERD. Esophageal manometry and pH monitoring are considered essential before performing an antireflux operation. Endoscopy reveals that 50% of patients do not have esophagitis. The only way to determine if abnormal reflux is present and if symptoms are actually caused by gastroesophageal reflux is through pH monitoring. Achalasia can present with heartburn. Only esophageal manometry and pH monitoring can be used to distinguish achalasia from GERD. Therapy is completely different for the two conditions. (See Workup.)

GERD is treated via a stepwise approach that is based on lifestyle modifications and control of gastric secretion by means of medical or surgical treatment. [1, 2, 3, 4, 5, 6] (See Treatment.)

GI disorders are some of the most frequent complaints during pregnancy, and gastroesophageal reflux is among these complaints. Some women have certain GI disorders that are unique to pregnancy, and others have chronic GI disorders that require special consideration during pregnancy. Understanding the presentation and prevalence of various GI disorders is necessary in order to optimize care for these patients.

For patient education resources, see Heartburn and GERD Center, as well as Acid Reflux (GERD), GERD FAQs (Gastroesophageal Acid Reflux), and GERD and Heartburn Medications.

Anatomy

The anatomy of the esophagus, stomach, and esophagogastric junction is critical in the understanding of the pathogenesis of reflux.

The esophagus is divided into three parts: cervical, thoracic, and abdominal. The body of the esophagus is made up of inner circular and outer longitudinal muscular layers. The proximal third of the esophagus is striated muscle, which transitions to smooth muscle in the distal two thirds. The proximal esophagus contains the upper esophageal sphincter (UES), which comprises the cricopharyngeus and thyropharyngeus muscles.

The distal thoracic esophagus is located on the left side of midline. As the thoracic esophagus enters the abdomen through the esophageal hiatus in the diaphragm, it becomes the abdominal esophagus. The hiatus is formed by the right crus of the diaphragm, which forms a sling around the esophagus with the right and left pillars, so that the esophagus narrows when the diaphragm contracts. [12, 13, 14] The actual contribution the diaphragm provides in maintaining an adequate length of intra-abdominal esophagus is not clearly understood; however, careful identification and approximation of the pillars during surgical treatment is crucial for preventing recurrence of reflux disease.

At this level, the phrenoesophageal ligament or membrane (see the image below), which is the reflection of the subdiaphragmatic fascia onto the transversalis fascia of the anterior abdominal wall, also encircles the esophagus. A prominent fat pad located on the anterior surface of the esophagus marks the lower limit of the phrenoesophageal ligament, which corresponds to the esophagogastric junction. This junction lies in the abdomen and forms the angle of His. The acute angle and the length of abdominal esophagus both contribute to the normal closure of the esophagus when intragastric and intra-abdominal pressures are high.

Gastroesophageal Reflux Disease. Relationship of the phrenoesophageal ligament to the diaphragm and esophagus.

The lower esophageal sphincter—or, more accurately, the distal esophageal high-pressure zone (HPZ)—is the distal most segment of the esophagus (3-5 cm in adults) and can be anywhere from 2-5 cm in length. Maintenance of an adequate intra-abdominal HPZ is crucial in preventing GERD. This HPZ does not correspond to any visible anatomic structure. It is a zone created by a complex architecture of smooth muscle fibers, and it is typically identified during manometry.

Usually, GERD is caused by a malfunction of one or more of these anatomic features. Proper surgical treatment requires complete preoperative and intraoperative evaluation and correction of all defective features.

Blood supply of esophagus and stomach

The blood supply of the esophagus is segmental (see the image below). The inferior thyroid artery supplies the cervical esophagus. Branches of the bronchial arteries and branches directly off of the aorta supply the proximal and distal thoracic esophagus, respectively. Finally, branches of the left gastric and inferior phrenic artery supply the abdominal esophagus. A relatively constant branch connects the left gastric and inferior phrenic arteries, called the Belsey artery.

Gastroesophageal Reflux Disease. Arterial blood supply and lymphatic drainage of the esophagus.

The blood supply of the stomach is rich, with overlap among the vessels. The lesser curve is supplied by the left and right gastric arteries, branches of the celiac trunk and hepatic artery, respectively. The greater curve is supplied by the right gastroepiploic artery arising from the gastroduodenal artery and the left gastroepiploic artery and the short gastric arteries originating from the splenic artery. This excellent collateral blood supply of the stomach allows the surgeon to ligate much of the arterial supply (ie, the short gastric arteries during fundoplication) without the risk of ischemia (see the image above).

Pathophysiology

Schematically, the esophagus, lower esophageal sphincter (LES), and stomach can be envisioned as a simple plumbing circuit as described by Stein and coworkers. [15] The esophagus functions as an antegrade pump, the LES as a valve, and the stomach as a reservoir. The abnormalities that contribute to GERD can stem from any component of the system. Poor esophageal motility decreases clearance of acidic material. A dysfunctional LES allows reflux of large amounts of gastric juice. Delayed gastric emptying can increase the volume and pressure in the reservoir until the valve mechanism is defeated, leading to GERD. From a medical or surgical standpoint, it is extremely important to identify which of these components is defective so that an effective therapy can be applied.

Esophageal defense mechanisms

Esophageal defense mechanisms can be broken down into two categories (ie, esophageal clearance and mucosal resistance). Proper esophageal clearance is an extremely important factor in preventing mucosal injury. Esophageal clearance must be able to neutralize the acid refluxed through the lower esophageal sphincter. (Mechanical clearance is achieved by esophageal peristalsis; chemical clearance is achieved with saliva.) Normal clearance limits the amount of time the esophagus is exposed to refluxed acid or bile and gastric acid mixtures. Abnormal peristalsis can cause inefficient and delayed acid clearance.

Whether peristaltic dysfunction is secondary to esophageal exposure to acids or a primary defect is not understood clearly. In a review by Kahrilas et al, peristaltic dysfunction was progressively more common in patients with greater degrees of esophagitis. [16] Abnormal peristalsis was identified in 25% of patients with mild esophagitis and 48% of patients with severe esophagitis.

Buttar and associates described the importance of esophageal mucosal resistance as a protective mechanism. [17] They classified the factors into pre-epithelial, epithelial, and postepithelial defenses. When the defenses fail, esophagitis and other complications of reflux disease arise.

Dysfunction of the lower esophageal sphincter

The lower esophageal sphincter (LES) is defined by manometry as a zone of elevated intraluminal pressure at the esophagogastric junction. For proper LES function, this junction must be located in the abdomen so that the diaphragmatic crura can assist the action of the LES, thus functioning as an extrinsic sphincter. In addition, the LES must have a normal length and pressure and a normal number of episodes of transient relaxation (relaxation in the absence of swallowing).

LES dysfunction occurs via one of several mechanisms: transient relaxation of the LES (most common mechanism), permanent LES relaxation, and transient increase of intra-abdominal pressure that overcomes the LES pressure.

Delayed gastric emptying

The postulated mechanism by which delayed gastric emptying may cause GERD is an increase in the gastric contents resulting in increased intragastric pressure and, ultimately, increased pressure against the lower esophageal sphincter. This pressure eventually defeats the LES and leads to reflux. However, objective studies have produced conflicting data regarding the role of delayed gastric emptying in the pathogenesis of GERD.

Hiatal hernia

When discussing the mechanisms for GERD, the issue of hiatal hernia must be addressed. Hiatal hernias can be encountered frequently in patients with reflux disease; however, it has been well proven that not all patients with hiatal hernias have symptomatic reflux.

Buttar and coworkers state that a hiatal hernia may contribute to reflux via a variety of mechanisms. [17] (See the image below). The lower esophageal sphincter may migrate proximally into the chest and lose its abdominal high-pressure zone (HPZ), or the length of the HPZ may decrease. The diaphragmatic hiatus may be widened by a large hernia, which impairs the ability of the crura to function as an external sphincter. Finally, gastric contents may be trapped in the hernial sac and reflux proximally into the esophagus during relaxation of the LES. Reduction of the hernias and crural closure are critical to restoring an adequate intra-abdominal length of esophagus and recreating the HPZ.

Gastroesophageal Reflux Disease. This radiograph shows a hiatal hernia.

Obesity as contributing factor

Some studies have shown that GERD is highly prevalent in patients who are morbidly obese and that a high body mass index (BMI) is a risk factor for the development of this condition. [18, 19, 20, 21, 22, 23] The hypothesis that obesity increases esophageal acid exposure is supported by the documentation of a dose-response relationship between increased BMI and increased prevalence of GERD and its complications. Therefore, the pathophysiology of GERD in patients who are morbidly obese might differ from that of patients who are not obese. The therapeutic implication of such a premise is that the correction of reflux in patients who are morbidly obese might be better achieved with a procedure that first controls obesity.

The mechanism by which a high BMI increases esophageal acid exposure is not completely understood. Increased intragastric pressure and gastroesophageal pressure gradient, incompetence of the lower esophageal sphincter (LES), and increased frequency of transient LES relaxations may all play a role in the pathophysiology of GERD in patients who are morbidly obese.

Etiology

Excessive retrograde movement of acid-containing gastric secretions or bile and acid-containing secretions from the duodenum and stomach into the esophagus is the etiologic effector of GERD. From a therapeutic point of view, informing patients that gastric refluxate is made up not only of acid but also of duodenal contents (eg, bile, pancreatic secretions) is important.

A functional (frequent transient LES relaxation) or mechanical (hypotensive LES) problem of the LES is the most common cause of GERD. Transient relaxation of the LES can be caused by foods (coffee, alcohol, chocolate, fatty meals), medications (beta-agonists, [24] nitrates, calcium channel blockers, anticholinergics), hormones (eg, progesterone), and nicotine.

Epidemiology

Western dietary habits have made GERD a common disease. The prevalence of GERD in Western populations is estimated to be 10-20%, whereas it is about 2.5-17.0% in Asian populations. [25]

Richter and associates reported that 25%-40% of Americans experience symptomatic GERD at some point. [19] Approximately 7%-10% of Americans experience symptoms of GERD on a daily basis. Because many individuals control their symptoms with over-the-counter (OTC) medications and without consulting a medical professional, the actual number of individuals with GERD is probably higher.

No sexual predilection exists: GERD is as common in men as in women. However, the male-to-female incidence ratio for esophagitis is 2:1-3:1. The male-to-female incidence ratio for Barrett esophagus is 10:1. White males are at a greater risk for Barrett esophagus and adenocarcinoma than other populations.

GERD occurs in all age groups. The prevalence of GERD increases in people older than 40 years.

Prognosis

Most patients with GERD do well with medications, although a relapse after cessation of medical therapy is common and indicates the need for long-term maintenance therapy.

Identifying the subgroup of patients who may develop the most serious complications of GERD and treating them aggressively is important. Surgery at an early stage is most likely indicated in these patients. After a laparoscopic Nissen fundoplication, symptoms resolve in approximately 92% of patients.

The LOTUS trial—a 5-year, exploratory randomized, open, parallel-group trial—demonstrated that with antireflux therapy for GERD, either using drug-induced acid suppression with esomeprazole or laparoscopic antireflux surgery, most patients achieve remission and remain in remission at 5 years. [26]

Most cases of gastroesophageal reflux in infants and very young children are benign and respond to conservative nonpharmacologic treatment (developmental disabilities represent an important diagnostic exception); 80% resolve by age 18 months (55% resolve by age 10 mo). Some patients require a "step-up" to acid-reducing medications, and only a very small minority require surgery. Because symptomatic gastroesophageal reflux after age 18 months likely represents a chronic condition, long-term risks are increased. For patients whose gastroesophageal reflux persists into later childhood, long-term therapy with antisecretory agents is often required.

In refractory cases or when complications related to reflux disease are identified (eg, stricture, aspiration, airway disease, Barrett esophagus), surgical treatment (fundoplication) is typically necessary. The prognosis with surgery is considered excellent. The surgical morbidity and mortality is higher in patients who have complex medical problems in addition to gastroesophageal reflux.

Complications of disease

Esophagitis

Esophagitis (esophageal mucosal damage) is the most common complication of GERD, occurring in approximately 50% of patients (see the images below).

Gastroesophageal Reflux Disease. This image demonstrates peptic esophagitis.

Gastroesophageal Reflux Disease. Reflux esophagitis is demonstrated on barium esophagram.

Esophagitis may be diagnosed using endoscopy, although it cannot always be appreciated on endoscopy. As many as 50% of symptomatic patients with GERD demonstrate no evidence of esophagitis on endoscopy. Still, documentation of this complication is important in diagnosing GERD. Degrees of esophagitis are described by the Savary-Miller classification as follows.

Grade I – Erythema
Grade II – Linear nonconfluent erosions
Grade III – Circular confluent erosions
Grade IV – Stricture or Barrett esophagus.

Stricture

Strictures are advanced forms of esophagitis and are caused by circumferential fibrosis due to chronic deep injury. Strictures can result in dysphagia and a short esophagus. Gastroesophageal reflux strictures typically occur in the mid-to-distal esophagus and can be visualized on upper GI tract studies and endoscopy. Presence of a stricture with a history of reflux can also help diagnose GERD. Patients present with dysphagia to solid meals and vomiting of nondigested foods.

As a rule, the presence of any esophageal stricture is an indication that the patient needs surgical consultation and treatment (usually surgical consultation). When patients present with dysphagia, barium esophagography is indicated to evaluate for possible stricture formation. In these cases, especially when associated with food impaction, eosinophilic esophagitis must be ruled out prior to attempting any mechanical dilatation of the narrowed esophageal region.

Barrett esophagus

The most serious complication of long-standing or severe GERD is the development of Barrett esophagus. Barrett esophagus is present in 8%-15% of patients with GERD. Barrett esophagus is thought to be caused by the chronic reflux of gastric juice into the esophagus. It is defined by metaplastic conversion of the normal distal squamous esophageal epithelium to columnar epithelium. Histologic examination of esophageal biopsy specimens is required to make the diagnosis. Varying degrees of dysplasia may be found on histologic examination.

Barrett esophagus with intestinal type metaplasia has malignant potential and is a risk factor for the development of esophageal adenocarcinoma (see the images below), increasing the risk of adenocarcinoma 30-40 times. The incidence of adenocarcinoma of the esophagus is increasing steadily in Western society. Currently, adenocarcinoma accounts for more than 50% of esophageal cancers in the Western industrialized nations.

Gastroesophageal Reflux Disease. Gastroesophageal reflux disease (GERD)/Barrett esophagus/adenocarcinoma sequence.

Gastroesophageal Reflux Disease. Endoscopy demonstrating intraluminal esophageal cancer.

As with esophageal stricture, the presence of Barrett esophagus indicates the need for surgical consultation and treatment (usually surgical fundoplication).

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Author

Marco G Patti, MD Surgeon, UNC Hospitals Multispecialty Surgery Clinic

Marco G Patti, MD is a member of the following medical societies: American Association for the Advancement of Science, American College of Surgeons, American Gastroenterological Association, American Medical Association, American Surgical Association, Association for Academic Surgery, Pan-Pacific Surgical Association, Society for Surgery of the Alimentary Tract, Society of American Gastrointestinal and Endoscopic Surgeons, Southwestern Surgical Congress, Western Surgical Association