Gastroesophageal reflux
The backflow or reflux of gastric and duodenal contents into the esophagus and past the lower esophageal sphincter (LES), without associated belching or vomiting, is called gastroesophageal reflux. Reflux may or may not cause symptoms or pathologic changes. Persistent reflux may cause reflux esophagitis (inflammation of the esophageal mucosa). The prognosis varies with the underlying cause.
Causes
The function of the LES — a high-pressure area in the lower esophagus, just above the stomach — is to prevent gastric contents from backing up into the esophagus. Normally, the LES creates pressure, closing the lower end of the esophagus, but relaxes after each swallow to allow food into the stomach.
Reflux occurs when LES pressure is deficient or when pressure within the stomach exceeds LES pressure.
The amount of time the reflux is in contact with the esophagus as well as the potency of the reflux relates to esophageal damage. Gastroesophageal reflux can also be related to delayed gastric emptying resulting from partial gastric outlet obstruction or gastroparesis. It may also be attributed to an abnormal esophageal clearance. In this instance, acid isn’t cleared and neutralized by esophageal peristalsis and salivary bicarbonates, as it is normally.
Clinical tip Gastroesopha-geal reflux may also be related to atypical symptoms, such as chronic cough, sore throat, asthma, and laryngitis, and atypical chest pain.
Predisposing factors include the following:
❑ pyloric surgery (alteration or removal of the pylorus), which allows reflux of bile or pancreatic juice
❑ long-term nasogastric (NG) intubation (more than 5 days)
❑ any agent that lowers LES pressure, such as food, alcohol, cigarettes, anticholinergics (atropine, belladonna, and propantheline), and other drugs (morphine, diazepam, and meperidine)
❑ hiatal hernia (especially in children)
❑ any condition or position that increases intra-abdominal pressure.
Signs and symptoms
Gastroesophageal reflux doesn’t always cause symptoms. The most common features of this disorder are indigestion and heartburn, which may become more severe 30 to 60 minutes after meals and on reclining and with vigorous exercise, bending, or lying down and which may be relieved by antacids or sitting upright.
The pain of esophageal spasm resulting from reflux esophagitis tends to be chronic and may mimic that of angina pectoris, radiating to the neck, jaws, and arms. Other symptoms include odynophagia, which may be followed by a dull substernal ache from severe, long-term reflux; dysphagia from esophageal spasm, stricture, or esophagitis; and bleeding (bright red or dark brown).
Rarely, nocturnal regurgitation wakens the patient with coughing, choking, and a mouthful of saliva. Reflux may be associated with hiatal hernia.
Pulmonary symptoms result from reflux of gastric contents into the throat and subsequent aspiration. They include chronic pulmonary disease or nocturnal wheezing, bronchitis, asthma, morning hoarseness, and cough.
In children, other signs consist of failure to thrive and forceful vomiting from esophageal irritation. Such vomiting sometimes causes aspiration pneumonia.
Diagnosis
After a careful history and physical examination, tests to confirm gastroesophageal reflux include barium swallow fluoroscopy, esophageal pH probe, endoscopy, and esophagoscopy. In children, barium esophagography under fluoroscopic control can show reflux. Recurrent reflux after age 6 weeks is abnormal.
An acid perfusion (Bernstein) test can show that reflux is the cause of symptoms. Degree of reflux may be determined with 12- to 36-hour esophageal pH monitoring. Finally, endoscopy and a biopsy allow visualization and confirmation of pathologic changes in the mucosa.
Treatment
Effective management relieves symptoms by reducing intra-abdominal pressure and reflux through gravity, neutralizing gastric contents, strengthening the LES with drug therapy and, in severe cases, performing surgery.
Positional therapy
To reduce intra-abdominal pressure and reflux, the patient should sleep in a reverse Trendelenburg position (with the head of the bed elevated) and should avoid lying down after meals and late-night snacks. In uncomplicated cases, positional therapy is especially useful in infants and children. The patient is also encouraged to reduce his weight to help reduce symptoms.
Drug therapy
In mild cases, over-the-counter antisecretory agents are helpful. In moderate cases, histamine-2 receptor blocking agents (cimetidine, ranitidine, famotidine, nizatidine) for 6 to 12 weeks provide symptom relief. Erosive esophagitis is better treated with proton pump inhibitors (omeprazole, lansoprazole, pantoprazole, or rabeprazole) and heals up to 90% of patients.
Surgery
Surgical intervention may be necessary to control severe and refractory symptoms, such as pulmonary aspiration, hemorrhage, obstruction, severe pain, perforation, incompetent LES, and associated hiatal hernia.
Surgical procedures include antireflux surgery, in which the fundus is wrapped around the esophagus (fundoplication). Also, vagotomy or pyloroplasty may be combined with an antireflux regimen to modify gastric contents.
UNDER STUDY: Endoluminal gastric plication (Endocinch) and radiofrequency energy delivery (Stretta system) are two modalities approved for outpatient treatment of gastroesophageal reflux. Endoluminal gastric plication involves ligating and tightening the lax area within the lesser curve of the stomach, thereby strengthening and increasing the LES pressure. Radiofrequency energy delivered to the target tissue results in the same effect. Both have shown promising short-term results.
Special considerations
❑ Teach the patient correct preparation for diagnostic testing. For example, he shouldn’t eat for 6 to 8 hours before having a barium X-ray or endoscopy.
❑ After surgery using a thoracic approach, carefully watch and record chest tube drainage and respiratory status. If needed, give chest physiotherapy and oxygen. Place the patient with an NG tube in semi-Fowler’s position to help prevent reflux. Offer reassurance and emotional support.
❑ Teach the patient how to avoid and treat reflux. (See Coping with reflux.)
Pictures
Book Source Details
- Book Title: Handbook of Diseases
- Author(s): Springhouse
- Year of Publication: 2003
- Copyright Details: Handbook of Diseases, Copyright © 2003 Lippincott Williams & Wilkins.
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Copyright Details: Handbook of Diseases, Copyright © 2008 Williams & Wilkins.
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More About This Book:
Title: Handbook of Diseases
Authors: Springhouse
Publisher: Lippincott Williams & Wilkins
Copyright: 2003
ISBN: 1-58255-266-5
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