gastroesophageal reflux disease
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gastroesophageal reflux disease (GERD),
Although the underlying abnormality in GERD is apparently inborn and irreversible, the incidence of symptomatic disease increases with age. In addition to reflux, most cases involve disordered gastric motility and delayed gastric emptying. Symptoms include recurring epigastric and retrosternal distress, usually described as heartburn, along with varying degrees of belching, nausea, gagging, cough, or hoarseness. Almost 50% of adults in the U.S. report experiencing these symptoms at least once a month, and almost 20% experience them at least once a week. GERD is increasingly recognized as a cause of throat irritation and chronic cough. The incidence of GERD among adults with asthma may be as high as 80%. The disorder is more common in men. The likelihood of symptomatic reflux is increased by obesity, pregnancy, cigarette smoking, diabetes mellitus, scleroderma, and other connective tissue diseases. Symptoms can be induced by recumbency, strenuous exercise, heavy lifting, smoking, eating large meals, or consuming alcohol, chocolate, fatty foods, and drugs such as theophylline, calcium channel blockers, and anticholinergic agents. Acid reflux can cause peptic esophagitis, ulcer formation, esophageal stricture, or metaplastic change in esophageal squamous epithelium, called Barrett esophagus, which can progress to carcinoma. Diagnosis of GERD is by history, esophageal pH monitoring, radiologic study showing reflux of swallowed barium, and endoscopy to identify ulceration or stricture and permit biopsy to rule out malignancy. Treatment includes avoidance of known aggravating factors and administration of antacids, H2 antagonists, prokinetic agents, and proton pump inhibitors. Surgical procedures to inhibit reflux mechanically, particularly Nissen fundoplication, can improve symptoms in severe disease but have not been shown to prevent carcinoma in patients with GERD and Barrett esophagus. Fewer than one half of patients who have had surgery remain symptom free without antisecretory medicine. Gastroesophageal reflux, with passive regurgitation of feedings, occurs in about 50% of healthy infants but seldom persists beyond 1 year of age.
gastroesophageal reflux disease
gas·tro·e·soph·a·ge·al re·flux dis·ease(GERD) (gas'trō-ĕ-sof'ă-jē'ăl rē'flŭks di-zēz')
Synonym(s): gastro-oesophageal reflux disease.
Gastroesophageal reflux disease (GERD)
Gastroesophageal Reflux Disease
|Mean LOS:||3.3 days|
|Description:||SURGICAL: Stomach, Esophageal, and Duodenal Procedure Without CC or Major CC|
|Mean LOS:||5.1 days|
|Description:||MEDICAL: Esophagitis, Gastroenteritis, and Miscellaneous Digestive Disorders With Major CC|
Gastroesophageal reflux disease (GERD) is a syndrome caused by esophageal reflux, or the backward flow of gastroesophageal contents into the esophagus. It is a common syndrome that is experienced by up to 40% of people at some point in their lives. GERD occurs because of inappropriate relaxation of the lower esophageal sphincter (LES) in response to an unknown stimulus. Reflux occurs in most adults, but if it occurs regularly, the esophagus cannot resist the irritating effects of gastric acid and pepsin because the mucosal barrier of the esophagus breaks down. Without this protection, tissue injury, inflammation, hyperemia, and even erosion occur.
As healing occurs, the cells that replace the normal squamous cell epithelium may be more resistant to reflux but may also be a premalignant tissue that can lead to adenocarcinoma. Repeated exposure may also lead to fibrosis and scarring, which can cause esophageal stricture to occur. Stricture leads to difficulty in swallowing. Chronic reflux is often associated with hiatus hernia.
Barrett’s esophagus is a condition thought to be caused by the chronic reflux of gastric acid into the esophagus. It occurs when squamous epithelium of the esophagus is replaced by intestinal columnar epithelium, a situation that may lead to adenocarcinoma. Barrett’s esophagus is present in approximately 10% to 15% of patients with GERD.
The causes of GERD are not well understood. Many patients with GERD have normal resting LES pressure and produce normal amounts of gastric acid. Possible explanations for GERD include delays in gastric emptying, changes in LES control with aging, and obesity. Environmental and physical factors that lower tone and contractility of the LES include diet (fatty foods, peppermint, alcohol, caffeine, chocolate) and drugs (nicotine, beta-adrenergic blockers, nitrates, theophylline, anticholinergic drugs).
Family history appears to be a significant risk factor for GERD. Twin concordance has been shown to be 42% among identical twins and only 26% between nonidentical twins. Barrett’s esophagus most likely has a genetic component as well because its incidence associated with GERD is highly variable.
Gender, ethnic/racial, and life span considerations
GERD occurs at any age but is most common in people over age 50. It occurs in both men and women, and it is a common disorder that affects as much as one-third of the total population. Although white males are more at risk for Barrett’s esophagus and adenocarcinoma than other populations, no gender or racial/ethnic considerations are reported for other types of gastroesophageal reflux.
Global health considerations
While the global prevalence of GERD is unknown, heartburn is a common problem in North America and Western Europe, with approximately 7% of the population reporting daily symptoms.
Elicit a history of contributing factors, including the regular consumption of fatty foods, caffeinated beverages, chocolate, nicotine, alcohol, or peppermint. Take a drug history to determine if the patient has been taking drugs that may contribute to GERD: beta-adrenergic blockers, calcium channel blockers, nitrates, theophylline, diazepam, anticholinergic drugs, estrogen, and progesterone.
Little relationship appears to occur between the severity of symptoms and the degree of esophagitis. Some patients have minimal evidence of esophagitis, whereas others with severe, chronic inflammation may have no symptoms until stricture occurs. Patients may describe the characteristic symptom of heartburn (also known as pyrosis or dyspepsia). The discomfort is often a substernal or retrosternal pain that radiates upward to the neck, jaw, or back. Patients describe a worsening pain when they bend over, strain, or lie flat. With severe inflammation, discomfort occurs after each meal and lasts for up to 2 hours. Patients may describe coughing, hoarseness, or wheezing at night.
Patients may also report regurgitation, with a sensation of warm fluid traveling upward to the throat and leaving a bitter, sour taste in the mouth. Other symptoms may include difficulty swallowing (dysphagia) and painful swallowing (odynophagia) during eating, as well as eructation, flatulence, or bloating after eating.
The most common symptoms are heartburn, regurgitation, and dysphagia. Generally, the patient’s physical appearance is unchanged by GERD. On rare occasions, some patients may experience unexplained weight loss.
Psychosocial assessment should include assessment of the degree of stress the person experiences and the strategies she or he uses to cope with stress.
|Test||Normal Result||Abnormality With Condition||Explanation|
|Esophageal pH monitoring||> 5||< 5||Presence of gastric contents in the esophagus decreases pH|
|Esophageal manometry||Congruent esophageal pressures bilaterally; competent LES||Abnormal contractions and peristalsis; incompetent LES; low resting pressure of LES||Multilumen esophageal catheter introduced through mouth; used to measure esophageal pressures during a variety of swallowing maneuvers|
Other Tests: Esophagogastroduodenoscopy, barium esophagogram, scintigraphy, barium esophagogram, Bernstein’s test (acidic solution infused into stomach causing heartburn in patients with GERD)
Primary nursing diagnosis
DiagnosisPain related to esophageal reflux and esophageal inflammation
OutcomesComfort level; Pain control behavior; Pain level; Symptom control behavior; Symptom severity
InterventionsMedication administration; Medication management; Pain management; Positioning; Environmental management: Comfort; Nutritional monitoring; Weight management
Planning and implementation
Although diet therapy alone can manage symptoms in some patients, most patients can have their GERD managed pharmacologically. Dietary modifications that may decrease symptoms include reducing intake of fatty foods, caffeinated beverages, chocolate, nicotine, alcohol, and peppermint. Reducing the intake of spicy and acidic foods lets esophageal healing occur during times of acute inflammation. Encourage the patient to eat five to six small meals during the day rather than large meals. Ingestion of large amounts of food increases gastric pressure and thereby increases esophageal reflux. Both weight loss and smoking-cessation programs are also important for any patients who have problems with obesity and tobacco use.
Surgical procedures to relieve reflux are generally reserved for those otherwise healthy patients who have not responded to medications. Three major surgical procedures are used: Nissen fundoplication (surgeon wraps fundus of the stomach around esophagus to anchor the LES area below the diaphragm), Hill’s repair (anchors gastroesophageal junction to the median arcuate ligament), and Belsey’s repair (transthoracic approach with a fundic wrap around the distal esophagus).
|Medication or Drug Class||Dosage||Description||Rationale|
|Antacids||Usually 30 mL between meals and as needed PO||Aluminum or magnesium salts||Neutralize gastric acid and relieve heartburn|
|Proton pump inhibitors (thought to be more effective) or H2 receptor antagonists||Varies with drug; routes vary||Decrease gastric acid production; omeprazole, lansoprazole, cimetidine, ranitidine, famotidine, nizatidine||Proton pump inhibitors are the most powerful medications available; used when GERD is well documented; proton pump inhibitors block final step in the H+ ion secretion by the parietal cell, have few adverse effects, and are well tolerated|
|Cisapride||10–20 mg PO qid before meals and at bedtime||Gastrointestinal (GI) stimulant||Increases LES pressure and improves esophageal clearance and gastric emptying|
|Metoclopramide||10 mg PO tid before meals||GI stimulant||Improves gastric emptying and increases LES pressure|
|Sulcrafate||1 g PO qid||Antiulcer||Forms a protective adhesive gel over areas of injury or inflammation|
Many patients experience nighttime reflux because of the recumbent position and infrequent swallowing. Changing the patient’s position by elevating the head of the bed during sleep may mitigate symptoms. Place 6-inch blocks under the head of the bed or place a wedge under the mattress to enhance nocturnal acid clearance. Encourage the patient to avoid food for 3 hours before going to sleep and advise the patient to eat slowly and chew food thoroughly. Encourage patients to avoid large meals.
Lifestyle modifications are important in the management of GERD. Lifestyle changes to reduce intra-abdominal pressure may be helpful to relieve symptoms. Encourage the patient to avoid the following: restrictive clothing, lifting heavy objects, straining, working in a bent-over position, and stooping. Support the patient’s efforts to stop smoking, lose weight, and reduce stress. Encourage them to avoid alcohol, chocolate, coffee, citrus fruit, and tomatoes. Make appropriate referrals to the dietitian to provide the knowledge essential for weight control.
Evidence-Based Practice and Health Policy
Jansson, C., Wallander, M.A., Johansson, S., Johnsen, R., & Hveem, K. (2010). Stressful psychosocial factors and symptoms of gastroesophageal reflux disease: A population-based study in Norway. Scandinavian Journal of Gastroenterology, 45(1), 21–29.
- A population-based, cross-sectional case-control study among 3,153 individuals reporting severe GERD symptoms and 40,210 individuals without symptoms revealed significant associations between workplace experiences and symptomatology risk.
- Those who reported high demands at work were twice as likely to report severe GERD compared to those who reported low demands (95% CI, 1.4 to 2.8; p < 0.001).
- The individuals who reported low decisional authority were 1.4 times more likely to report severe GERD than those who reported high decision authority (95% CI, 1 to 1.9; p = 0.03).
- Discomfort: Timing, character, location, duration, precipitating factors
- Nutrition: Food and fluid intake; understanding of dietary restriction and weight reduction for each meal; daily weight measurement
- Medication management: Understanding drug therapy, response to medications
- Response to nighttime positioning: Progress of changing position of head of the bed at night, tolerance to position change
Discharge and home healthcare guidelines
Teach the patient how to maintain adequate nutrition and hydration and to manage medications. Make sure the patient and family understand all aspects of the treatment regimen. Review dietary limitations, recommendations to reduce weight and cut out tobacco, and dosage and side effects of all medications. Make sure the patient understands the need to change position at nighttime and that he or she has the supplies required to do so.
gas·tro·e·soph·a·ge·al re·flux dis·ease(GERD) (gas'trō-ĕ-sof'ǎ-jē'-ăl rē'flŭks di-zēz')
Synonym(s): gastro-oesophageal reflux disease.
Patient discussion about gastroesophageal reflux disease
Q. Baby with Gastro esophageal Reflux... I have a baby with Gastro esophageal Reflux Disease, should I worry that she will have autism? I want to clarify my doubt to be more overcautious. Kindly guide me!
Q. how do you deal with a mild case of acid reflux
Try to refrain from lying down immediately after a meal, or eating just before bedtime. Overweight is a risk factor for reflux, so if it's relevant weight reduction is also recommended.
If you feel heartburn, you may chew in order to increase salivation and thus alleviate the symptoms. Smoking has a negative effect on salivation, so smoking cessation is also recommended.
And that's before we even mentioned OTC drugs...
Q. is there anything to cure G.E.R.D. instead of taking pills daily?
here is a nice tutorial about it:
and of course you can avoid some types of food and habits (sorry...long and tasty list...):