Gastroesophageal Reflux

– Esophageal, laryngeal, or pulmonary inflammation and injury related to repeated reflux of gastrointestinal contents. Esophageal inflammation is often called esophagitis.

Causes and Incidence

Reflux (backflow of gastric and intestinal contents into the esophagus) is the result of an incompetent lower esophageal sphincter. Factors that contribute to this incompetence include pyloric surgery; prolonged nosogastric tube intubation; drugs, alcohol, nicotine, or fatty foods, which lower intrinsic sphincter pressure; and conditions or positions (lying down) that increase intraabdominal pressure.

Disease Process

Hydrochloric acid and pepsin are belched back into the esophagus from the stomach. These gastric secretions attack intercellular junctions in the distal esophagus, causing patchy, superficial lesions, edema, and necrosis. When bile salts are also refluxed, they potentiate the corrosiveness of gastric secretions and attack the plasma membranes. As the disease progresses, the lesions spread to the entire esophagus. After the mucosal tissue necroses, the cells are replaced with a proliferation of basal cells, which cause a narrowing and branching of papillae, leading to hyperplasia of the esophagus. With chronic reflux, the normal squamous epithelium is gradually replaced by columnar epithelium (mucosal metaplasia). The esophagus eventually becomes scarred, develops strictures, and is shortened.

Symptoms

Early
Heartburn (particularly with spicy or fatty meals, exercise, and recumbent positions) that is relieved by antacids

Midcourse
Heartburn accompanied by high epigastric and substernal pain; regurgitation; dysphagia

Late
Bleeding; dysphagia; disappearance of heartburn

Potential Complications

Complications include obstruction, hemorrhage, and tearing or esophageal perforation from strictures. If the gastric contents are refluxed and then aspirated, the larynx, trachea, and lungs are damaged. Repeated aspiration may lead to chronic pulmonary disease. Infants, children with brain injuries, and adults in a vegetative state are particularly susceptible to pulmonary complications from repeated reflux and aspiration. Individuals with long-standing disease have a greater risk of esophageal cancer.

Diagnostic Tests

Esophageal acidity test
To confirm reflux

Esophageal manometry
To determine sphincter competence

Acid perfusion test
To confirm esophagitis

Endoscopy with biopsy
To evaluate extent of disease

Treatments

Surgery
Fundoplication to eliminate reflux is performed in patients with severe complications, particularly recurrent aspiration pneumonia.

Drugs
Antacids for pain; antisecretory drugs to reduce gastric secretions; gastrokinetics to stimulate salivation and improve sphincter pressure; anticholinergics are contraindicated because they lower sphincter pressure.

General
Head of bed elevated; avoidance of food or drink that stimulates acid production (e.g., coffee, alcohol) or lowers sphincter pressure (e.g., smoking, chocolate, fats); many small meals; no food at least 2 hours before bedtime, or remaining upright 2 hours after eating; increased fluid intake; esophageal dilation to manage strictures; periodic endoscopic evaluation for cancer.