Gastroenterology

Gastroenterology

GERD Beyond the burning basics By Michael Lemp, MSN, RN, NP-C

Diagnosis of GERD can be made based on clinical symptoms alone.

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GASTROESOPHAGEAL reflux disease (GERD) is one of the most common gastrointestinal conditions in the United States.1-4 The economic burden of GERD is estimated at more than $24 billion annually.2 In addition to economic costs and lost productivity, GERD significantly lowers quality of life. More alarming, GERD is the most common predisposing factor for esophageal adenocarcinoma.3 Heartburn and reflux are the most typical symptoms of GERD, but many other symptoms prompt inclusion of GERD in the differential list.4 Pathophysiology Some degree of gastric content reflux is normal. GERD occurs when the level of reflux causes symptoms and/or esophageal mucosal injury. This abnormal amount of reflux is caused by disruption of the antireflux barrier at the gastroesophageal junction. The three primary mechanisms of gastroesophageal junction incompetence are: transient lower esophageal sphincter

relaxations, a hypotensive lower esophageal sphincter, and anatomic disruption of the gastroesophageal junction.5 Factors such as hiatal hernia, obesity, delayed gastric motility, supine position, alcohol, nicotine, and certain foods can exacerbate gastroesophageal junction incompetence.3,5,6 Endogenous defenses protect against gastric content, including pepsin and bile products.3 Some of the defense mechanisms include esophageal peristalsis, saliva secretion and epithelial defenses. As the assault on the esophagus continues, the defenses become less effective. The defenses are further reduced by factors such as smoking, which decreases the amount of saliva produced. While GERD is a condition of reflux, not all reflux is acidic. In addition to typical erosive reflux disease, manifestations such as nonerosive esophageal reflux disease (NERD) and extraesophageal reflux disease exist and can include specific conditions such as laryngopharyngeal reflux.7,8 Each type of manifestation can have specific symptoms and different etiologies. In any manifestation of GERD in which erosive content is refluxed, concern exists for morphologic changes. As the esophagus and upper airway continue to be exposed to acidic fluids and their defensive mechanisms weaken, they undergo metaplastic changes. If exposure continues, the cells undergo dysplastic changes and eventually advance to carcinoma.9

Diagnosis Typical symptoms of GERD are heartburn (usually postprandial) and regurgitation.1,4,6,10,11 Atypical symptoms include epigastric fullness or pressure, epigastric pain, dyspepsia, nausea, bloating, belching, chronic cough, hoarseness, globus, chest pain, chronic aspiration, bronchitis, sinusitis, dental erosion, sleep apnea, and water brash.1,6,10,11 Alarm symptoms include dysphagia, odynophagia, bleeding, weight loss, anemia, early satiety, and vomiting.1,6,10,11 Diagnosis of GERD can be made based on clinical symptoms alone. Aids in diagnosis include response to acid suppression therapy and diagnostics such as upper

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Gastroenterology endoscopy, esophageal reflux monitoring (pH and impedance testing), and esophageal manometry.1,3,4,6,10 Diagnosis should be made in a graduated manner, first with consideration of symptoms and then with response to acid suppression therapy. Upper endoscopy should be reserved for patients with alarm symptoms, high risk of complications, patients refractory to proton pump inhibitor (PPI) therapy, or longstanding uncontrolled GERD.1,4 Esophageal reflux monitoring should

tions may not eliminate symptoms, but they can decrease the need for medications and invasive procedures. Medications have long been the mainstay of GERD management.1,3 The two most common classes used are histamine 2 receptor agonists (H2RAs) and PPIs. H2RAs are effective at reducing postprandial acid in comparison to antacids.1,3 H2RAs can also be utilized for on-demand treatment and control of nocturnal symptoms.1,3 PPIs should be

Two schools of thought exist about treatment. The first is to start with minimal treatment and titrate up to desired effect. The second is to start with high-dose therapy, titrate down until recurrence, then move back to the last effective regimen. be reserved for patients refractory to PPI therapy.1,4 Esophageal manometry should be reserved for complex cases or preoperative evaluation.1,4

Treatment Treatment goals are symptom reduction, esophageal healing, recurrence prevention and prevention of complications. Methods of treatment include diet and lifestyle modifications, medications and surgical intervention. Complex patients and patients with GERD that is refractory to PPI treatment should be referred to a gastroenterology practice. Lifestyle and diet modification is the most cost-effective and efficient longterm treatment option for GERD.1,4,6,10,11 Lifestyle modifications include weight loss; smoking cessation; elevating the head of the bed; avoiding postprandial recumbency; and avoiding potentiating medications.1,4,6,10,11 Diet modification consists of eliminating trigger foods, eating smaller portions and eating more frequently, and avoiding large meals.1-5,10,11 The most common triggers of GERD symptoms are caffeine, chocolate, alcohol, citrus products, tomato products, onion, garlic, carbonated beverages, peppermint, fatty and fried foods, and spicy foods.1,4,6,10,11 Lifestyle and diet modifica-

used for esophageal healing, relapse prevention, and for treatment of moderate to severe symptoms.1,3 PPIs can be used to control GERD symptoms, but they show less efficacy than when used for erosive esophagitis.1,3 Both H2RAs and PPIs should be taken 30 to 60 minutes before eating; 30 minutes is ideal. 1,3,4,6,10,11 Other medications can be used alone or as adjuvant treatments to help control symptoms. Some options include alginates (e.g. sodium alginate), protectants (e.g. sucralfate) and antacids (e.g. calcium carbonate). 1,3,4,6,10,11 While these drugs do not reduce acid, they can be quite effective in treating symptoms. In challenging cases, certain medications are effective in managing symptoms or concomitant complicating disease processes. These medications include bile acid agents, prokinetics, GABAb agonists, tricyclic antidepressants, selective serotonin reuptake inhibitors, and trazadone.1,3,4,6,10,11 Their use should be reserved for prescribers familiar with them, due to the complexities of care. Two dominant schools of thought exist about treatment. The first is to start with minimal treatment and titrate up to desired effect. The second is to start with high-dose therapy, titrate down until recurrence, then move back to the

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last effective regimen. Regimen selection should be made by considering the clinical efficacy of the proposed regimen, cost of treatment and likelihood of patient adherence.11 After symptom control has been gained and the esophagus has had time to heal (8 to 12 weeks), the provider can attempt to discontinue therapy.4,11 The provider should be aware that continuation of some level of treatment may needed for ongoing symptom management. For long-term GERD patients or patients with refractory symptoms, surgical intervention is an option. Procedures include fundoplication, bariatric surgery, LINX procedure, and radiofrequency ablation.1,3,4,6,10,11 Although surgery can be advantageous, it is only 52% effective at 3 to 5 years postprocedure.11

A Duty to Prevent Damage The healthcare provider has a duty to ensure that damage from GERD is arrested and not allowed to progress, since it can result in carcinoma. While an astute practitioner will understand the nuances of treating GERD, he or she will also know when to refer for consultation. ‫ڦ‬ References 1. Badillo R, Francis D. Diagnosis and treatment of gastroesophageal reflux disease. World J Gastrointest Pharmacol Ther. 2014;5(3):105-112. 2. Kubo A, et al. Dietary guideline adherence for gastroesophageal reflux disease. BMC Gastroenterol. 2014;14:144. 3. Nwokediuko SC. Current trends in the management of gastroesophageal reflux disease: a review. ISRN Gastroenterol. 2012;2012:391-631. 4. Katz PO, et al. Guidelines for the diagnosis and management of gastroesophageal reflux disease. Am J Gastroenterol. 2013;108(3):308-328. 5. Kahrilas PJ. Pathophysiology of reflux esophagitis. UpToDate. http://www.uptodate.com/contents/ pathophysiology-of-reflux-esophagitis 6. Singhal V, Khaitan L. Gastroesophageal reflux disease: diagnosis and patient selection. Indian J Surg. 2014;76(6):453-460. 7. Asaoka D, et al. Current perspectives on reflux laryngitis. Clin J Gastroenterol. 2014;7(6):471-475. 8. Fisichella PM. Hoarseness and laryngopharyngeal reflux. JAMA. 2015;313(18):1853-1854. 9. Oden KL. When heartburn gets serious: an update on Barrett’s esophagus. ADVANCE for NPs & PAs. 2011;2(8):37-38, 41, 50. 10. Kahrilas PJ. Clinical manifestations and diagnosis of gastroesophageal reflux in adults. UpToDate. http:// www.uptodate.com/contents/clinical-manifestationsand-diagnosis-of-gastroesophageal-reflux-in-adults 11. Universit y of Michigan Health System. Gastroesophageal Reflux Disease. http://www.med. umich.edu/1info/FHP/practiceguides/gerd/gerd.12.pdf

Michael Lemp is a nurse practitioner at Metro East Gastroenterology in Belleville, Ill.