Gastroesophageal Reflux Disease and Peptic Ulcer Disease
Alice Lim
Gastroesophageal reflux disease (GERD) and peptic ulcer disease (PUD) are two disorders of the gastrointestinal (GI) tract that can cause tissue damage and unpleasant symptoms. They are both commonly encountered in the primary care and gastroenterology settings and can also significantly decrease a patient’s health-related quality of life if left unmanaged.
GASTROESOPHAGEAL REFLUX DISEASE
GERD is defined as “troublesome symptoms and/or complications” resulting from the abnormal reflux of gastric contents into the esophagus or beyond, including the oral cavity or lungs. Troublesome symptoms are those that have a negative impact on the patient’s well-being and quality of life.
Depending on how the patient presents, GERD syndromes may be classified into two categories: (1) symptoms present but without erosions seen on endoscopic exam or (2) those with esophageal tissue injury. Esophageal erosions occur as a result of repeated exposure to refluxed material for prolonged periods of time.
GERD may occur in all ages, but most commonly occurs in those older than 40 years of age. Patients with mild symptoms do not always seek medical treatment and instead self-treat with lifestyle changes or over-the-counter remedies. As a result, the true prevalence of the disease is difficult to assess. It is estimated that 18% to 28% of adults in the United States suffer GERD symptoms weekly. Prevalence seems to be increasing worldwide, with highest rates in Western countries and lowest rates found in East Asia.
CAUSES
Symptoms and/or tissue damage associated with GERD is caused by exposure of the esophagus to gastric contents. This happens as a result of relaxation of the lower esophageal sphincter (LES) due to increase in intra-abdominal pressure (e.g., obesity, pregnancy), delayed gastric emptying, hiatal hernia, or certain medications or foods as listed in Table 29.1. Additional risk factors include family history, smoking, alcohol consumption, respiratory diseases, obesity, and reclining or lying down after eating.
PATHOPHYSIOLOGY
Under normal circumstances, the LES serves as a barrier between the esophagus and stomach and, coupled with peristalsis, promotes the forward movement of food. Bicarbonate found in saliva and secreted by the esophageal mucosa buffers acid present in the esophagus. Problems with these normal defense mechanisms contribute to the development of GERD.
Lower Esophageal Sphincter
The LES is a 3- to 4-cm-long smooth muscle located at the distal end of the esophagus. It serves as a high-pressure barrier between the esophagus and stomach and acts to prevent retrograde passage of gastric contents into the esophagus. The LES relaxes on swallowing, allowing food to enter the stomach. A number of mechanisms can cause disruption of this barrier, such as transient LES relaxation (TLESR), increase in intraabdominal pressure (e.g., pregnancy, obesity, bending over),
delayed gastric emptying, and hiatal hernia. Several foods and medications can also decrease LES tone as listed in Table 29.1.
delayed gastric emptying, and hiatal hernia. Several foods and medications can also decrease LES tone as listed in Table 29.1.
TABLE 29.1 Risk Factors for GERD | ||||||||||||||||||||||||||||||||||||
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TLESR is a normal physiological process that allows gas to escape the stomach and facilitate belching. This is typically accomplished without allowing liquids from escaping the stomach. In GERD, however, TLESR occurs more frequently and prolonged. TLESR is associated with more than half of the reflux episodes in patients with GERD.
Esophageal Clearance and Protection
The amount of time of exposure of gastric acid to the esophageal mucosa is an important determinant of GERD risk. Salivation and peristalsis contribute to the esophagus’ ability to clear this content and minimize the duration of contact between the gastric contents and esophagus. Forty to fifty percent of patients with GERD have abnormal peristalsis. Swallowing saliva, which contains bicarbonate, helps to clear esophageal contents and neutralize acid present. However, certain patients have reduced salivary production, especially the elderly or those with Sjögren syndrome or xerostomia (dry mouth). Additionally, swallowing is hindered during sleep, leading to nocturnal GERD.
The esophageal mucosa contains mucus-secreting glands that act to protect the esophageal wall by secreting bicarbonate. However, repeated exposure to acid can compromise this defense system. Cellular damage results, leading to erosive esophagitis.
TABLE 29.2 Complications of GERD | ||||||||||||
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Gastric Emptying
Slow emptying of stomach contents can increase intragastric pressure, which consequently contributes to GERD. Factors that are associated with delayed emptying include smoking and high-fat meals. Medications that increase gastric emptying and motility can help.
Refluxate
The refluxate properties, acidity, and volume are important determinants of GERD risk. While the stomach can withstand very low pH levels and enzymatic activity of gastric secretions, the squamous cells lining the esophageal mucosa are more sensitive and readily damaged if exposed to this chemical environment. Gastric acid causes direct damage to the esophageal mucosa. Additionally, pepsin, which is a gastric enzyme responsible for the breakdown of food proteins, becomes activated in acidic environments, causing further injury to the esophageal lining.
Complications
Complications of GERD occur from repeated exposure to refluxed gastric contents for prolonged periods of time. These complications are outlined and defined in Table 29.2. Esophageal adenocarcinoma appears to occur more commonly in older white males with elevated body mass index (BMI). Since Barrett’s esophagus is a risk factor for esophageal adenocarcinoma, screening for Barrett’s esophagus is recommended in this particular group.
DIAGNOSTIC CRITERIA
Diagnosis is mainly dependent on patient report of symptoms and review of risk factors present. Symptoms are commonly classified as typical, atypical, and extraesophageal and are listed
in Table 29.3. They tend to occur after meals and may be aggravated by reclining or lying down. Typical symptoms occur more commonly and include acid regurgitation and heartburn. Generally, a diagnosis of GERD is assumed if patients respond to an empiric trial of acid suppression therapy. Diagnosis of patients who present with atypical symptoms is challenging, since their symptoms may be caused by other conditions, such as PUD and gastroparesis. For these patients, further diagnostic evaluation may be considered prior to empiric therapy. Similarly, those presenting with chest pain must be evaluated to rule out cardiac causes.
in Table 29.3. They tend to occur after meals and may be aggravated by reclining or lying down. Typical symptoms occur more commonly and include acid regurgitation and heartburn. Generally, a diagnosis of GERD is assumed if patients respond to an empiric trial of acid suppression therapy. Diagnosis of patients who present with atypical symptoms is challenging, since their symptoms may be caused by other conditions, such as PUD and gastroparesis. For these patients, further diagnostic evaluation may be considered prior to empiric therapy. Similarly, those presenting with chest pain must be evaluated to rule out cardiac causes.
TABLE 29.3 Symptoms of GERD | ||||||
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Extraesophageal reflux syndromes are associated with symptoms that occur in organs other than the esophagus. These symptoms should only be associated with GERD if they occur with other GERD symptoms or with evidence of tissue injury since these symptoms are nonspecific and have many other causes.
Diagnostic tests may be helpful in patients who do not respond to therapy or those presenting with extraesophageal syndrome to confirm GERD as a cause, or to detect complications of GERD. Endoscopy (with or without biopsy) may be used to assess mucosal injury or other complications like strictures. Biopsy is necessary to detect esophageal adenocarcinoma or Barrett’s esophagus. Of note, normal endoscopy does not rule out GERD. On the other hand, tissue damage may not be specifically related to GERD. Other tests, such as ambulatory pH monitoring, can help to clarify diagnosis.
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