Gastroesophageal reflux disease.

This article examines the diagnostic and treatment options available to people who have gastroesophageal reflux disease. The role of nurses in advising and educating patients about lifestyle modifications, which reduce the severity of symptoms and increase the quality of life, is emphasised.     

Gastroesophageal reflux disease

Gastroesophageal reflux disease, usually manifested by frequent heartburn, occurs in approximately 10% of our adult population. The presence of a hiatal hernia is usually associated with, but does not necessarily cause, LES dysfunction, allowing acid reflux to produce esophageal and aerodigestive symptoms. The mucosa can be extensively damaged and, ultimately, a columnar lining, termed Barrett's esophagus, a premalignant condition, can develop. Treatment with H2-antagonists has been nirvana to some patients, but has proved only partially helpful to others. Adjunctive agents may increase relief and may help heal erosive esophagitis in some patients, but side effects and cost limit their use. Maintenance therapy with full doses is required, as the relapse rate for this chronic condition is high. Omeprazole temporarily heals almost everyone with otherwise resistant GERD, but it is currently used only on a short-term basis unless surgery, eminently successful in well-selected patients, is contraindicated.     

Gastroesophageal reflux disease

In this age of fast food, overeating, and busy schedules, many people frequently complain of heartburn or indigestion. Meal times are rarely consistent, so meal planning appears out of the question. What are the consequences of this lifestyle? Gastroesophageal reflux disease (GERD) is a common disorder that affects every population. This article defines this condition and provides a history, literature review, and pathophysiology for the disorder. Recommendations for diagnosis and guidelines for treatment and nursing care interventions also are given.     

Gastroesophageal reflux disease. Medical aspects

Symptomatic gastroesophageal reflux is one of the most common complaints encountered by clinicians. The pathogenesis of reflux remains unclear, but multiple factors are involved. Heartburn is the most common clinical manifestation. The history and barium esophagram provide sufficient diagnostic information in most cases. Other studies, including ambulatory pH monitoring, the Bernstein test, endoscopy with biopsy, and esophageal manometry, are warranted if the patient has atypical symptoms, an incomplete response to therapy, dysphagia, or abnormalities on the esophagram. Proper utilization of these studies requires an understanding of the questions each test answers. Reflux disease is often a chronic problem. Many patients can be treated symptomatically by a combination of life-style modifications and use of antacids. Patients who do not respond adequately to these simple measures or who have documented erosive esophagitis usually require further drug therapy.     

Gastroesophageal reflux disease: clinical manifestations.

Gastroesophageal reflux disease (GERD) is generally a lifelong illness that affects many people, but its significance is often underestimated. Chronic abnormal gastric reflux results in erosive esophagitis in up to 60% of patients with GERD. Esophageal stricture, Barrett's esophagus, and esophageal adenocarcinoma are the most serious complications of GERD. Although heartburn and acid regurgitation are the most common complaints, extraesophageal symptoms such as noncardiac chest pain, laryngitis, coughing, and wheezing can be manifestations of GERD. Unfortunately, the severity of symptoms is not a reliable indicator of the severity of erosive esophagitis. Endoscopy is the preferred method to diagnose and grade erosive esophagitis, and various classification systems are used to grade disease severity. The Los Angeles Classification is a valid and widely accepted system to evaluate the severity of erosive esophagitis. The immediate goals of treatment are to provide effective symptomatic relief and to achieve healing in patients with esophageal damage. The treatment regimen often begins by prescribing a therapy to reduce gastric acid secretion. A proton pump inhibitor is the preferred agent for many patients. Because GERD is a chronic, relapsing disease, long-term maintenance therapy is usually necessary to relieve symptoms, prevent complications, and improve the quality of life in patients with GERD.     

Gastroesophageal reflux disease: current treatment approaches.

Gastroesophageal reflux disease is a common, usually lifelong, disorder resulting from chronic abnormal exposure of the lower esophagus to gastric contents. Motor dysfunction of the lower esophageal sphincter is the primary cause of this disease. At this writing, no medical therapies can completely resolve abnormal lower esophageal sphincter function; therefore, the treatment of gastroesophageal reflux disease centers on suppression of intragastric acid secretion. Available acid-suppressant medications include proton pump inhibitors, H2-receptor antagonists, and antacids. Of these, the proton pump inhibitors are recognized generally as the mainstays of both short-term and long-term therapy for gastroesophageal reflux disease. All have a low incidence of side effects and are well tolerated by most patients. Five proton pump inhibitors are available currently for patients with gastroesophageal reflux disease. Of these, esomeprazole has shown greater efficacy in controlling intragastric acidity than the others. For patients with erosive esophagitis, esomeprazole has demonstrated higher healing rates and more rapid sustained resolution of heartburn than omeprazole or lansoprazole after up to 8 weeks of once-daily treatment. Because new therapies for gastroesophageal reflux disease are highly effective, patients can be reassured that their disease will be well controlled and their symptoms resolved with a safe and appropriate treatment.     

Gastroesophageal reflux disease and Barrett's esophagus

Gastroesophageal reflux disease (GERD) is a common clinical problem. Circumstantial evidence continues to suggest that infection with Helicobacter pylori may protect some patients from developing GERD and its complications. An empirical trial of a proton-pump inhibitor may now be a reasonable alternative to endoscopy or 24-hour pH testing for the diagnosis of GERD. Long-term follow-up data covering more than over a decade indicate that proton-pump inhibitors are effective and safe agents for the treatment of GERD. Furthermore, a strategy of proton-pump inhibitors first may be the most cost-effective approach to GERD. It remains unclear why some patients with GERD develop Barrett's esophagus, whereas others do not. Recent studies demonstrate the importance of pulses of acid or bile in increasing cell proliferation and cyclooxygenase-2 expression in Barrett's epithelium cell cultures. Short-segment Barrett's esophagus is now clearly associated with an increased risk of dysplasia or cancer compared to intestinal metaplasia of the cardia, and the cancer risk in this condition is similar to that with long-segment Barrett's esophagus. However, the overall cancer risk in patients with Barrett's esophagus is lower than previously estimated, at approximately 0.5% annually. Ablation techniques continue to show promise, but are not yet ready for routine clinical use. Endoscopic mucosal resection is a new treatment option for selected patients with high-grade dysplasia or superficial esophageal adenocarcinoma.     

Gastroesophageal reflux disease and Barrett's esophagus

GERD has emerged as an important medical issue by virtue not only of its high prevalence, but also by the concern that it may predispose to adenocarcinoma of the esophagus. It generally is classified into erosive and nonerosive forms. Nonerosive GERD tends to remain as such in most patients, and treatment is based on symptom relief. In contrast, erosive GERD mandates aggressive lifelong treatment based on its inevitable relapse without appropriate treatment. Two excellent therapies are available for GERD. Proton-pump inhibitors are highly efficacious and have an excellent long-term (> 10 years) safety profile. Laparoscopic fundoplication offers a new and easier method of delivering a standard reliable procedure also with excellent long-term efficacy. The occurrence of Barrett's esophagus among reflux patients has emerged as an important problem mostly because of the rapidly rising incidence of adenocarcinoma of the esophagus in the population. All patients with long-standing reflux symptoms should be screened for Barrett's and subsequently followed regularly with surveillance endoscopy if Barrett's is detected. Although there are no data to show that aggressive medical or surgical treatment alters the malignant potential of this disease, patients need lifelong therapy.     

Gastroesophageal reflux disease in diabetic patients

Esophageal dysfunctions occur frequently in patients with diabetic neuropathy, and the complication of gastroesophageal reflux disease(GERD) has also been reported. However, the characteristics of GERD complicated with diabetes mellitus are obscure because no detailed assessment was performed. We performed long-term ambulatory esophageal pH and motility monitoring in diabetic patients, and analyzed the data in detail. Esophageal dysfunctions including GERD were significantly related to diabetic neuropathy and duration. Although GERD was frequently complicated with diabetes mellitus, the symptoms were not apparent in diabetic patients. The average score of a questionnaire was extremely low, and no significant difference in score was observed between patients with and without gastroesophageal reflux. We should keep in mind that diabetic patients have the abnormal gastroesophageal reflux even when they do not complain of the related symptoms.     

Gastroesophageal reflux disease and Barrett's esophagus

Gastroesophageal reflux disease (GERD) is a common clinical problem. More frequent and extended acidic reflux episodes are characteristic of GERD, although substantial (nonacid) reflux per se is also observed in control individuals. Helicobacter pylori may protect some people from reflux disease, but others do not experience deterioration of GERD as a result of H. pylori eradication, for reasons so far unknown. Medical treatment, preferably with proton-pump inhibitors, is well established and is also recommended in endoscopy-negative forms of the disease, although the efficacy is less marked in comparison with erosive esophagitis. Surgery has emerged as an alternative to medical therapy, but the long-term results do not now appear to be as promising as was initially claimed. A number of new endoscopic techniques for the treatment of GERD have been developed, but the future for these is unclear. Barrett's esophagus develops in some patients with GERD for unknown reasons, and surveillance should be carried out in these patients due to the risk of subsequent malignant transformation. Several new approaches have been developed for detecting premalignant conditions, but these need to be investigated further. Ablative techniques are still under intensive investigation, and appear to be promising, at least in a subset of patients, although they are not devoid of major complications. Whether antireflux therapy, irrespective of the method used, can slow down the development of cancer is still an intriguing and clinically important question.     

Gastroesophageal reflux disease in diabetic patients

Esophageal dysfunctions occur frequently in patients with diabetic autonomic neuropathy, and the complication of gastroesophageal reflux disease (GERD) has also been reported. However, the characteristics of the GERD complicated with diabetes are obscure, because no detail assessment was performed. We recorded esophageal motility and acid reflux simultaneously in diabetic patients, and the correlation between esophageal dysfunction and diabetic neuropathy was examined. Esophageal dysfunctions including GERD were significantly related to diabetic motor neuropathy. Although the GERD is frequently complicated with diabetes, the symptoms are not apparent in diabetic patients. Therefore, physicians treating diabetic patients should have GERD in mind regardless of the symptoms. We also examined the effect of aldose reductase inhibitor (ARI) on the esophageal dysfunction in diabetic patients. Significant improvement of gastroesophageal reflux and esophageal motility were observed in diabetic patients by ARI treatment. ARI may be useful for the treatment of GERD complicated with diabetes.