Gastroesophageal Reflux Disease, Emergency Medicine

Basics

Description

Spectrum of pathology in which gastric reflux causes symptoms and damage to esophageal mucosa
Reflux esophagitis vs. nonerosive reflux disease
40% of general population experience symptoms monthly

Etiology

Incompetent reflux barrier allowing increase in frequency and duration of gastric contents into esophagus
Lower esophageal sphincter (LES):
- Main antireflux barrier
- Crural diaphragm attachment (diaphragmatic sphincter)
- Contributes to pressure barrier at gastroesophageal junction
- Esophageal acid clearance via peristalsis and esophageal mucosal resistance are additional barriers.
- Most healthy individuals have brief episodes of reflux without symptoms.
Transient lower esophageal sphincter relaxations (TLESRs):
- Occur with higher frequency in gastroesophageal reflux disease (GERD) patients
- Exposed esophageal mucosa becomes acidified and with time necroses
Decreased LES tone:
- Smoking
- Foods: Alcohol, chocolate, onion, coffee, tea
- Drugs: Calcium channel blockers, morphine, meperidine, barbiturates, theophylline, nitrates
Delayed gastric emptying, increased body mass, and gastric distention contribute to reflux
Hiatal hernias associated with GERD:
- Significance varies in any given individual
- Most persons with hiatal hernias do not have clinically evident reflux disease
Acid secretion is same in those with or without GERD
Associated medical conditions: Pregnancy, chronic hiccups, cerebral palsy, Down syndrome, autoimmune diseases, diabetes mellitus (DM), hypothyroidism

Diagnosis

Signs and Symptoms

Esophageal manifestations
- Heartburn (or pyrosis)
- Regurgitation
- Dysphagia
Extraesophageal manifestations
- Bronchospasm
- Laryngitis
- Chronic cough

History

Typical signs and symptoms:
- Heartburn (pyrosis):
  - Retrosternal burning pain
  - Radiates from epigastrium through chest to neck and throat
- Dysphagia:
  - Dysphagia suggests esophageal spasm or stricture.
- Odynophagia:
  - Odynophagia suggests ulcerative esophagitis.
- Regurgitation
- Water brash
- Belching
- Esophageal strictures, bleeding
- Barrett esophagus (esophageal carcinoma)
- Early satiety, nausea, anorexia, weight loss
- Symptoms worse with recumbence or bending over
- Symptoms usually relieved with antacids, although temporarily
Atypical signs and symptoms:
- Noncardiac chest pain
- Asthma
- Persistent cough, hiccups
- Hoarseness
- Pharyngeal/laryngeal ulcers and carcinoma
- Frequent throat clearing
- Recurrent pneumonitis
- Nocturnal choking
- Upper GI tract bleeding

Physical Exam

Nonspecific, may have some epigastric tenderness.
Symptoms worsen with placing patient flat on the bed or Trendelenburg position

Regurgitation is common in infants:
- Incidence decreases from twice daily in 50% of those age 2 mo to 1% of 1-yr-olds.
Signs:
- Frequent vomiting, irritability, cough, crying, and malaise
- Arching the body (hyperextension) at feeding and refusals of feedings
Failure to thrive
Formula intolerance
Sepsis

Essential Workup

Differentiate GERD from more emergent conditions such as ischemic heart pain, esophageal perforation, or aortic pathology.
Obtain typical history
Perform thorough physical exam: Vital signs, head, ears, eyes, nose, throat (HEENT), chest and abdominal exams

Diagnosis Tests & Interpretation

No gold standard
Lab

CBC:
- Chronic anemia from esophagitis
Stool testing for occult bleeding

Imaging

No routine Imaging
Chest radiograph:
- Evidence of esophageal perforation, hiatal hernia, aortic disease

Diagnostic Procedures/Surgery

Diagnostic trial of antacid:
- Those with persistent symptoms should be referred for endoscopy
- 90% of GERD patients respond to proton pump inhibitor (PPI) therapy
Barium esophagram for prominent dysphagia
Esophageal pH monitoring:
- Correlate symptoms to acid reflux
Esophageal manometry (poor sensitivity):
- Evaluate LES resting pressure and esophageal peristaltic contractions
Esophagogastroduodenoscopy (EGD)-detects reflux esophagitis and complications (Barrett esophagus, hiatal hernia, stricture, ulcers, malignancy)

Differential Diagnosis

Ischemic heart disease
Asthma
Peptic ulcer disease
Gastritis
Hepatitis/pancreatitis
Esophageal perforation
Esophageal foreign body
Esophageal infection
Cholecystitis/cholelithiasis
Mesenteric ischemia

Treatment

Pre-Hospital

Esophageal pain may mimic angina
Airway may need active control secondary to vomiting

Initial Stabilization/Therapy

ABCs need to be evaluated
IV fluid resuscitation for blood loss or shock

Ed Treatment/Procedures

Symptomatic relief:
- Antacids
- Antacids with viscous lidocaine
- Sublingual nitroglycerine for esophageal spasm
- Analgesics
Lifestyle modifications:
- Avoid late-night or heavy/fatty meals.
- Minimize time in supine position after eating.
- Elevation of head of bed
- Weight loss
- Eliminate smoking and alcohol intake
- Avoid direct esophageal irritants such as citric juices and coffee
- Avoid foods that decrease LES pressures such as fatty foods, chocolate, and coffee
- Avoid drugs that lower LES tone
PPIs:
- More potent long-acting inhibitors of gastric acid secretion than H2-blockers
- Faster healing than other drug therapies
- More efficacious in severe GERD and frank esophagitis
H2-blockers:
- Effective for mild to moderate disease
- Severe disease requires greater dosage than that used for peptic ulcer disease
Antacids (Maalox, Mylanta):
- Treatment of mild and infrequent reflux symptoms
- Not effective for healing esophagitis
- Alginic acid slurry floats on surface of gastric contents, providing mechanical barrier
Sucralfate:
- Binds to exposed proteins on surface of injured mucosa to form protective barrier
- May also directly stimulate mucosal repair
Metoclopramide (prokinetic drug):
- Improves peristalsis
- Accelerates gastric emptying
- Increases LES pressure
Drugs that modify TLESR
- Baclofen
- ADX10059
Endoscopic therapy:
- Suturing (plication), thermal injury, chemical injection
Antireflux surgery (goal: Increase LES pressure):
- Chronic reflux, younger patients, nonhealing ulceration, severe bleeding
- Fundoplication can be more effective than medical therapy in selected cases
- Currently newer incisionless procedure called transoral incisionless fundoplication available

Reflux present in 30-50% of pregnancies
Increased intra-abdominal pressure, hormonal fluctuations lead to increased TLESRs
EGD reserved for severe presentations
H2-blockers-1st-line therapy (longer safety record)
PPIs-limited safety history in pregnancy

Medication

Antacids: 30 mL + viscous lidocaine, 10 mL, PO q6h
Cimetidine: 400 mg PO BID, 300 mg IM/IV q6-8h
Esomeprazole: 20-40 mg PO daily
Famotidine: 20 mg PO/IV BID (peds: 0.5-1 mg/kg/d div. q8-12h, max. 40 mg/d)
Lansoprazole: 15-30 mg daily
Metoclopramide: 10-15 mg PO/IV/IM q6h before meals and nightly at bedtime
Nizatidine: 150 mg PO BID
Omeprazole: 20-40 mg PO daily
Pantoprazole: 40 mg PO/IV daily
Rabeprazole: 20 mg PO daily
Ranitidine: 150 mg (peds: 5-10 mg/kg q12h) PO BID or 300 mg PO nightly at bedtime
Sucralfate: 1 g PO 1 hr before meals and nightly at bedtime

First Line

Life style modifications:
- Head of bed elevation
- Dietary modification
- Refraining from assuming a supine position after meals
- Avoidance of tight-fitting garments
- Promotion of salivation by either chewing gum
- Restriction of alcohol use
- Reduction of obesity
Acid-suppressive medications:
- PPI or H2 blocker
Treatment of H. pylori infections

Second Line

Prokinetic drugs (bethanechol, metoclopramide)
Drugs that inhibit TLESRs (baclofen)

Follow-Up

Disposition

Admission Criteria

Significant esophageal bleeding
Uncontrolled reactive asthma
Dehydration
Starvation and failure to thrive

Discharge Criteria
Uncomplicated GERD: Refer to patients primary care physician (PCP) or gastroenterologist for further evaluation.
Issues for Referral
Extraesophageal manifestations such as asthma, laryngitis.

Followup Recommendations

Gastroenterologist for endoscopy in patients who require continuous maintenance medical therapy to rule out Barrett esophagus.

Pearls and Pitfalls

GERD therapy should include lifestyle changes.
In patients with worse than mild and intermittent GERD symptoms initiate acid-suppressive therapy.
In patients with GERD and moderate to severe esophagitis, provide acid suppression with a PPI rather than H2 blockers.
Endoscopy for patients who fail chronic therapy (at least 8 wk).
Antireflux surgery for patients on high doses of PPIs, specially in young patients who may require lifelong therapy.
Complications of GERD
- Esophagitis
- Peptic stricture and Barrett metaplasia
- Extraesophageal manifestations of reflux: Asthma, laryngitis, and cough.

Additional Reading

Cappell MS. Clinical presentation, diagnosis, and management of gastroesophageal reflux disease. Med Clin North Am. 2005;89(2):243-291.
DeVault KR, Castell DO, American College of Gastroenterology. Updated guidelines for the diagnosis and treatment of gastroesophageal reflux disease. Am J Gastroenterol. 2005;100:190-200.
Diav-Citrin O, Arnon J, Shechtman S, et al. The safety of proton pump inhibitors in pregnancy: A multicentre prospective controlled study. Aliment Pharmacol Ther. 2005;21:269-275.
Kahrilas PJ, Shaheen NJ, Vaezi MF. American Gastroenterological Association Institute technical review on the management of gastroesophageal reflux disease. Gastroenterology. 2008;135:1392-1413.
Kaltenbach T, Crockett S, Gerson LB. Are lifestyle measures effective in patients with gastroesophageal reflux disease? An evidence-based approach. Arch Intern Med. 2006;166:965-971.
Nwokediuko SC. Current trends in the management of gastroesophageal reflux disease: A review. ISRN Gastroenterol. 2012;2012:391631.

Codes

ICD9

530.11 Reflux esophagitis
530.81 Esophageal reflux

ICD10

K21 Gastro-esophageal reflux disease
K21.0 Gastro-esophageal reflux disease with esophagitis
K21.9 Gastro-esophageal reflux disease without esophagitis

SNOMED

235595009 Gastroesophageal reflux disease (disorder)
266433003 Gastroesophageal reflux disease with esophagitis (disorder)
266435005 Gastroesophageal reflux disease without esophagitis (disorder)

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