Gastroesophageal reflux disease: Difference between revisions
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==Cause/etiology== | ==Cause/etiology== | ||
Gastroesophageal reflux disease is a multifactorial disease.<ref name="pmid1864528">{{cite journal |author=Howard PJ, Maher L, Pryde A, Heading RC |title=Symptomatic gastro-oesophageal reflux, abnormal oesophageal acid exposure, and mucosal acid sensitivity are three separate, though related, aspects of gastro-oesophageal reflux disease |journal=Gut |volume=32 |issue=2 |pages=128–32 |year=1991 |pmid=1864528 |doi=}}</ref> | Gastroesophageal reflux disease is a multifactorial disease.<ref name="pmid1864528">{{cite journal |author=Howard PJ, Maher L, Pryde A, Heading RC |title=Symptomatic gastro-oesophageal reflux, abnormal oesophageal acid exposure, and mucosal acid sensitivity are three separate, though related, aspects of gastro-oesophageal reflux disease |journal=Gut |volume=32 |issue=2 |pages=128–32 |year=1991 |pmid=1864528 |doi=}}</ref> | ||
Obesity if associated with gastroesophageal reflux disease.<ref name="pmid17127706">{{cite journal |author=El-Serag HB, Ergun GA, Pandolfino J, Fitzgerald S, Tran T, Kramer JR |title=Obesity increases oesophageal acid exposure |journal=Gut |volume=56 |issue=6 |pages=749–55 |year=2007 |pmid=17127706 |doi=10.1136/gut.2006.100263}}</ref><ref name="pmid17047097">{{cite journal |author=Corley DA, Kubo A, Zhao W |title=Abdominal obesity, ethnicity and gastro-oesophageal reflux symptoms |journal=Gut |volume=56 |issue=6 |pages=756–62 |year=2007 |pmid=17047097 |doi=10.1136/gut.2006.109413}}</ref> | |||
Psychological stress may lead to physiologic abnormalities in the esophagus.<ref name="pmid17272649">{{cite journal |author=Farré R, De Vos R, Geboes K, ''et al'' |title=Critical role of stress in increased oesophageal mucosa permeability and dilated intercellular spaces |journal=Gut |volume=56 |issue=9 |pages=1191–7 |year=2007 |pmid=17272649 |doi=10.1136/gut.2006.113688}}</ref> | |||
===Hiatal hernia=== | ===Hiatal hernia=== | ||
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==Signs/symptoms== | ==Signs/symptoms== | ||
Patients with GERD may have heartburn or reflux symptoms; however, these symptoms may be due to [[peptic ulcer disease]].<ref name="pmid8224642">{{cite journal |author=Talley NJ, Weaver AL, Tesmer DL, Zinsmeister AR |title=Lack of discriminant value of dyspepsia subgroups in patients referred for upper endoscopy |journal=Gastroenterology |volume=105 |issue=5 |pages=1378–86 |year=1993 |pmid=8224642 |doi=}}</ref><ref name="pmid2021764">{{cite journal |author=Johnsen R, Bernersen B, Straume B, Førde OH, Bostad L, Burhol PG |title=Prevalences of endoscopic and histological findings in subjects with and without dyspepsia |journal=BMJ |volume=302 |issue=6779 |pages=749–52 |year=1991 |pmid=2021764 |doi=}} [http://www.pubmedcentral.nih.gov/articlerender.fcgi?pubmedid=2021764 Fulltext]</ref> | Patients with GERD may have heartburn or reflux symptoms; however, these symptoms may be due to [[peptic ulcer disease]].<ref name="pmid8224642">{{cite journal |author=Talley NJ, Weaver AL, Tesmer DL, Zinsmeister AR |title=Lack of discriminant value of dyspepsia subgroups in patients referred for upper endoscopy |journal=Gastroenterology |volume=105 |issue=5 |pages=1378–86 |year=1993 |pmid=8224642 |doi=}}</ref><ref name="pmid2021764">{{cite journal |author=Johnsen R, Bernersen B, Straume B, Førde OH, Bostad L, Burhol PG |title=Prevalences of endoscopic and histological findings in subjects with and without dyspepsia |journal=BMJ |volume=302 |issue=6779 |pages=749–52 |year=1991 |pmid=2021764 |doi=}} [http://www.pubmedcentral.nih.gov/articlerender.fcgi?pubmedid=2021764 Fulltext]</ref> | ||
It is unclear whether GERD can cause laryngeal symptoms.<ref name="pmid17397404">{{cite journal |author=Vavricka SR, Storck CA, Wildi SM, ''et al'' |title=Limited diagnostic value of laryngopharyngeal lesions in patients with gastroesophageal reflux during routine upper gastrointestinal endoscopy |journal=Am. J. Gastroenterol. |volume=102 |issue=4 |pages=716–22 |year=2007 |pmid=17397404 |doi=10.1111/j.1572-0241.2007.01145.x}}</ref><ref name="pmid17397405">{{cite journal |author=Vaezi MF |title=Are there specific laryngeal signs for gastroesophageal reflux disease? |journal=Am. J. Gastroenterol. |volume=102 |issue=4 |pages=723–4 |year=2007 |pmid=17397405 |doi=10.1111/j.1572-0241.2007.01143.x}}</ref> | |||
==Diagnosis== | ==Diagnosis== | ||
There is no single test that can identify all patients with GERD. However, most patients with have abnormalities of either 24 hour ph monitoring or the Berstein test.<ref name="pmid1864528"/> | There is no single test that can identify all patients with GERD. However, most patients with have abnormalities of either 24 hour ph monitoring or the Berstein test.<ref name="pmid1864528"/> | ||
===Response to antisecretory therapy=== | |||
One study found:<ref name="pmid17059519">{{cite journal |author=Aanen MC, Weusten BL, Numans ME, de Wit NJ, Baron A, Smout AJ |title=Diagnostic value of the proton pump inhibitor test for gastro-oesophageal reflux disease in primary care |journal=Aliment. Pharmacol. Ther. |volume=24 |issue=9 |pages=1377–84 |year=2006 |pmid=17059519 |doi=10.1111/j.1365-2036.2006.03121.x}}</ref> | |||
* [[sensitivity (tests)|sensitivity]] 91% | |||
* [[specificity (tests)|specificity]] 26% | |||
This leads to a negative likelihood ratio of 0.35 which indicates the test, when the patient does not respond to treatment, has some value in excluding the diagnosis of GERD. | |||
===Radiology=== | ===Radiology=== | ||
Revision as of 02:32, 12 October 2007
Cause/etiology
Gastroesophageal reflux disease is a multifactorial disease.[1]
Obesity if associated with gastroesophageal reflux disease.[2][3]
Psychological stress may lead to physiologic abnormalities in the esophagus.[4]
Hiatal hernia
The presence of a hiatal hernia correlates with abnormal 24 ph monitoring. In one study the presence of abnormal ph monitoring was:[5]
- No hernia 18%
- Hernia < 2cm 27%
- Hernia > 2cm 35%
Signs/symptoms
Patients with GERD may have heartburn or reflux symptoms; however, these symptoms may be due to peptic ulcer disease.[6][7]
It is unclear whether GERD can cause laryngeal symptoms.[8][9]
Diagnosis
There is no single test that can identify all patients with GERD. However, most patients with have abnormalities of either 24 hour ph monitoring or the Berstein test.[1]
Response to antisecretory therapy
One study found:[10]
- sensitivity 91%
- specificity 26%
This leads to a negative likelihood ratio of 0.35 which indicates the test, when the patient does not respond to treatment, has some value in excluding the diagnosis of GERD.
Radiology
Hiatal hernia
The accuracy of a radiologic hiatal hernia predicts abnormal 24 hour ph monitoring is:[5] Hernia of any size:
- sensitivity 74%
- specificity 42%
Hernia at least 2cm:
- sensitivity 40%
- specificity 74%
Reflux on manual stomach compression or valsalva
The accuracy of reflux during the upper gastrointestinal series predicts endoscopic esophagitis is:[11]
Spontaneous reflux:
- sensitivity 15%
- specificity >75(?)%
Reflux during abdominal compression:
- sensitivity 40% to 71%[12]
- specificity 74%
Treatment
Avoid tight fitting garments.
Medications
Some patients will be able to take 2-4 week course of medications as needed.[13]
15% of patients may be able to stop medications after symptoms are controlled.[14]
As needed versus scheduled
Step up or step down
References
- ↑ 1.0 1.1 Howard PJ, Maher L, Pryde A, Heading RC (1991). "Symptomatic gastro-oesophageal reflux, abnormal oesophageal acid exposure, and mucosal acid sensitivity are three separate, though related, aspects of gastro-oesophageal reflux disease". Gut 32 (2): 128–32. PMID 1864528. [e]
- ↑ El-Serag HB, Ergun GA, Pandolfino J, Fitzgerald S, Tran T, Kramer JR (2007). "Obesity increases oesophageal acid exposure". Gut 56 (6): 749–55. DOI:10.1136/gut.2006.100263. PMID 17127706. Research Blogging.
- ↑ Corley DA, Kubo A, Zhao W (2007). "Abdominal obesity, ethnicity and gastro-oesophageal reflux symptoms". Gut 56 (6): 756–62. DOI:10.1136/gut.2006.109413. PMID 17047097. Research Blogging.
- ↑ Farré R, De Vos R, Geboes K, et al (2007). "Critical role of stress in increased oesophageal mucosa permeability and dilated intercellular spaces". Gut 56 (9): 1191–7. DOI:10.1136/gut.2006.113688. PMID 17272649. Research Blogging.
- ↑ 5.0 5.1 Ott DJ, Gelfand DW, Chen YM, Wu WC, Munitz HA (1985). "Predictive relationship of hiatal hernia to reflux esophagitis". Gastrointestinal radiology 10 (4): 317–20. PMID 4054494. [e]
- ↑ Talley NJ, Weaver AL, Tesmer DL, Zinsmeister AR (1993). "Lack of discriminant value of dyspepsia subgroups in patients referred for upper endoscopy". Gastroenterology 105 (5): 1378–86. PMID 8224642. [e]
- ↑ Johnsen R, Bernersen B, Straume B, Førde OH, Bostad L, Burhol PG (1991). "Prevalences of endoscopic and histological findings in subjects with and without dyspepsia". BMJ 302 (6779): 749–52. PMID 2021764. [e] Fulltext
- ↑ Vavricka SR, Storck CA, Wildi SM, et al (2007). "Limited diagnostic value of laryngopharyngeal lesions in patients with gastroesophageal reflux during routine upper gastrointestinal endoscopy". Am. J. Gastroenterol. 102 (4): 716–22. DOI:10.1111/j.1572-0241.2007.01145.x. PMID 17397404. Research Blogging.
- ↑ Vaezi MF (2007). "Are there specific laryngeal signs for gastroesophageal reflux disease?". Am. J. Gastroenterol. 102 (4): 723–4. DOI:10.1111/j.1572-0241.2007.01143.x. PMID 17397405. Research Blogging.
- ↑ Aanen MC, Weusten BL, Numans ME, de Wit NJ, Baron A, Smout AJ (2006). "Diagnostic value of the proton pump inhibitor test for gastro-oesophageal reflux disease in primary care". Aliment. Pharmacol. Ther. 24 (9): 1377–84. DOI:10.1111/j.1365-2036.2006.03121.x. PMID 17059519. Research Blogging.
- ↑ Fransson SG, Sökjer H, Johansson KE, Tibbling L (1989). "Radiologic diagnosis of gastro-oesophageal reflux". Acta radiologica (Stockholm, Sweden : 1987) 30 (2): 187–92. PMID 2923744. [e]
- ↑ Sellar RJ, De Caestecker JS, Heading RC (1987). "Barium radiology: a sensitive test for gastro-oesophageal reflux". Clinical radiology 38 (3): 303–7. PMID 3581674. [e]
- ↑ Bardhan KD, Müller-Lissner S, Bigard MA, et al (1999). "Symptomatic gastro-oesophageal reflux disease: double blind controlled study of intermittent treatment with omeprazole or ranitidine. The European Study Group". BMJ 318 (7182): 502–7. PMID 10024259. [e]
- ↑ Inadomi JM, Jamal R, Murata GH, et al (2001). "Step-down management of gastroesophageal reflux disease". Gastroenterology 121 (5): 1095–100. PMID 11677201. [e]