Gastroesophageal Reflux
Popularly known as heartburn, gastroesophageal reflux is the backflow of gastric or duodenal contents (or both) into the esophagus and past the lower esophageal sphincter (LES) without associated belching or vomiting. Reflux may or may not cause symptoms or pathologic changes. Persistent reflux may cause reflux esophagitis, an inflammation of the esophageal mucosa. The prognosis varies with the underlying cause.
Causes
Normally, gastric contents don’t back up into the esophagus because the LES creates enough pressure around the lower end of the esophagus to close it. (The sphincter relaxes after each swallow to allow food into the stomach.) Reflux occurs when LES pressure is deficient or pressure within the stomach exceeds LES pressure. Any of the following predisposing factors may lead to reflux:
pyloric surgery (alteration or removal of the pylorus), which allows reflux of bile or pancreatic juice
nasogastric intubation for more than 4 days
any agent that lowers LES pressure: food; alcohol; cigarettes; anticholinergics,
such as atropine, belladonna, and propantheline; and other drugs, such as morphine, diazepam, calcium channel blockers, and meperidine
hiatal hernia with incompetent sphincter
any condition or position that increases intra-abdominal pressure.
Complications
Reflux esophagitis, the primary complication of gastric reflux, can lead to other sequelae, including esophageal stricture, esophageal ulcer, and replacement of the normal squamous epithelium with columnar epithelium (Barrett’s epithelium). A patient with severe reflux esophagitis may also develop anemia from chronic low-grade bleeding of inflamed mucosa.
Pulmonary complications may develop if the patient experiences reflux of gastric contents into his throat and subsequent aspiration. Reflux aspiration may lead to chronic pulmonary disease.
Assessment
Typically, the patient complains of heartburn, which worsens with vigorous exercise, bending, or lying down. He may report relief with antacids or sitting upright. If asked, he may recall regurgitating without associated nausea or belching. This symptom is often described as a feeling of warm fluid traveling up the throat, followed by a sour or bitter taste in the mouth if the fluid reaches the pharynx.
Although heartburn is the most common feature of reflux, the patient may report any of these signs and symptoms:
a feeling of fluid accumulation in the throat without a sour or bitter taste. This is caused by hypersecretion of saliva.
odynophagia, possibly followed by a dull substernal ache. This symptom may indicate severe, long-term reflux dysphagia from esophageal spasm, stricture, or esophagitis.
bright red or dark brown blood in vomitus.
chronic pain that may mimic angina pectoris, radiating to the neck, jaw, and arm. This pain may be associated with esophageal spasm and result from reflux esophagitis.
nocturnal hypersalivation, a rare symptom that the patient says awakens him with coughing, choking, and a mouthful of saliva.
Diagnostic tests
Although a careful history and physical examination are essential to the diagnosis, the following tests help to confirm it:
Esophageal acidity test, a standard test for acid reflux, is the most sensitive and accurate measure of gastroesophageal reflux.
Gastroesophageal scintillation test may also detect reflux.
Esophageal manometry
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