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Management of Gastroesophageal Reflux Disease (GERD)

Gastroesophageal reflux disease (GERD) is a common disorder that can be associated with serious complications, such as esophageal ulcerations, strictures, and adenocarcinoma. Pharmacists are often the first health care professionals approached for advice by patients experiencing symptoms of GERD. They can play an important role in patient counseling and monitoring.

Epidemiology

Gastroesophageal reflux disease (GERD) is defined as a set of symptoms associated with reflux of gastric contents into the esophagus. Patients having heartburn that affects quality of life more than twice a week for more than three consecutive weeks are often diagnosed with GERD. Forty-four percent of Americans report having heartburn at least once a month, and 14% to 18% report having it on a weekly basis. Sixty-five percent of those who report having heartburn have both daytime and nighttime heartburn. An estimated 2% of the adult population have gastroesophageal reflux disease (GERD).Fifty percent to 70% of those with GERD symptoms have no esophageal erosions at endoscopy; thus, this condition is often referred to as symptomatic gastroesophageal reflux disease (GERD), endoscopy-negative reflux disease, or nonerosive reflux disease. Symptomatic GERD is usually a chronic relapsing condition, with symptoms recurring in up to 75% of patients six months after therapy cessation.

Effect on Quality of Life

Patients who suffer from gastroesophageal reflux disease (GERD) have a significant decrease in health-related quality of life (HRQOL). Studies have shown that HRQOL in this population is inversely related to the frequency and severity of symptoms. HRQOL for GERD patients is lower than that in patients with diabetes, hypertension, ischemic heart disease, or mild heart failure. GERD patients have decreased productivity and use more sick days than those with other chronic diseases, such as asthma, COPD, or heart disease. Health-related quality of life (HRQOL) is similarly affected in patients with or without evidence of mucosal damage, since the symptom severity in patients with symptomatic gastroesophageal reflux disease (GERD) is similar to that of patients with erosive GERD.

Pathogenesis

Symptoms of gastroesophageal reflux disease (GERD) are caused by the exposure of esophageal mucosa to gastric acid and pepsin. Patients with GERD do not undergo an increase in acid production; rather, the amount of time in which the esophagus is exposed to gastric acid is increased.Several other factors contribute to the pathogenesis of gastroesophageal reflux disease (GERD). For gastric contents to backflow into the esophagus, the lower esophageal sphincter (LES) must be relaxed and the pressure gradient between the stomach and esophagus must allow for proximal flow. Usually relaxation of the LES is only transient. Many lifestyle factors, including ingesting onions, chocolate, peppermint, spearmint, citrus and tomato juices, caffeinated beverages, and alcohol, can temporarily weaken LES tone (TABLE 1). A high-protein diet has the opposite effect and can actually increase lower esophageal sphincter (LES) pressure. Many medications can lower LES tone and exacerbate GERD. Another important factor is delayed gastric emptying, which can increase intragastric pressure and contribute to reflux. Fatty meals significantly slow gastric motility and exacerbate symptoms of gastroesophageal reflux disease (GERD).Other influences, such as obesity, pregnancy, bending over, and wearing tight-fitting clothing, can increase intra-abdominal pressure and contribute to GERD.

Clinical Manifestations

The most common reasons for GERD-related medical attention are heartburn and regurgitation. Chest pain due to heartburn is often indistinguishable from angina. Patients with a history of or at risk for heart disease require further work-up to rule out ischemic changes. Regurgitation is a feeling of “burping up” food and/or acid and is often relieved by repeated swallowing. Water brash (hypersalivation) is an unusual symptom in which patients can secrete as much as 10 mL of saliva per minute in response to reflux. Globus sensation is the almost constant perception of a lump in the throat (irrespective of swallowing). This has been related to gastroesophageal reflux disease (GERD) in some studies.

Some patients with GERD present with atypical symptoms such as wheezing, cough, hoarseness, asthma, laryngitis, and dental erosions. There is a well-established association between asthma and gastroesophageal reflux disease (GERD), and acid-suppressive therapy with proton pump inhibitors (proton pump inhibitors (PPIs)) improves asthma outcomes.Otolaryngologic manifestations of gastroesophageal reflux disease can result from reflux of gastric contents with subsequent contact injury of the pharyngeal and laryngeal mucosa.

Complications of gastroesophageal reflux disease (GERD)

Fifty percent to 70% of symptomatic gastroesophageal reflux disease (GERD) patients do not have evidence of esophagitis (inflammation of esophageal mucosa) at endoscopy.Esophagitis can lead to erosions and ulcerations of the esophageal mucosa as well as esophageal strictures. In a small percentage of patients, esophageal ulcerations can result in bleeding and perforation. Those with dysphagia, odynophagia, signs and symptoms of bleeding, vomiting, unexplained weight loss, or anemia need immediate evaluation and treatment to prevent esophageal perforation.

Up to 5% of patients with GI symptoms have radiologic evidence of esophageal stricture. The pathogenesis of strictures involves the formation of fibrous scar tissue with mucosal healing after gastric reflux exposure and damage. While not common, strictures pose a serious concern because they can also be formed due to esophageal adenocarcinoma. Patients who develop strictures can present with symptoms of solid food dysphagia, odynophagia, and weight loss. These symptoms warrant immediate medical referral because of the serious nature of the consequences of GERD complications.

One of the most severe consequences of chronic gastroesophageal reflux disease (GERD) is Barrett’s esophagus, in which abnormal columnar epithelium replaces stratified squamous epithelia that normally lines the distal esophagus. Barrett’s is found in 4.5% to 12.4% of patients undergoing endoscopy for reflux symptoms. It is associated with a 5% to 10% incidence of adenocarcinoma of the esophagus and a 30% to 80% incidence of stricture formation. Data on the natural progression of GERD are scarce. Results of long-term follow-up studies reveal that symptomatic gastroesophageal reflux disease (GERD) rarely progresses to erosive esophagitis. However, most longitudinal studies are less than 10 years in duration and can be criticized on methodological grounds. A recent epidemiological survey suggested that symptomatic reflux, rather than Barrett’s esophagus, may be the crucial risk factor in the progression of the esophageal carcinoma. These data must be investigated further and clinical trials of GERD therapies should consider preventing esophageal carcinoma as one outcome measure.

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