GERD – PATHOPHYSIOLOGY, CLINICAL MANIFESTATIONS, AND INNOVATIVE MANAGEMENT APPROACHES

✦ Overview

Millions worldwide suffer from gastroesophageal reflux disease (GERD), characterised by the backflow of stomach acid into the oesophagus, leading to irritation and inflammation. The article thoroughly analyses GERD’s pathophysiology, clinical manifestations, and innovative management approaches.

✦ Pathophysiology of gastroesophageal reflux disease(GERD)

What is Gastroesophageal reflux disease?
Stomach acid or bile flowing back into the oesophagus causes irritation and inflammation, leading to a chronic digestive disorder known as GERD or Gastroesophageal reflux disease. In addition, the inner lining of the oesophagus, a muscular tube connecting the throat to the stomach, is not equipped to handle the corrosive effects of stomach acid, leading to irritation and inflammation caused by acid reflux.

✦ Anatomy of the Oesophagus and Stomach

The lower oesophagal sphincter (LES), a muscular ring located at the bottom of the oesophagus, acts as a one-way valve that allows food and liquid to enter the stomach and prevents reflux of the stomach acid and digestive enzymes back up into the oesophagus. The anatomy of the oesophagus begins with its structure. The oesophagus is a muscular tube composed of four layers: the mucosa, submucosa, muscularis, and adventitia. The stomach wall has four layers. It includes mucosa, submucosa, serosa and the muscularis externa.

✦ The function of the oesophagal sphincter

The LES relaxes, allowing food and liquid to pass from the oesophagus into the stomach. After the food has passed, the LES tightens, forming a barrier preventing stomach acid and digestive enzymes from flowing back into the oesophagus. However, if the LES does not function properly, acid can reflux back into the oesophagus, causing irritation and inflammation, leading to GERD.

✦ Role of stomach acid in gastroesophageal reflux disease (GERD)

The crucial digestive process is facilitated by stomach acid, which helps break down food and promotes nutrient absorption. However, when the LES fails to function properly, stomach acid can reflux back into the oesophagus, causing irritation and inflammation.

Clinical Manifestations of gastroesophageal reflux disease (GERD)

GERD, or Gastroesophageal Reflux Disease, symptoms range from mild to severe. Ignoring these symptoms can profoundly affect an individual’s overall well-being and should be given proper attention. This section will discuss the common symptoms, atypical symptoms, and complications of GERD.

✦ Common Symptoms of Gastroesophageal Reflux Disease (GERD)

The most common symptoms of GERD include:

➔ Heartburn: After eating or lying down, an individual may experience a burning sensation in their chest or throat, indicating the possibility of acid reflux.

➔ Dysphagia:The individual may experience difficulty swallowing or a feeling of food becoming lodged in the throat.

➔ Nausea and vomiting: These symptoms are more common in severe cases of GERD.

➔ Chest pain Chest pain can occur in some individuals with GERD and is often mistaken for a heart attack.

➔ Regurgitation: The sensation of stomach contents returning to the throat or mouth.

✦ Atypical Symptoms of Gastroesophageal Reflux Disease (GERD)

Atypical symptoms of GERD can complicate the diagnosis process. Such symptoms include:

➔ Asthma: Asthma symptoms can worsen in individuals with GERD, and GERD can also trigger asthma attacks.

➔ Laryngitis: The acid refluxing into the throat can cause voice box or larynx inflammation.

➔ Dental problems: Acid reflux can cause erosion of the tooth enamel, leading to tooth sensitivity, decay, and other dental problems.

➔ Chronic cough: A persistent cough unrelated to a respiratory infection or other underlying condition.

✦ Complications of GERD

Untreated or poorly controlled GERD can lead to various complications, including:

➔ Barrett’s oesophagus: A precancerous condition where the cells in the lining of the oesophagus change.

➔ Oesophagal stricture: Repeated inflammation can cause scarring in the oesophagus, narrowing the passage.

➔ Dental problems: GERD can cause tooth decay, gum disease, and bad breath.

➔ Respiratory problems: GERD can worsen asthma symptoms, cause chronic cough, and even lead to aspiration pneumonia.

➔ Esophagitis: Inflammation of the oesophagus due to prolonged exposure to stomach acid.

✦ Diagnosis of gastroesophageal reflux disease (GERD)

Various methods can diagnose gastroesophageal reflux disease (GERD), including medical history, physical examination, endoscopy, ambulatory acid (pH) probe test, and oesophagal manometry.

➔ Endoscopy

A flexible tube equipped with a camera on end is used during an endoscopy to examine the oesophagus, stomach, and small intestine. It is used to diagnose GERD by identifying the presence of oesophagal inflammation or ulceration. In addition, the healthcare provider may take tissue samples (biopsy) for further testing during the procedure.

➔ Ambulatory Acid (pH) Probe Test

Ambulatory acid (pH) probe test is a procedure that measures the amount of acid in the oesophagus over 24 hours. It is used to diagnose GERD by identifying episodes of acid reflux. The healthcare provider will insert a small tube through the nose into the oesophagus, which will be attached to a small device that measures acid levels.

➔ Esophageal Manometry

To diagnose GERD, healthcare providers may perform oesophagal manometry, a procedure assessing the oesophagus muscles’ strength and coordination. Oesophageal manometry is used to identify potential abnormalities that could cause acid reflux, which entails inserting a small tube through the nose and into the oesophagus to measure muscle pressure.

➔ Innovative Management Approaches for gastroesophageal reflux disease (GERD)

GERD is a chronic condition that requires long-term management to control symptoms and prevent complications. GERD treatment options include lifestyle changes, medications, surgical interventions, and non-surgical interventions. Some of the innovative management approaches for GERD.

✦ Lifestyle changes

Lifestyle changes are a critical component of GERD management. These changes can help reduce the frequency and severity of GERD symptoms. They include:

  • Losing weight if overweight or obese
  • Avoiding trigger foods and beverages such as citrus fruits, spicy foods, alcohol, and caffeine
  • Eating smaller, more frequent meals instead of large meals
  • Avoiding eating at least three hours before bedtime
  • Elevating the head of the bed by 6-8 inches
  • Quitting smoking

✦ Medications

Several types of medications can help alleviate GERD symptoms by reducing stomach acid production or neutralising acid in the stomach. These include:

  • Proton pump inhibitors (PPIs) such as omeprazole and lansoprazole
  • H2 receptor blockers such as ranitidine and famotidine
  • Antacids such as calcium carbonate and magnesium hydroxide
  • Prokinetics such as metoclopramide and bethanechol

✦ Surgical interventions

Patients with severe GERD who do not respond to lifestyle changes and medications typically consider surgical interventions. Wrapping the upper part of the stomach around the lower oesophagal sphincter to strengthen it and prevent reflux is the primary surgical intervention for GERD, known as fundoplication.

✦ Non-surgical interventions

Several non-surgical interventions are available for GERD management. These include:

➔ Transoral incisionless fundoplication (TIF)

Uses a device inserted through the mouth to create a valve at the base of the oesophagus, preventing reflux

➔ Stretta therapy

Radiofrequency energy is utilised to actively strengthen the muscle at the lower end of the oesophagus, reducing reflux symptoms.

➔ Endoscopic mucosal resection(EMR)

Which removes abnormal tissues from the oesophagus and stomach

➔ Magnetic sphincter augmentation (LINX)

This uses a device implanted around the lower oesophagal sphincter to prevent reflux.

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