gastroesophageal reflux disease gastroesophageal reflux disease gastroesophageal reflux disease (gerd) or gastro-oesophageal reflux disease (gord) is one of the upper gastrointestinal chronic diseases in which stomach content persistently and regularly flows up into the esophagus, resulting in symptoms and/or complications. symptoms include dental corrosion, dysphagia, heartburn, odynophagia, regurgitation, non-cardiac chest pain, extraesophageal symptoms such as chronic cough, hoarseness, reflux-induced laryngitis, or asthma. in the long term, and when not treated, complications such as esophagitis, esophageal stricture, and barrett's esophagus may arise. gastroesophageal reflux diseaseother namesbritish: gastro-oesophageal reflux disease (gord); gastric reflux disease, acid reflux disease, reflux, gastroesophageal refluxx-ray showing radiocontrast from the stomach (white material below diaphragm) entering the esophagus (three vertical collections of white material in the mid-line of the chest) due to severe refluxpronunciation/ɡæstroʊɪˌsɒfəˈdʒiːəl ˈriːflʌks/ gord /ɡɔːd/ gerd /ɡɜːrd/ specialtygastroenterologysymptomstaste of acid, heartburn, bad breath, chest pain, breathing problemscomplicationsesophagitis, esophageal strictures, barrett's esophagusdurationlong termcausesinadequate closure of the lower esophageal sphincterrisk factorsobesity, pregnancy, smoking, hiatal hernia, taking certain medicinesdiagnostic methodgastroscopy, upper gi series, esophageal ph monitoring, esophageal manometrydifferential diagnosispeptic ulcer disease, esophageal cancer, esophageal spasm, anginatreatmentlifestyle changes, medications, surgerymedicationantacids, h2 receptor blockers, proton pump inhibitors, prokineticsfrequency~15% (north american and european populations) part of a series onhuman body weight general concepts obesity (epidemiology) overweight underweight body shape weight gain weight loss gestational weight gain diet (nutrition) weight management overnutrition 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effect social aspects comfort food fast food (criticism) fat acceptance movement fat fetishism health at every size hunger obesity and the environment obesity and sexuality sedentary lifestyle social determinants of obesity social stigma of obesity weight cutting weight class risk factors include obesity, pregnancy, smoking, hiatal hernia, and taking certain medications. medications that may cause or worsen the disease include benzodiazepines, calcium channel blockers, tricyclic antidepressants, nsaids, and certain asthma medicines. acid reflux is due to poor closure of the lower esophageal sphincter, which is at the junction between the stomach and the esophagus. diagnosis among those who do not improve with simpler measures may involve gastroscopy, upper gi series, esophageal ph monitoring, or esophageal manometry. treatment options include lifestyle changes, medications, and sometimes surgery for those who do not improve with the first two measures. lifestyle changes include not lying down for three hours after eating, lying down on the left side, raising the pillow or bedhead height, losing weight, and stopping smoking. foods that may precipitate gerd symptoms include coffee, alcohol, chocolate, fatty foods, acidic foods, and spicy foods. medications include antacids, h2 receptor blockers, proton pump inhibitors, and prokinetics. in the western world, between 10 and 20% of the population is affected by gerd. it is highly prevalent in north america with 18% to 28% of the population suffering from the condition. occasional gastroesophageal reflux without troublesome symptoms or complications is even more common. the classic symptoms of gerd were first described in 1925, when friedenwald and feldman commented on heartburn and its possible relationship to a hiatal hernia. in 1934 gastroenterologist asher winkelstein described reflux and attributed the symptoms to stomach acid. signs and symptoms adults the most common symptoms of gerd in adults are an acidic taste in the mouth, regurgitation, and heartburn. less common symptoms include pain with swallowing/sore throat, increased salivation (also known as water brash), nausea, chest pain, coughing, and globus sensation. the acid reflux can induce asthma attack symptoms like shortness of breath, cough, and wheezing in those with underlying asthma. gerd sometimes causes injury to the esophagus. these injuries may include one or more of the following: reflux esophagitis – inflammation of esophageal epithelium which can cause ulcers near the junction of the stomach and esophagus esophageal strictures – the persistent narrowing of the esophagus caused by reflux-induced inflammation barrett's esophagus – intestinal metaplasia (changes of the epithelial cells from squamous to intestinal columnar epithelium) of the distal esophagus esophageal adenocarcinoma – a form of cancer gerd sometimes causes injury of the larynx (lpr). other complications can include aspiration pneumonia. children and babies gerd may be difficult to detect in infants and children since they cannot describe what they are feeling and indicators must be observed. symptoms may vary from typical adult symptoms. gerd in children may cause repeated vomiting, effortless spitting up, coughing, and other respiratory problems, such as wheezing. inconsolable crying, refusing food, crying for food and then pulling off the bottle or breast only to cry for it again, failure to gain adequate weight, bad breath, and burping are also common. children may have one symptom or many; no single symptom is universal in all children with gerd. of the estimated 4 million babies born in the us each year, up to 35% of them may have difficulties with reflux in the first few months of their lives, known as 'spitting up'. about 90% of infants will outgrow their reflux by their first birthday. mouth frontal view of severe tooth erosion in gerd. severe tooth erosion in gerd. acid reflux into the mouth can cause breakdown of the enamel, especially on the inside surface of the teeth. a dry mouth, acid or burning sensation in the mouth, bad breath and redness of the palate may occur. less common symptoms of gerd include difficulty in swallowing, water brash, chronic cough, hoarse voice, nausea and vomiting. signs of enamel erosion are the appearance of a smooth, silky-glazed, sometimes dull, enamel surface with the absence of perikymata, together with intact enamel along the gum margin. it will be evident in people with restorations as tooth structure typically dissolves much faster than the restorative material, causing it to seem as if it "stands above" the surrounding tooth structure. barrett's esophagus main article: barrett's esophagus gerd may lead to barrett's esophagus, a type of intestinal metaplasia, which is in turn a precursor condition for esophageal cancer. the risk of progression from barrett's to dysplasia is uncertain, but is estimated at 20% of cases. due to the risk of chronic heartburn progressing to barrett's, egd every five years is recommended for people with chronic heartburn, or who take drugs for chronic gerd. causes a comparison of a healthy condition to gerd a small amount of acid reflux is typical even in healthy people (as with infrequent and minor heartburn), but gastroesophageal reflux becomes gastroesophageal reflux disease when signs and symptoms develop into a recurrent problem. frequent acid reflux is due to poor closure of the lower esophageal sphincter, which is at the junction between the stomach and the esophagus. factors that can contribute to gerd: hiatal hernia, which increases the likelihood of gerd due to mechanical and motility factors. obesity: increasing body mass index is associated with more severe gerd. in a large series of 2,000 patients with symptomatic reflux disease, it has been shown that 13% of changes in esophageal acid exposure is attributable to changes in body mass index. factors that have been linked with gerd, but not conclusively: obstructive sleep apnea gallstones, which can impede the flow of bile into the duodenum, which can affect the ability to neutralize gastric acid in 1999, a review of existing studies found that, on average, 40% of gerd patients also had h. pylori infection. the eradication of h. pylori can lead to an increase in acid secretion, leading to the question of whether h. pylori-infected gerd patients are any different than non-infected gerd patients. a double-blind study, reported in 2004, found no clinically significant difference between these two types of patients with regard to the subjective or objective measures of disease severity. diagnosis endoscopic image of peptic stricture, or narrowing of the esophagus near the junction with the stomach: this is a complication of chronic gastroesophageal reflux disease and can be a cause of dysphagia or difficulty swallowing. the diagnosis of gerd is usually made when typical symptoms are present. reflux can be present in people without symptoms and the diagnosis requires both symptoms or complications and reflux of stomach content. other investigations may include esophagogastroduodenoscopy (egd). barium swallow x-rays should not be used for diagnosis. esophageal manometry is not recommended for use in the diagnosis, being recommended only prior to surgery. ambulatory esophageal ph monitoring may be useful in those who do not improve after ppis and is not needed in those in whom barrett's esophagus is seen. investigation for h. pylori is not usually needed. the current gold standard for diagnosis of gerd is esophageal ph monitoring. it is the most objective test to diagnose the reflux disease and allows monitoring gerd patients in their response to medical or surgical treatment. one practice for diagnosis of gerd is a short-term treatment with proton-pump inhibitors, with improvement in symptoms suggesting a positive diagnosis. short-term treatment with proton-pump inhibitors may help predict abnormal 24-hour ph monitoring results among patients with symptoms suggestive of gerd. endoscopy endoscopy, the examination of the stomach with a fibre-optic scope, is not routinely needed if the case is typical and responds to treatment. it is recommended when people either do not respond well to treatment or have alarm symptoms, including dysphagia, anemia, blood in the stool (detected chemically), wheezing, weight loss, or voice changes. some physicians advocate either once-in-a-lifetime or 5- to 10-yearly endoscopy for people with longstanding gerd, to evaluate the possible presence of dysplasia or barrett's esophagus. biopsies performed during gastroscopy may show: edema and basal hyperplasia (nonspecific inflammatory changes) lymphocytic inflammation (nonspecific) neutrophilic inflammation (usually due to reflux or helicobacter gastritis) eosinophilic inflammation (usually due to reflux): the presence of intraepithelial eosinophils may suggest a diagnosis of eosinophilic esophagitis (ee) if eosinophils are present in high enough numbers. less than 20 eosinophils per high-power microscopic field in the distal esophagus, in the presence of other histologic features of gerd, is more consistent with gerd than ee. goblet cell intestinal metaplasia or barrett's esophagus elongation of the papillae thinning of the squamous cell layer dysplasia carcinoma reflux changes that are not erosive in nature lead to "nonerosive reflux disease". severity severity may be documented with the johnson-demeester's scoring system: 0 – none 1 – minimal – occasional episodes 2 – moderate – medical therapy visits 3 – severe – interference with daily activities differential diagnosis other causes of chest pain such as heart disease should be ruled out before making the diagnosis. another kind of acid reflux, which causes respiratory and laryngeal signs and symptoms, is called laryngopharyngeal reflux (lpr) or extraesophageal reflux disease (eerd). unlike gerd, lpr rarely produces heartburn, and is sometimes called silent reflux. differential diagnosis of gerd can also include dyspepsia, peptic ulcer disease, esophageal and gastric cancer, and food allergies. treatment the treatments for gerd may include food choices, lifestyle changes, medications, and possibly surgery. initial treatment is frequently with a proton-pump inhibitor such as omeprazole. in some cases, a person with gerd symptoms can manage them by taking over-the-counter drugs. this is often safer and less expensive than taking prescription drugs. some guidelines recommend trying to treat symptoms with an h2 antagonist before using a proton-pump inhibitor because of cost and safety concerns. medical nutrition therapy and lifestyle changes medical nutrition therapy plays an essential role in managing the symptoms of the disease by preventing reflux, preventing pain and irritation, and decreasing gastric secretions. some foods such as chocolate, mint, high-fat food, and alcohol have been shown to relax the lower esophageal sphincter, increasing the risk of reflux. weight loss is recommended for the overweight or obese, as well as avoidance of bedtime snacks or lying down immediately after meals (meals should occur at least 2–3 hours before bedtime), elevation of the head of the bed on 6-inch blocks, avoidance of smoking, and avoidance of tight