Comprehensive Notes on GERD

Gastroesophageal Reflux Disease (GERD)

Can lead to esophagitis or malignancy in severe cases.

Background

Gastroesophageal reflux is a normal physiological phenomenon experienced intermittently, especially after meals. GERD occurs when the amount of gastric juice refluxing into the esophagus exceeds the normal limit, causing symptoms with or without esophageal mucosal injury (esophagitis).

Pathophysiology

The esophagus functions as an antegrade pump, the lower esophageal sphincter (LES) as a valve, and the stomach as a reservoir. Abnormalities contributing to GERD can stem from any of these components:

  • Poor esophageal motility decreases clearance of acidic material.

  • A dysfunctional LES allows reflux of large amounts of gastric juice.

  • Delayed gastric emptying can increase the volume and pressure in the reservoir, leading to GERD.

Etiology

Excessive retrograde movement of acid-containing gastric secretions or bile and acid-containing secretions from the duodenum and stomach into the esophagus is the etiologic factor of GERD.

A functional (frequent transient LES relaxation) or mechanical (hypotensive LES) problem of the LES is the most common cause of GERD.

Transient relaxation of the LES can be caused by:

  • Foods: coffee, alcohol, chocolate, fatty meals

  • Medications: beta-agonists, nitrates, calcium channel blockers, anticholinergics

  • Hormones: progesterone

  • Nicotine

During pregnancy, GERD symptoms may worsen due to hormonal and mechanical factors affecting smooth muscles of the GIT (esophagus).

Laryngopharyngeal Reflux (LPR)

LPR is another form of GERD considered atypical because it doesn't present with typical GERD symptoms. Reflux occurs in patients who also have a relaxed upper esophageal sphincter, allowing acid to travel into the larynx and pharynx.

GERD and LPR exhibit different symptoms but can both cause harmful oral manifestations that can be pre-cancerous or embarrassing.

Epidemiology

  • About 25%-40% of Americans experience symptomatic GERD at some point.

  • Approximately 7%-10% of Americans experience symptoms of GERD daily.

  • No sexual predilection exists; GERD is as common in men as in women.

  • GERD occurs in all age groups.

  • The prevalence of GERD increases in people older than 40 years.

Diagnosis

Typical symptoms include heartburn, regurgitation, and dysphagia. However, a diagnosis of GERD based on typical symptoms is only correct in 70% of patients.

Abnormal reflux can cause atypical (extraesophageal) symptoms such as coughing, chest pain, and wheezing.

According to the American College of Gastroenterology (ACG) guideline, for patients with consistent symptoms and history, GERD diagnosis may be assumed, and empirical therapy can be started.

Why atypical symptoms? The esophagus shares nerves with the chest wall (intercostal nerves), sharing the same sensations as the wall of the stomach (abdomen).

Diagnostic methods:

  • Upper GI endoscopy: Can help confirm the diagnosis by showing esophagitis, strictures, or Barrett's esophagus.

  • Manometry: Helps identify any esophageal motility disorders.

  • 24-hour pH testing: Helps confirm the diagnosis in patients with unclear history, atypical symptoms, or no complications of reflux disease shown by endoscopy. A probe is sent into the esophagus to measure pH levels over 24 hours.

Treatment

Involves a stepwise approach. Goals are to control symptoms, heal esophagitis, and prevent recurrent esophagitis or other complications. Treatment is based on:

  1. Lifestyle modification

  2. Control of gastric acid secretion through medical therapy with antacids or PPIs or surgical treatment with corrective antireflux surgery.

Lifestyle Modifications:

  • Losing weight (if overweight)

  • Avoiding alcohol, chocolate, citrus juice, tomato-based products, peppermint, coffee.

  • Avoiding large meals

  • Waiting 3 hours after a meal before lying down

  • Elevating the head of the bed by 8 inches

  • Refraining from ingesting food (except liquids) within 3 hours of bedtime

Pharmacologic Therapy

  • Antacids: Effective in controlling mild symptoms of GERD. Taken after each meal and at bedtime.

  • H2 receptor antagonists: First-line agents for patients with mild to moderate symptoms and grades I-II esophagitis. Examples include cimetidine (Tagamet) and famotidine (Pepcid).

  • Proton pump inhibitors (PPIs): Most powerful medications available for treating GERD. Examples include omeprazole (Prilosec), lansoprazole (Prevacid), rabeprazole (Aciphex), and esomeprazole (Nexium). PPIs inhibit acid secretion in the stomach.

Surgical Treatment

Both transthoracic and transabdominal fundoplications are performed, including partial (anterior or posterior) and circumferential wraps. The most commonly performed operation is the Nissen fundoplication. However, a percentage of patients required a redo fundoplication or needed to restart their antireflux medications within 6 months of surgery.

Dental Aspects

Refluxed acid attacks the palatal surfaces of the upper incisor teeth first. If the condition continues, erosion of the occlusal surfaces of the posterior teeth in both arches and the labial or buccal surfaces results.

In more severe cases, the pattern of erosion may be more widespread, usually with the occlusal and buccal surfaces of the lower teeth being eroded next.

Oral symptoms associated with GERD include burning mouth syndrome, dental sensitivity, loss of vertical dimension, and esthetic problems.

Other dental problems associated with GERD:

  • Gum recession

  • Tooth regression

  • Caries

  • Halitosis

  • Metallic taste

Xerostomia

The salivary flow of patients with GERD is often reduced, resulting in a lower buffering capacity.

Saliva plays a large role in neutralizing the pH of the oral cavity and cleansing the oral structures to help reduce oral diseases, such as dental caries.

Oral Malodor

Oral malodor affects a significant percentage of the United States population and is typically linked to coated tongue, dry mouth, and hard/soft tissue diseases.

Oral malodor is also linked to systemic disorders, including GERD and LPR. In healthy individuals, intestinal acids and their corresponding odors remain in the GI tract. However, in those with GERD and/or LPR, these acids, odors, and sometimes bacteria can enter the oral cavity and cause malodor.

Oral health professionals can play an important role in aiding in the detection of potential cancer-causing diseases and making appropriate referrals. Clinicians should be aware of possible oral manifestations of reflux disorders, assess, and communicate their findings with the patient. Awareness of reflux, as well as its related oral manifestations, enables oral health professionals to help patients prevent future oral conditions and seek the treatment they need.