Causes and Diagnosis of Gastroesophageal Reflux

What is Gastroesophageal Reflux?

Gastroesophageal reflux disease (GERD) is a chronic and recurrent condition affecting up to 60% of the Western population, significantly impacting quality of life. It's characterized by prolonged and frequent exposure of the mid-distal esophageal mucosa to acidic gastric secretions. In a small percentage of cases, esophageal reflux is alkaline, with mucosal damage caused by bilio-pancreatic juice. More commonly, in gastro-duodenal reflux, bile acids act synergistically with gastric acid, exacerbating its harmful effects.

Symptoms are often underestimated or unrecognized, contributing to the chronicity or complication of the disease.

Gastroesophageal Reflux: Causes and Risk Factors

What are the causes of GERD?

GERD primarily results from recurrent dysfunction of the lower esophageal sphincter (LES). The LES, located at the esophageal-gastric junction, prevents stomach acid from entering the esophagus. Hiatal hernia, the upward displacement of part of the stomach into the chest through the esophageal hiatus in the diaphragm, can also cause esophageal-gastric junction dysfunction. Smoking, poor diet, and obesity are additional contributing factors.

What are the risk factors for GERD?

Factors that worsen GERD include abdominal obesity, pregnancy, gastric hypersecretion, delayed gastric emptying, and esophageal peristalsis abnormalities.

Weight reduction is recommended for overweight or recently weight-gained individuals with GERD, as studies show weight loss often improves symptoms.

For nighttime symptoms, elevating the head of the bed often helps. Eating meals at least 2-3 hours before bedtime improves symptoms of gastric acidity but not nocturnal symptoms.

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Symptoms of Gastroesophageal Reflux (GERD)

While "heartburn" describes various digestive issues, medically, it's the hallmark symptom of GERD. In GERD, stomach contents reflux into the esophagus, causing a burning sensation between the lower chest (rib cage) and just below the neck. This burning can radiate to the chest or neck, even the throat.

Pyrosis (retrosternal burning) is the typical GERD symptom. This is often accompanied by food reflux and regurgitation, eructation (often uncontrolled), dysphagia (difficulty swallowing), and a feeling of a lump in the throat.

Beyond typical symptoms, atypical symptoms stemming from reflux into the pharynx, lungs, and throat are important to consider, as these may be the only symptoms presented.

Diagnosis of Gastroesophageal Reflux (GERD)

How is the diagnosis of GERD established?

A presumptive GERD diagnosis can be made with typical symptoms (heartburn and regurgitation). Empirical treatment with a proton pump inhibitor (PPI) can confirm the diagnosis when GERD is suspected in patients with typical symptoms.

If chest pain precedes treatment, ruling out cardiac causes is mandatory. Similarly, dysphagia warrants prompt diagnostic testing to exclude other possibilities.

Pepsin Detection in the Diagnosis of GERD

Diagnosis usually involves gastroscopy and/or 24-hour esophageal pH-metry. Both are cumbersome, particularly pH-metry, which is invasive. A new, easy, non-invasive test detects pepsin in saliva to quickly diagnose pathological GERD. Pepsin is an enzyme produced by the gastric mucosa.

The test uses a saliva sample collected with a special kit to determine pepsin levels and aid in GERD diagnosis. Results are available within hours. Negative results with reflux suggest non-acid reflux. Positive results may necessitate further testing, depending on symptoms. Specialist consultation is always advisable.

Remember, any treatment should be guided by a gastroenterologist. Avoid self-treating with antacids (PPIs) as long-term use without specialist supervision can cause more harm than good.

Gastroesophageal Reflux: When is surgery indicated?

Surgery may be considered for patients with GERD unresponsive to medical and dietary management, especially those with a long life expectancy.

Surgical indications for GERD include:

• Intolerance to long-term medical/pharmacological treatment;
• GERD recurrence during adequate medical treatment;
• GERD recurrence after cessation of repeated medical treatment;
• Complications like esophageal stenosis, bleeding ulcers, Barrett's esophagus;
• Massive hiatal hernia;
• Reflux disease without esophageal inflammation but with significant extra-esophageal symptoms (e.g., cough, asthma, sleep apnea, halitosis, pharyngitis and laryngitis, dysphonia, etc.);

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