Gastroesophageal Reflux Disease (GERD)

The initial symptoms consist of chest pain on heartburn due to the mucosa injury that may worsen after the ingestion of food or drugs.

Ethiology

GERD arises from conditions that lead to successive expositions of acids on the esophagus mucosa. These conditions (hormones, nerve agents, food and others) include disturbs that increase the LES spontaneous relaxation frequency. That conditions that increase the stomach volume or pressure (increased production of acid and pyloric obstruction) also contribute to esophagitis. Coffee and tobacco cause relaxation of the cardia.

The hiatal hernia (proximal portion of the stomach that slides to the chest cavity) causes descent LES and consequently the reflux occurrence.

Pathology and Pathogenesis

The LES tonic contraction allows a effective barrier to the acid reflux of stomach. These barrier efficiency can be changed by LES tone loss, increased frequency of the transitory relaxation and increased stomach volume, that may become the reflux acid enough to cause pain and erosion. The recurrent reflux can cause mucosa injury and inflammation (esophagitis resulting from granulocytes and eosinophils infiltration with basal cell hyperplasia and blooding ulcers formation). The reflux predisposes the occurrence of more reflux due to the cicatrisation of the inflamed epithelium.  

On regular conditions, the LES transient relaxations are accompanied by the increased esophageal peristalsis. Thus, the individuals with defects on the excitatory pathways that promote peristalsis may be at increased risk of developing esophagic reflux.

Clinical Manifestations

The usual symptom is heartburn, aggravated by a supine position. It can be developed a stenosis (esophagus narrowing) in the distal portion of the esophagus. The progressive obstruction manifests itself in the form of dysphagia. Other reflux complications include bleeding or perforation and pneumonia due to the gastric aspiration into the lungs.

Smoking and alcohol, associated to recurrent reflux, result in changes on the esophagic epithelium (columnar to squamous), called as Barrett’s Esophagus (it mat lead to adenocarcinoma development)

Treatament

1. Decreased stomach pressure (drugs that promote gastric emptying; avoid eating a lot before going to bed)

2. Decreased gastric acidity (antacids)

3. Maintaining of cardia pressure (reduce alcohol, coffee and fat; eat little portions each time)

4. Protection of the esophagus mucosa.