gastroesophageal reflux disease

Gastroesophageal Reflux Disease (GERD), which is caused by the reflux of stomach contents into the esophagus without retching and vomiting, is one of the most common gastrointestinal diseases. GERD is highly heterogeneous and has a wide spectrum of symptoms. At one end of this spectrum, there is the classical picture of reflux disease with typical symptoms, while at the other end there are clinical pictures with few or silent typical symptoms of the esophagus, but with extra-esophageal symptoms. GERD occurs with equal frequency in men and women. However, its complications are more common in men and older people. The incidence of intermittent symptoms in patients with GERD is 40%. Reflux symptoms are seen in 7% of the patients every day and 20% of them at least once a week.1-6. In a study conducted in our country, the rate of retrosternal burning at least once a week was 10% and the rate of regurgitation was 15.6% in patients diagnosed with GERD. In the same study, the rate of those who described retrosternal burning and/or regurgitation at least once a week was found to be 20%.3%

The symptoms and signs seen in GERD can be grouped under three main headings.:1,3 ,5

1-Typical Symptoms

2-Atypical Symptoms and Signs

3-Symptoms and Signs of Complications

Approximately 1/3 of patients experience typical symptoms. However, only 47-79% of patients with typical symptoms have endoscopic signs of esophagitis. It has been shown that only 65% ​​of patients with esophagitis have GERD symptoms. 1,2,7,8

1-Typical Symptoms:

The most common typical symptoms in GERD are retrosternal burning (Heartburn). ), regurgitation, nonobstructive dysphagia, and chest pain. Other symptoms are seen less frequently.8-10 (Table 1)

Table 1: Typical Symptoms in GERD

Retrosternal Burning

Burning behind the sternum, in the midline, between the xiphoid and manibrium Feeling the sensation of burning is called retrosternal burning. It is the most common symptom in GERD. Sometimes it can spread to the upper part of the epigastrium, the interscapular region of the back, the throat, and even to the chin and under the ears. The burning sensation may increase over time and turn into pain. However, sometimes, even in the presence of severe esophagitis, peptic ulcer, and Barrett’s Esophagitis, paradoxically, retrosternal burning may not be observed.12

Retrosternal burning usually begins 30-60 minutes after meals. It increases when lying on the back or when the patient leans forward. It can also increase with exercise. Sometimes it can wake you up at night. Cold and hot drinks, coffee, tea, acidic and alcoholic beverages increase combustion. Citrus fruits, fatty foods, and chocolate can also increase retrosternal burning. Patients state that they feel relief in 3-5 minutes when they drink antacids. Burning is also relieved when milk is consumed. There is no correlation between the frequency and severity of retrosternal burning and esophageal mucosal damage. Retrosternal burning may also occur due to non-reflux causes. 14-16

It has been reported that 10% of the people living in the USA experience retrosternal burning every day, and 1/3 of them once a month. Retrosternal burning is observed in approximately 25% of women during their pregnancy.17

Reflux can also occur in normal healthy individuals, but stomach contents that escape into the esophagus by various mechanisms are quickly cleared. Therefore, no symptoms occur. This reflux, which does not cause symptoms or mucosal damage and occurs mostly after meals every day, is also called physiological reflux.12

Regurgitation

is one of the most important symptoms that can be seen in GERD. Gastric acid coming into the mouth. It differs from vomiting in that it is free of nausea and absence of abdominal contractions. In addition, it is another feature of regurgitation that it does not exert effort and starts with a change in posture.7,10

Patients report that their food comes into their mouths and they feel bitterness in their mouths. Usually, retrosternal burning is accompanied by regurgitation of acid into the throat and mouth.8,10

Patients report that they have acidic water in their mouths, especially when they lean forward or lie on their back. When they stand up, they relax. Some patients complain of a sour taste in their mouth, a lack of taste, and rarely a burning lip.8,10

Non-Obstructive Dysphagia

Non-obstructive dysphagia is reported in approximately 30% of patients with GERD. It has been reported that it can be seen in 45 of them.12

Dysphagia is usually seen in the lower esophagus, and to a lesser extent in the cervical esophagus. Patients may also complain of a feeling of fullness in the throat, difficulty in swallowing, and frequent swallowing for relief. Difficulty in swallowing occurs especially with solid foods. Passage is achieved with repeated swallowing, so dysphagia is temporary. However, when a stricture develops, dysphagia can also become permanent.8,12

In patients with GERD, dysphagia may also result from peristaltic dysfunction as a result of severe esophagitis or peptic stricture.15

Non-Cardiac Chest Pain

Most non-cardiac chest pain is caused by esophageal diseases. Among the esophageal diseases, GERD is the most common cause of chest pain. Esophagitis was found in approximately 23% of patients who applied to the emergency department with the suspicion of myocardial infarction.18 In another study, it was shown that the pain was of non-cardiac origin in 38% of the patients referred to cardiology clinics for chest pain. It has been reported that 30% of the patients who underwent coronary angiography for chest pain had normal coronary arteries and 50% of the patients with coronary heart disease had esophageal symptoms. Therefore, GERD should be kept in mind in the differential diagnosis of patients with chest pain.19

Odynophagia

Odynophagia, also called painful swallowing, is a less common symptom in GERD. It may be an indication of a more advanced stage of the disease. It is usually associated with esophageal ulcers or erosions.12 It usually occurs as a result of the provocation of hot and alcoholic beverages. Esophageal sensitivity is greatly increased. In the presence of odynophagia, GERD should be considered first.10,12

Excessive salivation

It is a relatively common GERD symptom. It is also called waterbrush. Patients state that they suddenly have a sour-salty liquid in their mouths. This occurs when the salivary glands increase their secretions in response to increased intraesophageal acid. This response of the salivary glands to acid reflux is a protective response for the patient.8,20

2-Atypical Symptoms

Atypical Symptoms, also called Extraesophageal Clinical Tables or Supraesophageal Symptoms, Larynx, Pharynx Includes signs and symptoms of Oral cavity, Nose, Nasal sinuses and Lungs. It is possible to examine these in three groups as Ear Nose and Throat (ENT) Symptoms, Pulmonary Symptoms and Symptoms in Infants.4,8,21,22 (Table 2).

Table 2: Atypical Symptoms in GERD

Atypical findings seen in GERD can cause aphthae in the oral cavity, gingivitis, dental caries and tooth deformities, ulcerative oral mucosal lesions, chronic sinusitis, It has been reported that it can cause asthma, chronic interstitial lung diseases, and especially sudden death in infants.23 Laryngeal reflux, which is seen in a wide group of patients among atypical clinical forms, includes chronic laryngitis, contact ulcers and granulomas of the larynx, vocal fold nodules, Reinke’s edema, Subglottic stenosis, laryngotrachea. eal stenosis has been shown to cause paroxysmal laryngeal spasms, chronic cough, globus pharyngeus, and even laryngeal and pharyngeal cancers. Symptoms may be in the background. For example, it has been reported that 40-60% of asthmatics, 57-94% of those with ENT symptoms and 43-75% of those with chronic cough may not have typical GERD symptoms.4,5,21

Chronic Cough

Cough in GERD occurs as a result of irritation caused by laryngopharyngeal reflux and activation of reflex mechanisms. Usually, there is a chronic cough or recurrent cough and frequent throat clearing habit. As the pathological mechanism itself causes inflammation in the vocal cord epithelium, the symptoms of the patients become increasingly severe and sometimes permanent.29,30

Cough lasting longer than three weeks is called chronic cough. Cough in GERD is a chronic cough. Chronic cough can have many causes. GERD has been reported in 21% of chronic cough cases. 29,30

GERD can lead to chronic cough in several ways.25,29:

1- Stimulation of the cough center of the vagus nerve by stimulating the receptors in the esophagus

2-Increasing the secretion in the respiratory tract via the vagus nerve with the stimulation of the receptors in the esophagus

3-Direct connections between the esophagus and the trachea

4- Direct stimulation of the larynx or main respiratory tract by micro or macro aspiration

5-Sensitization of the receptors or reflex arc due to various reasons in GERD

Cough is seen in most patients during the day, while in some patients after going to bed at night arises. It can be in the form of productive or dry cough. Cough usually starts after upper respiratory tract infection. 29-31

Voice Disorders

It is one of the ENT pathologies caused by Laryngeopharyngeal Reflux. The most common form of voice disorder is hoarseness and can sometimes be the most important symptom. The duration and severity of hoarseness vary according to the degree of damage caused by the reflux content on the vocal cord mucosa. If the changes in the vocal cord mucosa are in the early inflammatory stage, the patient’s complaint is usually mild hoarseness that recurs frequently. Bifurcation of the voice may also be seen before hoarseness. It may be accompanied by symptoms such as vocal fatigue, chronic throat clearing, excessive mucus secretion in the throat, and globus. It is accepted that hoarseness occurs in two ways.24,28,32:

1-As a result of direct tissue damage by acid as a result of esophageal reflux or

2-As a result of stimulation of receptors in the esophagus cough and tickling sensation with reflex stimulation of the larynx and pharynx, frequent throat clearing and hoarseness as a result of larynx injury.

3-Complication Findings

The most common complications in GERD are esophagitis, esophageal erosion and ulcerations. Bleeding may occur due to erosions and ulcers. More serious complications such as stricture and Barret’s esophagus may develop, especially in cases of long-term illness.12,32,33. (Table 3)

Table 3: Complications in GERD

Alarm Symptoms

Some of the symptoms seen in GERD especially indicate that the disease is more serious and therefore require prompt treatment. These symptoms are called alarm symptoms. In the presence of alarm symptoms, serious complications such as cancer must be ruled out.12,32-35 (Table 4).

Table 4: Alarm Symptoms in GERD: