Esophagitis

Esophagitis is common with GERD and may be classified as erosive or nonerosive with the severity based on the number and location of mucosal breaks. Other types of esophagitis, such as eosinophilic esophagitis, present with similar symptoms as GERD and are commonly misdiagnosed. The common presentation of eosinophilic esophagitis is dysphagia and food impaction. Additional symptoms may include epigastric pain, emesis, weight loss, and failure to thrive.21 The diagnosis is based on a histologic finding of greater than 20 eosinophils per high-powered field in the esophageal squamous mucosa. This condition also presents with motor disturbances that may cause food impaction in the absence of strictures. Manometry shows high amplitude long-duration waves in the distal esophagus particularly at night. The symptoms often respond to elimination or elemental dietary regimens and antiallergy treatment.22 Standard skin-prick tests measure type 1 hypersensitivity reactions, which are typically mediated by immunoglobulin E (IgE). (It is possible to have a positive skin test but normal blood levels of IgE on a radioallergosorbent test [RAST].) However, these tests do not diagnose many food-allergy reactions, which are frequently IgG-mediated. Thus, IgG testing can offer additional insights that are frequently missed with standard skin-prick tests.

Respiratory Conditions

GERD is associated with numerous respiratory conditions. Approximately 10% of patients presenting to ENT specialists have conditions that may be attributed to GERD.23 One study revealed that GERD is present in 75% of individuals with refractory ENT symptoms, and PPI therapy provided symptom relief or reduction in the majority of these individuals.24 Asthma is associated with the presence of GERD symptoms, and although the relationship has not been well-studied. It is estimated that prevalence of GERD in people with asthma is between 60%-80% in adults and 50%-60% in children. Although the direct correlation is unknown, researchers have suggested that reflux aggravates asthma, which in turn induces further reflux.25 GERD is associated with a chronic nonproductive cough in some individuals; the cough occurs primarily during the day and while these patients are in an upright position. One study demonstrated that chronic cough was caused by reflux in 21% of cases. In addition, the researchers showed that chronic cough was the sole presenting symptom in GERD 43% of the time.26

Otitis media may also be linked to GERD.27 A study examining otitis media with effusion in adults demonstrated that pepsinogen concentration was higher in middle-ear effusion in patients who reported GERD symptoms. In addition, treatment for GERD with PPIs provided some patients with GERD symptom relief as well as decreasing the concentration of pepsinogen in the effusion. Additionally, research has indicated that patients with chronic rhinosinusitis have an increased prevalence of GERD. These chronic rhinosinusitis symptoms in many patients are reduced when their GERD is treated.28 Laryngeal symptoms may be associated with GERD. Often, they present as hoarseness, frequent throat clearing, a postnasal drip, excess phlegm, sore throat, dysphagia, a globus sensation, or cough. Chronic laryngitis and chronic sore throat are associated with GERD in as many as 60% of patients.29 In addition, one study showed that at least 50% of patients presenting with laryngeal and voice disorders had laryngopharyngeal reflux.30 Less-common GERD-related laryngopharyngeal disorders include paroxysmal laryngos-pasm, subglottic stenosis, vocal-cord granuloma, and laryngeal and pharyngeal carcinoma.31

Oral Health

GERD has been shown to affect overall oral health. One study showed that children with GERD have increased dental erosion, salivary yeast, and salivary Mutans streptococci compared with healthy children.32 In addition, research indicates that children with GERD have more dental caries and more severe erosion compared with healthy children.33

Sleep Apnea

Sleep disturbance is common in individuals with GERD. Patients with obstructive sleep apnea (OSA) have GERD symptoms significantly higher than the general population.34 Studies have indicated that the severity of GERD symptoms is correlated positively to the severity of OSA.35 One study showed that treatment with continuous positive airway pressure (CPAP) in individuals with GERD and OSA reduced supine esophageal-acid contact time to within normal levels in 81% of the study patients.36 In addition, researchers have shown that treatment of GERD in patients who have OSA decreases the number of arousals during sleep.37

Barrett's Esophagus and Cancer

Barrett's esophagus is a precancerous condition showing intestinal metaplasia of the lower esophagus and mucosecretory cells on histologic examination. It is the precursor to esophageal adenocarcinoma. Approximately 8%-10% of individuals with GERD have Barrett's esophagus.38 In fact, the cancer risk for an individual with Barrett's esophagus is 30 times higher than in the general population. Risk factors for Barrett's esophagus include GERD for at least five years' duration, male gender, Caucasian race, and age over 50.39 A study with U.S. veterans showed that GERD increases the risk of both laryngeal and pharyngeal cancers independent from other risk factors.40

CONVENTIONAL TREATMENT Pharmaceuticals

Pharmaceutical acid blockers are usually the initial recommendation for both diagnosis and treatment. Treatment recommendations are usually based on a step-up or step-down approach depending on the severity of symptoms. Step-up treatment typically involves an eight-week trial of a histamine H2-receptor antagonist taken two times per day as needed, changing to a PPI if symptoms are not controlled. The step-down approach begins with an eight-week trial of a PPI taken 30 to 60 minutes before the first meal of the day and then decreasing to the lowest possible dosage that provides relief. Studies have indicated that both PPI therapy and H2 blockers provide symptom relief for the majority of patients. One study showed that eight weeks of therapy with the PPI omeprazole relieved symptoms in 74%, and eight weeks of the H2 blocker ranitidine relieved symptoms in 50% of individuals with reflux esophagitis.41 Low-dose antacids have also been shown to decrease reflux symptoms better than a placebo.42

Long-term therapy with acid blockers has not been well-studied. Some research has indicated that nutrient deficiencies may arise with these treatments. Research has also suggested that long-term therapy with both PPI and H2 blockers increases the risk of vitamin B12 deficiency significantly in elderly adults.43 In fact, one study demonstrated that therapy with H2 blockers caused a 53% decrease in absorption of protein-bound vitamin B12.44 H2 blockers have also been associated with decreased absorption of folic acid, iron, and zinc.45-47 Research has demonstrated that treatment with the H2 blocker cimetidine significantly decreases intestinal calcium transport as well as altering vitamin D metabolism.48,49 There is also evidence that long-term use of PPIs increases the risk of hip fracture significantly.50

Baclofen is a gamma-aminobutyric acid (GABA) receptor B agonist currently being investigated as a possible treatment for GERD symptoms. Studies have indicated that baclofen reduces the rate of transient LES relaxations significantly, reduces the rate of gastroesophageal acid-reflux episodes, increases basal LES pressure, and increases gastric pH. Studies have also suggested that the drug is well-tolerated by patients.51 Atropine has also been studied as a

Commonly Prescribed Pharmaceuticals for GERD

Histamine H2-receptor antagonists

Proton pump inhibitors

Cimetidine (Tagamet)

Lansoprazole (Prevacid)

Famotidine (Pepcid)

Esomeprazole (Nexium)

Ranitidine (Zantac)

Omeprazole (Prilosec)

Nizatidine (Axid)

Pantoprazole (Protonix)

Sleep Apnea

Sleep Apnea

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