The acronym GERD stands for gastroesophageal reflux disease. Afflicting approximately 7 million people in the U.S., its incidence increases dramatically with age. GERD is a term that describes a backflow of food, liquids, and gastric acid from the stomach into the esophagus. It can be felt as either heartburn, which is experienced as a burning sensation in the chest and throat, or regurgitation, which is the sensation of acid backing up into the esophagus. This can cause not only irritation of the esophagus, but damage to its delicate mucosal wall as well. GERD is a multifaceted disease that includes a reduced resting lower esophageal sphincter (LES) tone, transient episodes of inappropriate LES relaxation, irritation from gastric acid and digestive enzymes, decreased peristalsis, and defective mucosal resistance to caustic liquids. In addition, there is impaired esophageal clearance of acid from the esophagus, as well as delayed gastric emptying. Although a certain amount of reflux is normal, severe or chronic GERD perpetuates a continuous inflammatory state, leading to esophageal scarring with a subsequent loss of esophageal motility and flexibility. At its most severe, GERD can lead to life-threatening complications.

Patients with this condition can be found in all age groups. Nurses are a vital factor in recognizing GERD’s signs and symptoms in its early stages. They most often occur after meals, since eating causes an increase in gastric acid production. GERD spans a spectrum that ranges from symptoms of erythema, through several degrees of erosion and ulceration, to Barrett’s esophagus. Barrett’s esophagus is a late-stage condition in which the normal squamous cell lining of the esophagus is replaced by the columnar epithelium that constitutes the mucosal lining of the balance of the GI tract. A patient with Barrett’s esophagus is 30 to 125 times more likely to develop esophageal cancer than a member of the general population.¹

The problem in assessing adults who have GERD is that many have elected to self-medicate with antacids for a significant period — sometimes for years — before reporting the condition to a health care provider. By the time it becomes severe enough to cause symptoms that are uncomfortable enough to cease to be “normal” in the patient’s perception, the disease has advanced to its latter stages.

Preexisting conditions

When food is swallowed and passes into the stomach, it travels through the cardiac sphincter or LES — the primary defense against reflux. Located at the junction of the esophagus and stomach, the LES is a muscular thickening that is approximately one centimeter in length in infants and three to four centimeters in children and adults.

Reflux can occur as a result of an incompetent cardiac sphincter. A patient may have a valve that frequently relaxes, does not close adequately, or transiently loses muscle tone. Caffeine, alcohol, smoking, and drugs that relax smooth muscle, such as beta-adrenergic antagonists, calcium channel blockers, and nitrates, may trigger reflux. Anticholinergics, theophylline, meperidine, and calcium channel blockers decrease the resting tone of the LES. Other contributing factors include chocolate and foods that contain high concentrations of fat or carbohydrates, all of which decrease LES pressure and increase heartburn.

Reflux may also be the result of an abnormal pressure gradient between the esophagus and the stomach at the level of the LES, secondary to either diminished esophageal motility or a full stomach. Diaphragmatic displacement during pregnancy — especially during the third trimester — ascites, obesity, and dietary indiscretions of large meals or ample bedtime snacks can all raise intragastric pressure and stimulate reflux.

Changes in position that move gastric contents closer to the esophagus, such as bending over or lying supine, can also promote GERD. For example, infants may experience reflux if they are placed lying down immediately after eating. Exercise can precipitate reflux and jogging following a meal is the most common exercise-induced cause.

Hiatal hernia — a protrusion of part of the stomach through the diaphragmatic muscle into the thoracic cavity — modestly predisposes one to GERD. The mechanism is unclear, but the hernia probably exaggerates reflux during transient sphincter relaxations by trapping gastric acid near the esophagus. These sphincter relaxations occur while awake or during transient arousals from REM stage sleep. However, anatomic factors such as hiatal hernia are not as likely as once was believed to be the cause of reflux.

Reflux can be both a trigger and a complication of asthma. A patient with GERD may complain of wheezing similar to that experienced by asthmatic patients simply because the reflux of acid rises to a high enough level to spill over on to the epiglottis, allowing droplets to descend into the upper airway. GERD may be a continual trigger in patients with asthma, whose bronchoconstriction fails to respond consistently to treatment. Some medications used to treat asthma, specifically those designed to relax airway smooth muscle, such as theophylline, can impair LES function. Asthmatic children may experience nocturnal reflux due to supine positioning or diminished salivation and swallowing related to antihistamine medications and/or mouth breathing that can lead to reflux-induced bronchospasm.

Presenting symptoms

A patient can present with a variety of nonspecific symptoms, which may be mistaken for those of other conditions. The most common initial complaint is an upward-moving heartburn, typically described as retrosternal or subxiphoidal burning, usually occurring one hour after meals and/or when a person bends over or belches. Regurgitation of fluid or food particles may occur, particularly at night. The patient may describe soiling of the pillow with gastric contents or may awake because of coughing or a strangling sensation. Nocturnal aspiration is occasionally associated with gastroesophageal reflux and can cause recurrent pneumonias, bronchospasm, sore throat, vocal cord inflammation, hoarseness, and chronic cough. Gastric acid that reaches the oral cavity can dissolve tooth enamel.

Atypical symptoms include noncardiac substernal chest pain, epigastric discomfort, coughing, or wheezing. The respiratory symptoms of GERD can mimic those of asthma; pain symptoms can mimic angina, because the same nerve complex serves both the heart and the esophagus. Pain arising from either area may be indistinguishable. Older children, as well as adults, may complain of recurrent epigastric or right upper quadrant abdominal pain that can resemble cardiac angina. Interestingly, recent studies have shown that esophageal hyperacidity may induce a true form of angina, as coronary blood flow velocity in some patients is reduced in response to the reflux acid. This is known as “linked” angina. Pain associated with GERD can be so severe that sufferers may be afraid to eat.

Dysphagia is a primary presentation of GERD. This difficulty swallowing may be related to peptic strictures, which develop after gastric contents repeatedly inflame the esophageal mucosa. Painful or difficult swallowing (odynophagia, dysphagia) usually indicates chronic reflux disease and also active inflammation, stricture, or both. Solid food may lodge in the distal esophagus, although food usually passes into the stomach following repeated swallowing or drinking of liquids. Severe erosion, a malignancy, or infection may cause the symptom odynophagia (painful swallowing). Frequent vomiting or regurgitation of liquids may be seen in patients of any age. When Barrett’s Esophagus (the presence of gastric columnar cells in the esophagus) is accompanied by dysphagia and weight loss, it may indicate the presence of adenocarcinoma.

Pediatric considerations

Many of the clinical signs and symptoms are similar in adults and children, but some manifestations are virtually exclusive in infants. Infants may display irritability. Stomach acids inflaming the esophagus cause this crankiness. In some instances, an infant may cough after feedings or during sleep, and suffer periodic apneic spells or recurrent pneumonitis. Reflux-associated apnea occurs most often in the awake, recently fed infant who is seated or supine. Although the relationship between GERD and apnea is unclear, it is thought that the presence of acid may stimulate receptors in the esophagus, causing a reflex constriction of the upper airway and larynx, leading to an apneic episode. Another possibility is that refluxed material may enter the lungs directly during aspiration, causing bronchospasm and apnea. In these cases, therapy aimed at subduing the reflux will probably diminish the occurrence of apnea.

Hiccups are often noted in infants and children with GERD and esophagitis. They can also present with Sandifer’s Syndrome, an odd arching of the neck that may simply be a response to pain, which aids in the clearance of esophageal refluxate. Standard therapy for GERD may resolve these symptoms, along with the syndrome. Discounting an organic dysfunction or anomaly, infants tend to outgrow reflux problems between six and 12 months of age, while older children and adults may experience reflux disease as a chronic problem.

Gold standards and routine diagnostics

When evaluating a patient for possible GERD, a pertinent health history will include questions about eating habits, the relationship of symptoms to meals, the frequency and characteristics of emesis, and a description of any aggravating factors. (See sidebar, Aggravating Factors.) Question the patient or the parent about the presence of respiratory problems, the nature of the symptoms, the time at which the respiratory episodes occur, and any associated events (such as emesis) that occur prior to or directly after the event. Determine whether medications used to treat respiratory problems may be among those suspected of predisposing to GERD. Ask for a description of any episodes of transient abdominal or epigastric pain and inquire about the use of and response to antacids.

The physical examination should include a thorough gastrointestinal system assessment including a stool guaiac test for occult blood, respiratory assessment, cardiac assessment, and, for infants or children, an assessment of growth and nutritional status.

A thorough history is most often sufficient to establish the diagnosis. There is no single standard test for diagnosing reflux disease and diagnostic testing is usually only needed in atypical or severe cases. Tests that are used to diagnose GERD — barium swallow, 24-hour esophageal pH probe study, esophagoscopy with biopsy, and Bernstein test — are generally the same for infants, children, and adults.

A barium swallow, or upper GI series, helps to visualize anatomical abnormalities, such as hiatal hernia, stricture, or mass, and evaluates gastric emptying by tracking the barium into and through the stomach. Although its sensitivity for diagnosing GERD is as low as 25%, it is useful for identifying stricture or tumor.

The esophageal pH probe study has become the gold standard for the measurement of acidity with GERD because it is the most sensitive and specific test for reflux. A flexible pH electrode is fed down into the lower esophagus to measure refluxed acidic material over a period of 12 to 24 hours. Symptoms that occur during the study are correlated with the recorded episodes of reflux. The nurse must stress the importance of accurate documentation and adherence to preprocedural dietary or medication restrictions associated with this test to the patient or parent/caregiver. When properly performed, this test can lead to the differential diagnosis of GERD. However, it is very expensive and is not available in all facilities.

A patient should have esophagoscopy to rule out a neoplasm or a complication of reflux if dysphagia (painful swallowing), significant weight loss, or occult blood loss is present. Patients who don’t respond to treatments, such as behavior modification or medication, are also candidates for an esophagogastroduodenoscopy (EGD).This diagnostic procedure provides direct visualization of the esophageal mucosa. For infants and children, this procedure may require general anesthesia. For adults, topical anesthetics (such as Hurricane Spray, Cetacaine Spray, or Tessalon Perles) and/or moderate sedation using a combination of opiates and benzodizepines (meperidine and midazolam being the most commonly used drugs of choice) are administered. A flexible, fiberoptic scope, inserted into the mouth of the sitting or lying patient, is manipulated downward to visualize the interior of the esophagus, sphincter, and sometimes the upper portion of the stomach. Some patients with recurrent esophagitis may have an esophageal lining that appears normal, so a biopsy is often obtained during the test.

The Bernstein acid perfusion test is indicated for patients who have multiple or atypical symptoms, and where a diagnosis cannot be determined definitively by esophagoscopy. This test involves inducing reflux symptoms. It’s most useful for determining whether chest pain is a consequence of acid reflux. The procedure is contraindicated for patients who cannot tolerate intubation or who have active ulcers or active or recent GI bleeding. Before the test, the patient should avoid antacids or pain medications and take nothing by mouth. With the patient in a sitting position, a nasogastric tube is passed to the mid-esophagus, which is about 30 cm from the nares. Normal saline is infused for 15 minutes, followed by 0.1 NaHCl at a rate of 100 gtts/min to 200 gtts/min. The results are positive for reflux once symptoms of substernal pain are reproduced twice and relieved by an infusion of normal saline. Pain related to gastric or duodenal lesions will not be relieved by the saline infusion. However, a negative test does not rule out GERD because false positive results are common. The diagnosis is made using a compilation of data from the history and physical exam. After the test is completed, the esophagus should be flushed of the hydrochloric acid with normal saline.

Standard therapy

GERD is a chronic condition without a definitive cure at the present time. However, it can be effectively managed with lifestyle alterations, medication, and, in extreme cases, surgery to alleviate the worst of the patient’s symptoms. Currently recommended treatments for GERD follow a step-wise approach. Patients who are otherwise healthy can initially be treated with nonpharmacological interventions such as diet modification, lifestyle changes, and antacids. Compliance with these measures is essential to a successful outcome, constitutes the foundation of any treatment strategy, and is the most cost effective for the majority of patients.

While remaining sensitive to the demands placed on the family or caregiver, nurses can emphasize the importance of simple changes in lifestyle that can help to control reflux in patients of all ages. These lifestyle alterations include sleeping in a prone position; raising the head of the bed to a 30 to 45 degree angle; avoiding fatty, spicy, or acidic foods; eliminating bedtime snacks; avoiding eating before exercise; and refraining from overeating at any one sitting. Gastroenterologists at The Graduate Hospital in Philadelphia found that sufferers of GERD may ease their discomfort by sleeping on their left side. According to their study, reflux was most severe when patients were on their right side. Patients should remain in an upright position after meals for 45 to 60 minutes. Parents can thicken infants’ formula with rice cereal (one tablespoon of cereal per ounce of formula) to help gravity keep stomach contents in place. Weight reduction should be encouraged for obese patients, and all patients should avoid cigarettes, alcohol, and smoking. Antacids, which immediately neutralize postprandial acid, are prescribed depending upon the severity of symptoms.

Patients taking smooth muscle-relaxing medications for concomitant conditions should consult with the prescribing health care professional to determine whether medication administration timing can be adjusted so that peak serum level times do not occur at bedtime.

Drug therapy targeted at controlling acid secretion is the next step in the treatment strategy when dietary modifications, lifestyle changes, and antacids are ineffective in controlling GERD symptoms. Histamine2 blocker (H2-blocker) treatment can be substituted for or used in combination with antacid therapy. The H2-blockers provide sustained acid suppression, better round-the-clock symptom relief, and esophageal healing. H2-blockers and antacids should not be taken at the same time because the absorption of the H2-blockers may be reduced by up to 20%. A twice-daily, full dose H2-blocker drug regimen is most effective — for example, cimetidine (Tagamet) 800 mg twice daily, ranitidine (Zantac) 150 mg twice daily, famotidine (Pepcid) 20 mg twice daily, or nizatidine (Axid) 150 mg twice a day. Patients who have milder reflux often can be effectively treated with a combination of a single daily dose of an H2-blocker taken during the time of day they experience their most pronounced symptoms, in conjunction with an antacid used to relieve any breakthrough heartburn. The H2-blockers have similar adverse effects, but more drug-drug interactions are associated with cimetidine.

Proton pump inhibitor (PPI) therapy with drugs such as omeprazole (Prilosec, Losec), lansoprazole (Prevacid, Zoton, Inhibitol), esomeprazole (Nexium), pantoprazole (Protonix, Somac, Pantoloc, Protium), and rabeprazole (Aciphex, Rabecid, Pariet) are another option for patients whose symptoms are unresponsive to diet modification and lifestyle changes. A single daily dose of a PPI suppresses gastric acid production almost completely and promotes healing of damaged tissue. Unfortunately, relapses are common when therapy is discontinued, thus long-term maintenance therapy with a PPI should be considered, especially for people with erosive esophagitis. The adverse effects of PPI drugs are similar but the differences in drug-drug interactions and cost require careful evaluation before selecting a PPI.

Omeprazole/sodium bicarbonate (Zegerid) is the most recent addition to the PPI arsenal. Unlike predecessors, however, it is the first and only immediate-release oral proton pump inhibitor. It not only provides rapid release of its active ingredients, but continuous acid control as well. Dosing is once daily.²

Prokinetic drugs such as metoclopramide (Reglan), cisapride (Propulsid), and bethanechol (Urecholine) may be indicated for those patients whose symptoms persist despite the use of H2-blockers and/or PPI drugs. Metoclopramide, a dopamine receptor antagonist, is the drug of choice for prokinetic therapy, because it promotes gastric emptying and increases LES tone. People without severe heartburn and those with gastroparesis benefit most from this drug. Unfortunately, patients may not tolerate the drug’s adverse effects on the central nervous system, which manifest as agitation, anxiety, and extrapyramidal reactions.

Cisapride (Propulsid), a dopamine antagonist, has minimal central nervous system adverse effects. However, when it’s taken with a drug that inhibits hepatic cytochrome P-450 metabolism, the drug-drug interaction may trigger life-threatening arrhythmias such as ventricular tachycardia and ventricular fibrillation. These findings resulted in the Food and Drug Administration (FDA) issuing a warning that cisapride is contraindicated when a patient is taking a drug that inhibits hepatic cytochrome P-450 metabolism. Its also contraindicated for use in persons with a cardiac rhythm disturbance, renal failure, electrolyte imbalance, or in those patients who are also taking a proarrhythmic drug. An EKG should be done prior to prescribing cisapride to rule out a rhythm disturbance or prolongation of the QT interval.

Bethanechol (Urecholine), a potent cholinergic agonist, raises LES pressure, increases salivary flow, and improves acid clearance by the esophagus. However, because of its cholinergic side effects, it increases the secretion of gastric acid and often requires concomitant use of an H2-blocker and antacids. This drug is contraindicated in patients with asthma and other conditions in which cholinergic therapy may aggravate symptoms.

Surgical intervention is reserved for patients whose chronic reflux is disabling and unresponsive to non-pharmacological and pharmacological management, or who have developed complications such as stricture, bleeding, Barrett’s esophagus, or pulmonary aspiration. Younger patients and those with preserved function of the esophageal body have the best outcomes. Difficulty with gastric emptying (gastroparesis) is the major complication of surgery and causes chronic bloating. Breakdown of the surgical repair after five years occurs in a substantial percentage of patients and although symptoms may not return, a second surgical repair must be considered.

There are five surgical interventions. The four fundoplication techniques include Nissen, laparoscopic Nissen, Hill, and Belsey. The fifth surgical option involves placing a synthetic prosthesis (Angelchik), a C-shaped silicone gel-filled device around the distal esophagus, which maintains the LES in the abdominal cavity and reinforces sphincter pressure.

The Nissen fundoplication is the most common procedure, which involves mobilization of the distal esophagus, a 360-degree wrap of the fundus of the stomach to create the action of an artificial sphincter, and a gastrostomy to decompress the stomach postoperatively. Standard postoperative care is employed with close monitoring of gastrostomy tube output, fluid and electrolyte maintenance, and both preoperative and postoperative teaching for the patient and/or family. Laparoscopic Nissen fundoplication (LNF) is a newer anti-reflux surgery that has been introduced with great success. This procedure has significantly reduced recovery time and medical expense. It is an especially beneficial surgical method for infants and children. The Hill and Belsey repair techniques involve a fundal wrap of less than 360 degrees.

New Treatment Options

Until recently vigilant observation (every three to six months), photodynamic therapy ablation (PDT), or surgical excision were the therapeutic options of choice in the treatment of Barrett’s esophagus, a progressive complication of GERD, and a disease affecting approximately 1 million people in the U.S.³ Now there is a fourth option — endoscopic radiofrequency ablation. Like the Stretta procedure that preceded it, a technique that has also been used to treat other cancers, as well as benign prostatic hypertrophy and certain cardiac dysrrhythmias, it can be performed in an outpatient setting. Requiring no surgical incisions, this new technique has proven effective in curing Barrett’s esophagus with as few as one or two treatments. Performed during the therapeutic portion of an EGD, ablative energy is delivered to the site of the damaged tissue via a small balloon catheter that is inserted into the esophagus. Able to offer complete, circumferential ablation of the diseased tissue to the level of the muscularis propria without damaging the submucosal tissue layer, the marriage of a balloon and a bipolar electrode array delivers a safe and uniform depth of ablation. Postprocedure symptoms of soreness or discomfort may be experienced, but they are mild and only last for a minimal amount of time.⁴ Although not a cure for GERD, it is a promising start along the treatment path that targets the disease processes that evolve because of it. Vigilant control of GERD remains a lifelong challenge.

Other endoscopic options have not proven to be as successful. Procedures that involve the endoscopic passage of a needle and subsequent suture into the biopsy channel of the endoscope to create plications at the gastroesophageal junction for the prevention of GERD include endoluminal gastroplication (ELGP/EndoCinch), the endoluminal full-thickness plicator (NDO plicator), and the Syntheon ARD plicator.⁵ Most patients experienced symptom recurrence within a short period of time.⁵

Synthetic implants and injections consist of an implantable biopolymer (Enteryx), an implantable prosthesis (Gatekeeper), and implantable plexiglass microspheres (PMMA).⁵ Enteryx is injected into the muscle of the lower esophageal sphincter (LES) during an endoscopic procedure.⁶ Once in place, it forms a soft, spongy, permanent implant in the sphincter muscle creating a barrier between the esophagus and the stomach which prevents reflux of fluids and acids into the esophagus from the stomach. This is an outpatient procedure, and takes less than an hour to complete.⁷

The ideal candidate for the Enteryx procedure has a confirmed diagnosis of GERD, a desire to control the symptoms without a daily dependence on medications, and has not had prior surgery to treat the condition. The procedure is indicated for those with a prior diagnosis of Barrett’s Esophagus, esophagitis, esophageal strictures, esophageal dysmotility, cancer of the esophagus or stomach, scleroderma, large hiatal hernia, GERD symptoms unrelieved by medication, and in pregnancy. The procedure is contraindicated for the patient who has known esophageal varices, portal hypertension attributable to chronic liver disease, and in those individuals in which an endoscopic procedure itself would be contraindicated (such as the noncompliant patient).

Adverse effects include temporary mild to moderate chest discomfort, difficulty swallowing (dysphagia), low-grade fever, and belching, all of which usually resolve within two weeks of the procedure.

The Enteryx procedure is intended to reduce or eliminate patient dependence on medications. However, some patients may still require PPI therapy after their procedure. In a clinical study of 85 patients in the U.S. and abroad, three out of every four patients were either off their PPI entirely, or had reduced their dosages significantly. However, a year after their procedure, 60% of patients still had abnormal reflux symptoms.⁸

Enteryx cannot be removed once it is injected into the LES. In a clinical trial at one year postprocedure, all or most of the Enteryx remained at the site of injection for 55% of the patients. Another 20% to 30% of the patients ha only half of the Enteryx remaining and it was concluded that the balance most likely sloughed off into the intestinal tract and was eliminated by the body.⁹

Many questions remain unanswered about this new procedure such as “Is more than one Enteryx procedure required? Is this the safest, and most effective treatment option for GERD currently available? Would Enteryx interfere with future treatment options including surgery?” While further studies are underway that will answer these questions, this promising treatment option is now available to those suffering with GERD. Although Enteryx appeared to be a promising therapeutic treatment pathway for GERD, it has currently been recalled by Boston Scientific Corporation. It has been found that in rare instances the liquid was being injected into areas close to the esophagus as opposed to into its muscular wall, resulting in serious complications that included internal bleeding, reduced renal function, and death.⁹

EMR (endoscopic mucosal resection) is an endoscopic technique that is reserved for Barrett’s esophagus accompanied by high-grade dysplasia. While it is an effective technique for treating localized lesions, it has not proven as effective in treating larger ones. Complications of this technique include perforation, bleeding, and stricture formation.¹⁰

Nurses play a vital role in early identification of GERD and promoting compliance with therapy. Thorough history taking, especially the use of over-the-counter H2-blockers, cimetidine, and famotidine and antacids, and recognition of typical and atypical symptoms facilitates early diagnosis and intervention. Knowing that relapse rates are high when measures to control the disease are not consistently followed, nurses can assist patients and families to effectively manage GERD. Teaching them about the disease and its treatment, as well as providing emotional and professional support, fosters both therapy compliance and successful outcomes.