Gastroesophageal Reflux Disease (GERD)

1. Definition

• Rosen's Emergency Medicine, 9th ed.
• Sabiston Textbook of Surgery, 21st ed.

Pathophysiology

1. Lower esophageal sphincter (LES) - a 3-4 cm smooth muscle high-pressure zone
2. Crural diaphragm - pinches the esophagus, augmenting LES during inspiration/exertion
3. Angle of His - the acute angle between esophagus and gastric fundus
4. Gubaroff valve - mucosal thickening acting as a cushion at the EGJ
5. Intraabdominal esophageal length - positive abdominal pressure compresses the esophageal wall

• Increased abdominal pressure (obesity, pregnancy, excessive abdominal training)
• Decreased thoracic pressure (obstructive pulmonary disease)
• Defective valve (hiatal hernia - the most common reason; also transient LES relaxations, generalized LES hypotension)

• Sabiston Textbook of Surgery, 21st ed.

2. Clinical Manifestations

Typical (Esophageal) Symptoms

Atypical (Extraesophageal) Symptoms

• Respiratory: chronic cough, asthma-like wheeze, aspiration pneumonia, laryngitis (hoarseness), chronic sinusitis
• Ear, nose, throat: posterior laryngitis, globus sensation, subglottic stenosis in infants
• Dental: enamel erosion of palatal surfaces of maxillary teeth, dentinal hypersensitivity (irreversible)
• Cardiac-mimicking: non-cardiac chest pain

Alarm Features (requiring urgent endoscopy)

• Dysphagia / odynophagia
• Unexplained weight loss
• GI bleeding or iron-deficiency anemia
• Vomiting
• Age >55 with new-onset symptoms

3. Investigations

A. Upper GI Endoscopy (EGD)

• Alarm symptoms
• Screening of high-risk patients (long-standing GERD, male, >50 years, obese)
• Surveillance for Barrett's esophagus (BE)

• Normal appearance (does not exclude GERD)
• Minimal-change esophagitis: papillary elongation, basal cell hyperplasia, intercellular edema
• Erosive esophagitis (Los Angeles Classification grades A-D): mucosal breaks of increasing severity
• Ulceration and scarring
• Stricture formation (peptic stricture)
• Salmon-pink metaplastic tongues of Barrett's mucosa above the GEJ

• Biopsies should be taken >2 cm above the GEJ to reliably diagnose esophagitis (lower 1-2 cm may show mild changes even in asymptomatic subjects)
• For Barrett's screening: 4-quadrant biopsies every 2 cm (surveillance for dysplasia); every 1 cm if high-grade dysplasia suspected
• Histology reveals: basal cell hyperplasia, papillary elongation, epithelial necrosis, intraepithelial eosinophils/neutrophils/lymphocytes, "balloon cells," and surface erosions
• Clinical Gastrointestinal Endoscopy, 3rd ed.

B. Ambulatory 24-hour pH Monitoring

• Transnasal pH catheter (most common): placed 5 cm above the LES (location confirmed by prior manometry); multiple sensors can detect height of reflux; more uncomfortable but cheaper and reliable
• Wireless Bravo capsule: clipped to esophageal mucosa endoscopically; allows 48-96 hour recording; better tolerated; risk of premature detachment or capsule-related chest pain; more expensive; data loss possible due to radio interference

• DeMeester score (composite score, normal <14.72)
• % time pH <4 (normal <4% upright, <2% supine, <4.5% total)
• Number of reflux episodes
• Symptom Index (SI) and Symptom Association Probability (SAP)
• Pattern: upright, supine, or combined

• Diagnose GERD when symptoms are suggestive
• Evaluate extraesophageal/atypical symptoms
• Assess GERD severity (DeMeester score)
• Pre-operative workup before antireflux surgery
• Post-operative evaluation of persistent symptoms

C. Esophageal Manometry

• Cannot diagnose GERD - a normal LES does not exclude GERD (abnormal transdiaphragmatic gradient may overcome it), and an abnormal LES is not synonymous with GERD
• Primary role: to localize the LES for precise pH catheter placement; to diagnose coexisting primary esophageal motility disorders (e.g., achalasia, ineffective esophageal motility); to evaluate before and after antireflux surgery
• Classifies EGJ types (I, II, III) based on whether LES and diaphragm pressures are coincident or separated (manometric hiatal hernia)
• Classified by Chicago Classification (v4.0)

• Localizing LES before pH monitoring
• Evaluating dysphagia
• Diagnosing primary esophageal motility disorders
• Pre-operative assessment before antireflux surgery
• Evaluating symptomatic patients after esophageal surgery
• Sabiston Textbook of Surgery, 21st ed.

D. Barium Swallow / Upper GI Series

E. Empiric PPI Trial

4. Complications

A. Peptic (Reflux) Esophageal Stricture

B. Barrett's Esophagus (BE)

• Endoscopic evidence of columnar metaplasia >1 cm above the GEJ (tongues or circumferential reddish mucosa)
• Histological confirmation of intestinal metaplasia (goblet cells on H&E staining - mucin vacuoles impart the "wine goblet" appearance)
• Both components required for diagnosis in North America (UK/Japan: IM not mandatory)

• GEJ = most proximal aspect of gastric folds
• Squamocolumnar junction (SCJ/Z-line) = junction of squamous and columnar mucosa
• In BE, the SCJ is displaced proximally above the GEJ

• Non-dysplastic BE: endoscopy every 3-5 years
• LGD: every 6-12 months
• HGD or intramucosal carcinoma: therapeutic intervention (RFA, endoscopic mucosal resection, or esophagectomy)
• Robbins & Kumar Basic Pathology, 10th ed.
• Clinical Gastrointestinal Endoscopy, 3rd ed.

C. Esophageal Adenocarcinoma

• Adenocarcinoma now accounts for 50% of all esophageal cancers in Western countries (was <5% before 1970)
• 7x more common in men than women; predominantly Caucasian
• Risk factors: documented dysplasia, long-standing GERD, tobacco use, obesity (OR 2.4 men, 2.1 women), previous radiation therapy
• Annual incidence of progression from BE to dysplasia: 0.2-1%

• Early: flat or raised patches within intact mucosa
• Advanced: large exophytic masses, diffuse infiltration, or deep ulcerating lesions
• Microscopy: mucin-producing glands (back-to-back glands with blue-gray mucin)

• Progressive dysphagia, odynophagia, weight loss, chest pain, vomiting
• Usually diagnosed at advanced stage (submucosal lymphatic invasion at presentation)
• 5-year survival <25% overall; ~80% if limited to mucosa

• Robbins & Kumar Basic Pathology, 10th ed.

5. Homoeopathic Therapeutics for GERD

1. Robinia pseudoacacia

• Keynote: Constant and profuse belching of intensely sour, acrid fluid; "acid fermentation"
• Sour vomiting, especially at night; burning in stomach and esophagus
• Headache from acidity; flatulence
• Worse: lying down at night
• Consider as a primary GERD remedy

2. Nux Vomica

• Keynote: GERD from overindulgence in food, alcohol, coffee, or spicy foods; sedentary lifestyle
• Heartburn 1-2 hours after eating; nausea in the morning
• Sour/bitter regurgitation; retching without full vomiting ("feels he could vomit if only he could")
• Waterbrash; sensation of pressure/heaviness in epigastrium
• Constitution: Irritable, impatient, Type A personality, overworked
• Worse: morning, after eating, mental exertion
• Better: after vomiting, rest

3. Iris versicolor

• Keynote: Burning of the entire GI tract from mouth to anus; "like fire"
• Profuse burning eructations; sour, acrid vomiting that excoriates the mouth and throat
• Frontal headache with GI symptoms; right-sided
• Worse: evenings; periodically (Sunday evenings); during rest
• Better: continued motion

4. Natrum Phosphoricum

• Keynote: Neutralizes excess acid; "the acid-antidote"
• Sour belching, sour vomiting, sour-smelling stools
• Regurgitation of sour fluid; creamy yellow coating at the base of the tongue
• Heartburn after eating; waterbrash
• Useful in GERD associated with dyspepsia and worm infestation in children

5. Arsenicum Album

• Keynote: Burning pain in stomach and esophagus, paradoxically better from warm drinks (distinguishes it from Phosphorus)
• Vomiting of food and water; nausea and retching; acrid regurgitation
• Intense thirst for small, frequent sips of water
• Constitution: Anxious, restless, perfectionistic, fastidious; worse midnight-2 AM
• Weakness disproportionate to illness

6. Pulsatilla

• Keynote: Reflux and heartburn after fatty, rich, or indigestible foods; greasy taste in mouth
• No thirst; symptoms worse in a warm room; better in open air
• Late-evening aggravation; changeable/shifting symptoms
• Constitution: Mild, yielding, emotional, seeks sympathy; women and children

7. Lycopodium clavatum

• Keynote: Burning heartburn and sour eructations; bloating immediately after eating even small amounts
• Sensation of fullness in upper abdomen; "everything ferments"
• Worse: 4-8 PM; flatulent colic; better after midnight, warm drinks, motion
• Constitution: Intellectual but weak physically; apprehensive; right-sided complaints

8. Phosphorus

• Vomiting of water/food as soon as it warms in the stomach
• Burning in esophagus and stomach; heartburn
• Waterbrash; thirst for cold water which is vomited when it becomes warm
• Constitution: Tall, slender, open, sympathetic

9. Carbo vegetabilis

• Burning heartburn; heaviness in stomach; "almost any food causes distress"
• Sour, rancid eructations; tremendous abdominal distension
• Worse: lying down; after eating fatty foods; better from belching
• Useful in elderly or debilitated patients with GERD

10. Calcarea carbonica

• Sour eructations; sour vomiting; heartburn; waterbrash
• Craving for indigestible things (chalk, coal, pencil)
• Constitution: Obese, flabby, cold, sweaty; excessive perspiration on the head at night

Biochemic Approach

General Management (Integrated Approach in Homoeopathy)

• Dietary modification: Elimination of trigger foods (spicy, fatty, acidic foods, alcohol, caffeine, chocolate); small frequent meals; avoiding meals 2-3 hours before bedtime
• Lifestyle: Head-of-bed elevation; weight loss in obesity; smoking cessation; avoiding tight clothing
• Supplementation: Probiotics to restore gut flora; avoidance of refined carbohydrates
• Classical homoeopathic treatment targets the root cause (constitutional weakness) rather than only suppressing acid

Summary Table

• Rosen's Emergency Medicine, 9th ed. - Rosen's EM
• Sabiston Textbook of Surgery, 21st ed. - Sabiston Surgery
• Clinical Gastrointestinal Endoscopy, 3rd ed. - Clinical GI Endoscopy
• Robbins & Kumar Basic Pathology, 10th ed. - Robbins Pathology
• Yamada's Textbook of Gastroenterology, 7th ed. - Yamada GI
• Homoeopathic therapeutics synthesized from classical materia medica (Boericke, Clarke) and contemporary homoeopathic practice resources