Gastroesophageal reflux disease

Learning objectives

Gastroesophageal reflux disease (GERD) occurs when gastric content repeatedly and regularly flows back into the distal esophagus, this regurgitation (acid reflux) can irritate the lining of the esophagus
Caused by frequent acid reflux or reflux of nonacidic content from the stomach due to inadequate closure of the lower esophageal sphincter (LES)

Classic symptoms

Heartburn (burning sensation in the chest), especially after eating, might be worse at night or while lying down
Regurgitation (acid reflux)
Taste of acid
Upper abdominal or non-cardiac chest pain
Globus
Swallowing difficulties (dysphagia) and painful swallowing (odynophagia)
Bad breath
Bloating and belching

Extraesophageal symptoms

Reflux esophagitis: Inflammation of the esophageal epithelium which can cause ulcer formation
Esophageal stricture: Persistent narrowing of the esophagus caused by reflux-induced inflammation
Barrett’s esophagus (precancerous changes to the esophagus): Intestinal metaplasia (changes of the epithelial cells from squamous to intestinal columnar epithelium) of the distal esophagus
Esophageal carcinoma

Factors that exacerbate acid reflux

Smoking
Eating large meals or eating late at night
Eating certain foods (e.g., fatty or fried foods)
Drinking certain beverages (e.g., alcohol, coffee)
Taking certain medications (e.g., aspirin, benzodiazepines, calcium channel blockers, tricyclic antidepressants, NSAIDs, and certain asthma medicines)

Lifestyle changes
- Avoid chocolate, mint, high-fat food, coffee, and alcohol
- Weight loss in overweight and obese patients
- Avoid bedtime snacks or lying down immediately after meals
- Avoid smoking
Medications: Antacids, H2 receptor blockers, proton pump inhibitors (PPIs), prokinetics
Surgery: Nissen fundoplication (the gastric fundus (upper part) of the stomach is wrapped around the lower end of the esophagus and stitched in place, reinforcing the closing function of the LES)

Patients with GERD are at an increased risk of pulmonary aspiration during anesthesia
Factors that increase the risk of aspiration include the urgency of surgery, airway problems, inadequate depth of anesthesia, use of the lithotomy position, gastrointestinal problems, depressed consciousness, increased severity of illness, and obesity
The main anesthetic goal in patients with GERD is to minimize regurgitation and aspiration of gastric contents
Avoid drugs that decrease LES tone (e.g., opioids, anticholinergics, tricyclics, dopamine, and beta-agonists)