Complicated GERD OR ACID REFLUX

Complicated GERD gastroesophageal acid reflux disease

Numerous complications have been associated with persistent GERD (gastroesophageal acid reflux disease), especially when it is nocturnal. In a study comparing daytime GERD(gastroesophageal acid reflux disease), nighttime GERD or a combination of both, the incidence of esophagitis was higher among individuals with nocturnal symptoms than those with daytime GERD(gastroesophageal acid reflux disease), although patients who had both experienced the highest rate of esophagitis . Poh et al.  recently demonstrated that the duration of nocturnal reflux events is longer and usually asymptomatic. The potential esophageal complications of persistent GERD(gastroesophageal acid reflux disease) include esophagitis, peptic strictures, esophageal ulcerations and bleeding, Barrett’s esophagus and esophageal adenocarcinoma. Management of complicated GERD(gastroesophageal acid reflux disease) includes dilation for benign peptic stricture in patients presenting with dysphagia. These patients should be supplemented with long-term PPI to reduce the need for repeated dilations (Poh CH, et al , 2010).

Patients presenting with bleeding esophageal ulcers can be treated endoscopically with adrenaline injections, hemoclips and heater probes. They should be on long-term PPI to ensure healing of the ulcer. The management of Barrett’s esophagus and esophageal adenocarcinoma is beyond the scope of this review. GERD(gastroesophageal acid reflux disease) in the elderly Gastrointestinal disorders are common in elderly patients. A population-based study from Finland showed that the prevalence of daily GERD(gastroesophageal acid reflux disease) symptoms in those aged 65 years and older was 8% in males and 15% in females . (Plant RL.1998)

Furthermore, Zhu et al. observed that abnormal  gastroesophageal reflux occurred more frequently in the elderly than in younger individuals. The mean time pH\4 was significantly higher in the elderly as compared to younger individuals, 32.5 versus 12.9%. In addition, more elderly patients (21%) have grade III–IV erosive esophagitis (based on Savary–Miller criteria) compared to younger patients (3.4%), p\0.002 . Aging may result in various physiological changes in the gastrointestinal tract . These changes may increase the risk of development of disorders such as GERD (gastroesophageal acid reflux disease). Co-morbidity and concomitant use of medications in the elderly can diminish esophageal sphincter tone, esophageal clearance mechanisms and saliva production. Some of the common medications that can predispose the elderly to reflux are calcium channel blockers, nitrates, narcotics, medications with anti-cholinergic effects and theophylline. The manifestation of GERD(gastroesophageal acid reflux disease) in the elderly differs from that in younger individuals. Heartburn occurs less frequently, and acid regurgitation is present in less than 25% of patients.( Mold JW, et al ,1991)

Mold et al.  reported that only 54% of elderly patients complained of heartburn. In contrast, atypical symptoms such as vomiting, anorexia, dysphagia, respiratory symptoms, belching, dyspepsia and postprandial fullness are common presentations in the elderly with GERD(gastroesophageal acid reflux disease) . The main clinical concern of atypical presentation of GERD in the elderly is the delay in diagnosis and hence the delay in giving the appropriate treatment. Diagnostic modalities for GERD (gastroesophageal acid reflux disease)that are available for elderly patients parallel those for younger patients. Upper endoscopy is usually advocated in the elderly because they present with atypical symptoms and are at increased risk for malignancy and peptic ulcer disease.   Treatment of GERD(gastroesophageal acid reflux disease) in the elderly is similar to the treatment in younger patients. However, a very aggressive therapeutic approach should be considered in elderly patients with GERD(gastroesophageal acid reflux disease) because they tend to present with more severe disease. When treating elderly patients with acid suppression therapy such as H2RAs and PPIs, caution needs to be exercised for potential drug interactions considering that polypharmacy in the elderly is not uncommon. Several recent studies suggested that elderly patients on long-term PPI treatment have an increased risk of bone fracture, community-acquired pneumonia and hospitalacquired Clostridium difficile diarrhea . While most of these studies were population based, not prospective studies, and remain to be proven, elderly patients should receive the lowest dose of PPI that controls their symptoms, and usage of PPI should be limited to peptic-related disorders. (Laheij RJF,, et al,2004)