Gastroesophageal Reflux Disease
Gastroesophageal Reflux Disease (GERD) is one of the most common chronic digestive disorders seen in clinical practice today. GERD occurs when stomach contents leak back into the esophagus. Normally, this backup of acid occurs briefly in most people. It becomes a disease when it occurs frequently, causing damage to the actual tissue of the esophagus. The tissue damage leads to symptoms, most common of which is heartburn.
There are many causes of GERD. Muscle weakness of the Lower Esophageal Sphincter (LES) valve is one cause. The LES is found in the esophagus (swallowing tube) and the stomach. The LES is meant to close when food reaches the stomach after a meal. With muscle weakness, the LES does not close properly, either because it is too loose or too wide – leading to acid reflux. In turn, this damages the lining of the esophagus and its nerve endings, which sense various degrees of pressure and acidity.
Reflux occurs commonly from overeating. Reflux can also occur as a response to certain types of foods, stress, or by the effects of excess weight. Reflux can also be caused by structural abnormalities such as a hiatal hernia. In this case, the stomach is pushed up through a weakening in the diaphragm. Many persons with hiatal hernias will experience some degree of gastroesophageal reflux.
Factors that induce GERD are foods and drinks with high fat, caffeine, and acidity. These include alcoholic drinks, citrus fruits, and tomato-based products. Conditions such as obesity and pregnancy can also increase the risk for GERD. Lifestyle factors such as weight gain, smoking, and eating close to bedtime can also increase the risk for GERD.
Signs & Symptoms
The most common symptom of reflux is heartburn – a feeling of burning and/or pressure in the chest spreading toward the throat or sternum. Other symptoms may include the sensation of food backing-up (regurgitation), excessive belching, and difficulty swallowing (dysphagia). A persistent cough, sore throat, and hoarseness sometimes occur.
Screenings and Diagnostic Tests
Classic GERD is diagnosed by taking a detailed medical history and is confirmed by a complete response to a PPI (Proton Pump Inhibitor) Test.
A detailed medical history: Discussing symptoms, dietary habits and past treatments will help diagnose the presence of reflux.
PPI Test: Patients who do not respond to PPI Therapy are less likely to have GERD.
Endoscopic Examination: typical cases of GERD can be diagnosed and treated without endoscopy. However, endoscopy can sometimes be recommended to assess for complications, contributing causes of reflux such a hiatal hernia, and treatment guidance.
Barium X-Ray and Upper GI Series: A barium X-ray is a radiographic test of the GI tract. The barium mixture is used to coat the walls of the digestive tract. This type of test is rarely recommended.
Esophageal pH Monitoring: The procedure measures the reflux of acid that flows into the esophagus. It is usually performed by placing a thin catheter through the patient’s nostril and down into the esophagus. The catheter contains sensors that record reflux of acid over a 24 hour period. An alternative method involves placement of a sensor capsule just above the lower esophageal sphincter.
Once reflux is diagnosed, an anti-reflux treatment program can begin. Treatment of esophageal reflux consists of two major components; lifestyle changes and medications.
Diet & Lifestyle
Cut down or quit smoking: Cigarettes and other types of tobacco products can decrease LES pressure and increase acid secretion that aggravates reflux and contribute to ulcer formation.
Avoid large meals and overeating: Wait at least 3 hours after meals before lying down or engaging in physical activities that increase pressure on the stomach and may force acid back into the esophagus.
Elevate the head of your bed: Elevating the head of your bed four inches or more (depending on your doctor’s recommendation) will help prevent reflux.
Lose excess weight: Shedding even 8-10 pounds can cause a major improvement in reflux symptoms.
Wear comfortable clothing to minimize your reflux problem.
Limit or avoid alcohol, coffee, fatty foods, citrus juices and tomato sauce.
The goals of treatment of GERD are to relieve symptoms, heal the esophageal lining and reverse and prevent damage even when symptoms are not active. So in addition to diet and lifestyle changes, your doctor might recommend medications to help fight reflux. There are three main types of medications that neutralize or prevent acid.
Acid neutralizers: Antacids are usually the first drugs recommended by physicians to relieve sporadic heartburn and other mild GERD symptoms. They are also used to treat breakthrough symptoms which can occur despite taking acid blocker medications. Side effects of acid neutralizers, such as diarrhea and constipation, are associated with magnesium and aluminum salts. Aluminum and magnesium salts are often combined in a single product to balance these effects. Calcium carbonate antacids can also be a supplemental source of calcium. They seldom cause constipation.
H2 blockers reduce but do not completely block, acid production by the stomach. These drugs provide short-term relief. Some products are combined in one pill with an antacid.
Proton pump inhibitors (PPI’s) PPI’s are much stronger at blocking acid production than H2 blockers, and one dose typically lasts 24 hours. PPI’s include:
- Omeprazole (Prilosec, Zegerid)
- Lansoprazole (Prevacid)
- Pantoprazole (Protonix)
- Rabeprazole (Aciphex)
- Esomeprazole (Nexium)
- Dexlansoprazole (Dexilant)
Though we seldom recommend it, some patients can benefit from surgical treatment for their GERD.
Nissen Fundoplication or “wrap” operations: Involves pulling the hiatal hernia part of the stomach back down into the abdomen, and wraps the upper end of the stomach around the lower end of the esophagus. Both aspects help create a better-functioning lower sphincter zone, so that reflux diminishes greatly.
LINX Procedure: Involves placement of a bracelet with magnetic beads at the gastroesophageal junction to constrict the loose LES valve.
Treatment Outlook for GERD
Although long-term treatment of GERD can be challenging, currently available medications appear to be safe for long-term use. It is important to remember that dietary and lifestyle changes are crucial in managing symptoms of GERD and may be better effective at helping patients wean off medical therapy.