Gastroesophageal reflux disease (reflux disease or GERD) is a pathologic condition
resulting from the backing-up (or reflux) of acid content of the stomach into the
esophagus.
When refluxed acid enters the esophagus and is in contact with the esophageal lining,
it causes a burning pain behind the breastbone or in the throat, called heartburn.
Heartburn that occurs more than twice a week may indicate the presence of GERD
characterized by inflammation and damage to the esophagus, leading to several serious
complications, namely Barrett's esophagus and esophageal cancer.
FACTORS CONTRIBUTING TO HEARTBURN AND GERD
Heartburn is a very common condition affecting approximately 20 million people every
day and about 40 million people at least once a week.
The factors contributing to heartburn may be related to anatomic conditions, lifestyle
and diet.
The anatomic anomaly most frequently associated with heartburn is hiatal hernia. Hiatal
hernia occurs when the upper part of the stomach protrudes above the diaphragm into the
chest. To learn more about hiatal hernia, click
here ( Hiatal hernia is the protrusion of the stomach into the chest through the
esophagus hiatus - the opening in the diaphragm through which the esophagus passes. The
diaphragm is the muscle wall that separates the abdominal organs from the chest. The
diaphragm helps the lower esophageal sphincter - a muscle ring between esophagus and
stomach - to keep the gastric acid from coming up into the esophagus).
Lifestyle factors that most frequently contribute to heartburn are:
1. overweight
2. pregnancy
3. smoking
3. alcohol use
Most common foods and therapeutic drugs that trigger the acid reflux and heartburn
include:
- fatty and fried foods
- spicy foods
- tomato-based sauces: spaghetti sauce, chili and pizza sauce
- citrus fruits and juices
- carbonated beverages
- chocolate and coffee
- aspirin, nitrates, calcium channel blockers.
- burning pain behind the breastbone and in the throat
- chest pain similar to heart attack
- hoarseness and/or dry cough in the morning
- dysphagia (difficulty in swallowing)
- loss of appetite
- weight loss
- anemia due to chronic bleeding
The diagnosis of GERD is usually suggested by the symptoms (type, duration and
frequency) the patients report to their doctor. If the symptoms persist after lifestyle
changes (weight loss, stop smoking, avoiding trigger foods) and acid suppression therapy
(over-the-counter drugs or prescription medications), the following diagnostic tests may
be used in order to confirm GERD and detect possible complications:
1. Upper endoscopy.
Upper endoscopy is a specialized procedure performed by
gastroenterologists or surgeons in a hospital or office setting.
During endoscopy a thin tube equipped with a video camera is pushed
down the esophagus and stomach.
The images of the esophageal and gastric lining captured by the video
camera are projected on a monitor and examined by the doctor.
If necessary, small tissue samples (biopsies) can be removed using a
small forceps attached to the endoscope. The biopsies are sent to the pathology laboratory
for processing (for detailed information on tissue processing click here) and microscopic
examination by specialized physicians (pathologists).
2. Barium swallow radiograph.
This is a procedure using a contrast fluid and X-rays to help detect
anatomic anomalies of the esophagus that can be the cause (hiatal hernia) or the
complication (stricture) of GERD.
With this test, the patient drinks the contrast liquid and then the
X-rays are taken.
This test does not detect the severity and extent of esophageal
inflammation (esophagitis) that occurs with GERD.
3. Esophageal pH monitoring.
This test is used for patients that experience heartburn, but do not
have damage of the esophageal lining.
During the test, an acidity (pH) probe is placed into the esophagus and
kept there for 24 hours. The probe will measure and record the degree of acidity present
in the esophagus, while the patient goes about his/her daily activities.
Gastroesophageal reflux disease follows a variable chronic course, patients
experiencing partial, complete or no symptomatic relief with lifestyle changes or
anti-acid medications.
The most serious long-term complications are Barrett's esophagus and esophageal
adenocarcinoma.
· Lifestyle and diet changes.
These measures may result in improvement of the symptoms in the patients with mild and
infrequent heartburn. Their goal is to decrease the amount of gastric acid reflux and to
avoid further or more severe damage to the esophageal lining (mucosa).
- lose weight if overweight
- stop smoking and excessive alcohol intake
- have supper a few hours before sleep
- avoid large meals
- avoid food and beverages known to trigger heartburn, such as: fatty,
fried or spicy foods, chocolate, coffee, tomatoes sauces, citrus fruit and juices
· Medication
- non-prescription (over-the-counter) medications neutralize the
gastric acid (antacids, such as Maalox, Mylanta, Pepto-Bismol, Tums and other), stop acid
production (H2-blockers, such as Tagamet, Pepcid AC, Axid, Zantac) or help the gastric
muscles that empty the stomach (prokinetics, such as Urecholine and Metoclopramide)
- prescription medications include proton pump inhibitors (Prilosec,
Prevacid, Protonix, Nexium and others) and are more effective the H2 blockers)
· Surgery
Surgery should be considered when lifestyle changes and medications do
not work and as a long-term management of GERD.
Nissen fundoplication is a surgical procedure that can be done
laparoscopically, through small incisions in the abdomen using a laparoscope equipped with
a video camera and small surgical instruments.
During the surgery, the upper portion of the stomach is wrapped around
the lower esophagus and sutured to itself, strengthening the lower esophageal sphincter
(the muscle ring around the lower esophagus).
This technique allows for short hospitalization (1-3 days), is safe and
is as effective as the proton pump inhibitor treatment in controlling the symptoms,
healing of esophagitis, prevention of strictures and keeping the GERD in remission.
Side effects associated with laparoscopic Nissen fundoplication include
trouble swallowing (dysphagia), bloating, diarrhea, and other, affecting about 5% of the
patients.
· Endoscopic procedures
The endoscopic procedures approved for treatment of GERD consist in using an endoscope to
strengthen the lower esophageal sphincter by placing stitches or pleats in the upper
stomach (Endocinch system), applying thermal energy (Stretta procedure) or injecting
bulking agents into or around the esophagus (Enteryx polymer injection).
Additional information about esophageal disorders:
American Gastroenterological
Association
National Institutes of Health
Mayo Clinic
