What Is Gastroesophageal Reflux Disease (GERD)
Gastroesophageal reflux disease or GERD is a condition in which the esophagus becomes inflamed due to the backward flow of digestive acids and enzymes from the stomach into the esophagus.
- When the lower esophageal sphincter malfunctions, materials from the stomach flow back into the esophagus.
- Heartburn or pain and discomfort felt in the middle of the chest is the common symptom.
- Characteristic symptoms help in diagnosing the condition.
- Drug treatment, as well as avoiding food which aggravate the condition, brings relief.
Stomach is naturally protected from the action of the acids by a tough mucous membrane. But esophagus, which does not have this natural protection, becomes severely damaged when the acids and enzymes from the stomach flows backwards into it.
A ring shaped muscle called lower esophageal sphincter protects the esophagus from reflux. But sometimes the action of the sphincter may not be proper and some of the digestive juices and partially digested food pass through the sphincter into the esophagus. The reflux becomes worse when the person is lying down; but when a person is in an upright position, gravity prevents reflux to a certain extent. A full stomach worsens the reflux because the added volume of food and the extra production of acids make the sphincter less efficient in keeping the contents of the stomach out of the esophagus. Obesity is a risk factor for GERD. Caffeine containing beverages, carbonated drinks, alcohol consumption, chocolate and fatty foods are some of the factors that make the condition worse. Some drugs such as antidepressants and antihistamines, drugs used to treat heart failure such as nitrates and calcium channel blockers and the hormone progesterone also have an adverse effect.
When there is a condition called delayed emptying of the stomach, it may increase the likelihood of reflux. It is common among people who are diabetic. Alcohol, coffee and stimulants also add to the risk.
Symptoms and Complications
Gastroesophageal reflux has typical symptoms such as a severe heart burn felt under the breast bone. The pain may extend to throat, neck and facial region and occasionally regurgitation of food may bring stomach contents even up to the mouth. Some patients express their condition as if having acidic stomach.
The esophagus may become inflamed resulting in a condition called esophagitis. If there is bleeding in the esophagus due to esophagitis, blood may come up in vomit or it may be passed in the stool as a dark substance. Passing of such black tarry stools is called melena.
Constant irritation due to the reflux may trigger the development of ulcers on the walls of the esophagus which can result in pain and bleeding.
Difficulty in swallowing with the steady narrowing of the esophagus caused by gastroesophageal reflux. Wheezing and difficulty in breathing may result, if airways are narrowed. GERD precipitates other symptoms such as sore throat, excessive production of saliva, hoarse voice, feeling of having a lump in the throat etc.
Barrett’s esophagus is a condition in which, the constant irritation caused by the reflux induces an abnormal change in the esophageal lining. The cells of the esophageal lining become precancerous and in some instances it may eventually turn into esophageal cancer.
Diagnosis of Gastroesophageal Reflux Disease
When the characteristic symptoms or GERD are present, the diagnosis is made accordingly, without further testing and treatment with drugs is started straightaway. But if the symptoms are not typical or if the initial treatment with drugs has not produced the desired effect, endoscopic examination of esophagus is done. Other useful tests include x-ray imaging, esophageal pH tests and manometry or pressure measurement test of the lower esophageal sphincter. They can confirm the diagnosis and can also check for other possible complications. Barrett’s esophagus or esophagitis can be detected by endoscopy. It can also detect the presence of cancer of the esophagus. X-ray is taken after the ingestion of radio opaque dye such as barium, which can show very clearly, the abnormalities in the esophagus. The patient is made to lie on a bed tilted back to keep the head at a lower level so that the barium solution refluxes into esophagus from the stomach. A slight pressure exerted on the abdomen may increase the reflux and it can be picked up by an x-ray. In addition to determining the extent of the reflux, the test can also detect the narrowing of the esophagus as well as the presence of ulcers.
A sphincter that is working poorly can be detected by measuring the pressure at the lower esophageal sphincter which indicates the strength of the sphincter. In assessing the need and suitability of surgery, this information can be very useful.
Esophageal pH testing is considered the ideal test for GERD. A narrow flexible tube fitted with a sensor probe is guided into the esophagus through the nose. A monitor worn by the patient is connected to the probe and it records the acid levels detected by the probe over a period of 24 hours. The test can correctly determine the actual amount of reflux occurring in the esophagus. It can also correlate between the reflux and the symptoms and it is very useful for people who have symptoms uncharacteristic of gastro esophageal reflux. People who find it difficult to have a tube in the nose can opt for an implantable pH electrode which can transmit data to a receiver outside.
Prevention and Treatment
Certain lifestyle changes as well as drug treatment may help relieve gastroesophageal reflux. Sleeping with head raised about 6 inches (15 cms) can prevent backward flow of acid into the esophagus. Drugs and foods which are known to cause the reflux should be avoided. Patients are advised to quit smoking. Drugs such as metoclopramide or bethanechol can help close the lower sphincter tightly.
Substances which trigger extra acid production and those which delay the emptying of the stomach, such as coffee, cola drinks, orange juice and vinegar, in addition to alcohol, should be avoided.
Proton pump inhibitors are found to be extremely effective in treating gastroesophageal reflux because they inhibit acid production. Since, acid in very small amounts also can result in severe symptoms; these drugs work better than antacids which help to neutralize the acid already produced. However, antacids when taken at bed time offer some relief, especially by relieving pain due to ulcers in the esophagus. Because of the slow healing of the ulcers, active reduction of the stomach acid level for an extended period of one to three months is required to achieve reasonable relief. However, ulcers may reappear any time. After healing too, narrowed esophagus is a possibility.
In addition to drug treatment, dilations of the narrowed esophagus can be done repeatedly, with the use of balloons or by increasing the size of dilators gradually, to correct the condition to a satisfactory level, thereby enabling the patient to eat normally.
The disappearance of symptoms because of the treatment does not mean that Barrett’s esophagus is completely cured. People who have Barrett’s esophagus need to get an endoscopic examination once in 2 or 3 years to make sure that they are not developing cancer due to their condition.
When drug treatment has not brought enough relief from symptoms or when esophagitis has not cleared even after relief from symptoms has been achieved through treatment, surgical option is considered. Surgery can also help avoid the need for long years of drug treatment. A laparoscopic procedure which is minimally invasive is an option but 30% of those who opt for this procedure are found to be developing a difficulty to swallow as well as discomfort in stomach following meals.
GERD Video Summary
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Yasser Elnahas
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