GASTRO-ESOPHAGEAL REFLUX DISEASE (GERD)

What Is GERD? GERD describes the regurgitation of acidic stomach contents into the esophagus, resulting in a spectrum of clinical manifestations, the most common being heartburn. Reflux occurs when the pressure inside the stomach is higher than that maintained by the muscles found where the stomach and esophagus meet. This can happen for a number of reasons, outlined below.

What Causes GERD? In normal individuals, muscles at the junction of the esophagus and stomach prevent the regurgitation of stomach contents. The muscles responsible for preventing reflux are the lower esophageal sphincter (LES, a ring of muscle around the bottom of the esophagus) and the diaphragm (the flat muscle which separates the abdomen from the thorax). GERD results most commonly from: (1) decreased muscle tone or abnormal relaxation of the LES; (2) reduced stomach motility, allowing food to remain too long in the stomach, where it is more likely to regurgitate; or (3) hiatus hernia, a condition in which part of the stomach bulges upward through the diaphragm, acting like a fluid trap for the acidic stomach contents. Episodes of reflux are triggered or worsened by a variety of factors. Symptoms may be aggravated by chocolate, caffeine, alcohol, and spicy foods, which stimulate acid secretion, or by fatty foods, which delay stomach emptying. Gravity works against normal digestion and can promote reflux when the patient bends over or lies horizontally. In addition, pregnancy or constipation may worsen GERD by increasing intra-abdominal pressure.

What Are The Signs And Symptoms Of GERD? Most commonly, people with GERD will complain of heartburn, a painful or uncomfortable feeling in the chest which may radiate to the back. Often the patient will recognize a pattern of symptoms related to timing, food, or body position. In addition to heartburn, difficult or painful swallowing, a sour taste in the mouth, and frequent belching are common. Less typical features include chronic cough, hoarseness, sore throat and a sensation of fullness in the neck. Heartburn may be mistaken for angina pectoris, which is pain in the chest related to heart disease; a careful history and physical should distinguish between the two (although it is certainly possible for a patient to have both). Symptoms are most often present after meals, especially after eating certain foods, and at night, while lying in bed, and may be relieved temporarily by antacids or milk.

How Is GERD Diagnosed? GERD can often be diagnosed by history alone, especially if symptoms are consistent with a typical pattern (after heavy meals, at night, while bending, etc.). When there is any doubt as to the origin of the problem, the physician must determine first, whether reflux is, in fact, present and responsible for the patient's symptoms, and second, whether acidic reflux has damaged the esophagus. Several tests are available to aid diagnosis. The presence of acid reflux is best tested by the insertion of a small pH (acid-base) probe into the esophagus for 24 hours. Muscle tone of the LES can be tested by esophageal manometry, which measures pressures inside the esophagus, but cannot detect reflux. Damage to the esophageal lining can be detected by two methods; either by esophagoscopy, the insertion of a small camera into the esophagus, which allows for direct visualization of the esophageal lining, or by barium swallow, in which the patient swallows a liquid which facilitates x-ray visualization of the inside of the esophagus and stomach.

What Are The Complications Of GERD? Frequent reflux of acid into the esophagus can cause damage to the esophageal lining and underlying tissue. Esophagitis, inflammation of the esophagus, can lead to ulceration, bleeding, or accumulation of scar tissue resulting in stricture (narrowing). The development of Barrett's esophagus may result from prolonged inflammation; in this condition, there is a change of cell type in the esophageal lining associated with an increased risk of developing cancer.

What Is The Treatment For GERD? The simplest and often most effective treatment of GERD involves lifestyle modification. Symptoms can be avoided by elevating the head of the bed, refraining from eating within 3 hours of bed time, avoiding trigger foods, and losing weight (if overweight). Antacids containing either aluminum hydroxide or magnesium hydroxide can be taken with meals or as needed. In mild cases, no further treatment is necessary. More severe cases, however, may require more definitive therapy. Antacids containing alginic acid (e.g. Gaviscon) may be taken regularly, rather than at the onset of pain. Your doctor may prescribe drugs to increase the stomach's motility and increase LES pressure (Prepulsid [cisapride] and Maxeran [metoclopramide] are two examples). Drugs known as histamine antagonists or H-2 blockers (e.g. Tagamet [cimetidine] and Zantac [ranitidine]) may be prescribed to reduce acid secretion and allow for esophageal healing. If severe esophagitis has been demonstrated, drugs called proton pump inhibitors (e.g. Losec [omeprazole]) give the most drastic acid reduction and the fastest healing. Patients with difficult, recurring symptoms, may require ongoing medication. Surgery may be an option for patients who are otherwise healthy; various procedures are possible to restore LES function or repair hiatus hernia.