Gastro-esophageal Reflux Disease (GERD)

Many people experience gastroesophageal reflux. This is actually normal, especially after eating a large meal. But when it happens too often, like more than twice in a week, it becomes known as
gastro-esophageal reflux disease or GERD. Also, it may be possible that you hear or read gastro acid reflux, acid reflux or simply acidity. These are all synonyms.

GERD is a condition wherein stomach contents flow back up into the esophagus and causes a burning sensation in the throat, referred to as heartburn. Heartburn is a common symptom, affecting up to 7% of the total population. Out of this 7%, it is estimated that about 20-40% is caused by GERD (gastro-esophageal reflux disease). This condition affects males as much as it affects females. It also occurs across all age groups, but is more commonly seen in people over the age of 40.

Anatomy and Physiology
When you swallow food, it first goes through a hollow muscular tube, called the esophagus, before it enters the stomach. Food passage is aided by repetitive wavelike contractions of the esophagus, referred to as peristalsis. Before food reaches the stomach, it passes a muscular sphincter that guards the stomach’s entrance and keeps stomach contents from rising back up. This is called the lower esophageal sphincter (LES) or cardiac sphincter, because of its proximity to the heart.

Causes of heartburns
The most common cause of GERD (gastro-esophageal reflux disease) is a weak or incompetent LES, which allows stomach contents to reflux back up into the esophagus. Other causes of heartburn are abnormalities of the diaphragm. The diaphragm assists the LES in keeping stomach contents from flowing back into the esophagus, so diseased conditions of the diaphragm, such as hiatal hernia, may cause GERD (gastro-esophageal reflux disease) as well. Other factors which can contribute to GERD (gastro-esophageal reflux disease) include pregnancy and obesity. Both conditions increase the pressure in the abdomen, possibly helping stomach contents to be pushed back up. Several medications may also bring about or worsen GERD (gastro-esophageal reflux disease), such as those for high blood pressure or asthma. Investigation of the causes can provide you with some tips for getting rid of heartburn.

Diagnosis
Usually, GERD (gastro-esophageal reflux disease) can be alleviated by medications (like Proton Pump Inhibitors (PPIs)) and lifestyle modifications. But if your condition is severe, your doctor may order certain laboratory tests to be performed. These are done to either rule out or confirm other conditions that might have caused your GERD (gastro-esophageal reflux disease), or identify if complications have arisen. Some of these tests include:

1. Esophagogastroduodenoscopy, or EGD, which uses a thin tube that is inserted into your esophagus, then into your stomach, up to the initial section of your small intestine. This tube has a fiber-optic camera at its tip, so the doctor can visualize the internal structure of your organs, and can detect if there is irritation or damage to its lining.

2. A barium swallow, you to swallow a chalky-white solution containing barium. A special type of X-ray, called fluoroscopy, is done to detect the barium. This is performed to detect structural abnormalities in your esophagus, stomach and small intestine.

3. Esophageal pH monitoring, which employs the use of a small tube inserted into your esophagus through the nose or mouth. This tube stays in for 24 hours, while you go about and record your daily activities. This cannot detect if there are structural abnormalities, but is helpful in determining if your GERD (gastro-esophageal reflux disease) is associated with other symptoms, such as coughing.

4. Esophageal manometry, which utilizes a thin tube that can detect how much pressure is exerted onto it. This tube is inserted into your stomach through either your mouth or nose, and is then pulled back gradually until it sits in your esophagus. The doctor will ask you to swallow, so he can take pressure readings at different levels of your esophagus.

Signs and Symptoms
The most common symptom of GERD (gastro-esophageal reflux disease) is heartburn. Because stomach fluid is acidic, reflux causes a burning sensation either in your upper abdomen or chest, or under the breastbone. This can get especially severe if you lie down after a meal. Many patients also feel nauseous after eating.

Less common reflux symptoms include coughing, hiccupping, and difficulty in swallowing. You may also experience hoarseness or recurrent sore throats due to the irritant effect of the acid reflux.

Complications
Repeated exposure to gastro acid reflux can cause inflammation in your esophagus. This is medically known as esophagitis. Chronic esophagitis can cause scarring and fibrosis in the esophageal mucosa. This can cause the esophageal opening to narrow down, making it difficult to swallow food. Some patients may develop Barrett’s esophagus, where there is a change in the cells of the esophageal lining. This is a pre-cancerous condition that, if left untreated, may eventually lead to esophageal cancer.

Treatment of GERD (gastro-esophageal reflux disease)
If your case of gastro acid reflux is relatively mild, some lifestyle changes may help reduce your symptoms. Here are some helpful tips for getting rid of heartburn symptoms:

1. Quit smoking, if you’re a smoker. Smoking is known to slow down esophageal peristalsis. Moreover, it is a risk factor for esophageal cancer, and other cancers as well.
2. Eat smaller and more frequent meals throughout the day, instead of just 3 large ones.
3. Don’t lie down immediately after eating. Wait up to 2-3 hours after your last meal before going to bed.
4. Elevate the head of your bed, so you can take advantage of gravity to help keep the food down.
5. Don’t wear constrictive clothing.
6. Try to lose weight, if you’re overweight or obese.
7. Avoid irritant foods. These include, but are not limited to:

1. Alcohol
2. Caffeine
3. Carbonated drinks
4. Chocolate
5. Citrus fruits
6. Spicy foods
7. Fatty foods
8. Tomato-based foods
9. Dairy products

There are some medications that can decrease reflux symptoms. However, consult first with your physician before starting any of these medications:

Antacids help to neutralize the acidity in your stomach. There are many types of antacids, and each has its own pros and cons (Tums, Rolaids, Gaviscon, Maalox, Pepto-Bismol).

1. H2 antagonists decrease stomach acid production (Zantac, Axid, Tagamet, Pepcid).
2. Proton pump inhibitors (PPIs) work similar to, but are more effective than, H2 antagonists (Nexium, Prilosec, Protonix, Prevacid, Aciphex)
3. Prokinetics or pro-motility drugs help hasten stomach emptying.

If you want more information regarding medication follow our blog, because we will review the pros & cons of the most common drugs used for the treatment of GERD (gastro-esophageal reflux disease).
You may also elect to undergo surgery if your reflux symptoms don’t improve, even with intensive medication therapy. The mainstay surgical operation for GERD (gastro-esophageal reflux disease) is called Nissen fundoplication. During this surgery, a portion of the upper stomach is taken and wrapped around the LES, such that it fortifies the LES and strengthens it. This procedure can be done laparoscopically. Laparoscopic surgeries have the advantage of smaller incisions, thus scars are smaller and recovery is faster.

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