GERD (Gastroesophageal Reflux Disease)
What is GERD (Gastroesophageal Reflux Disease)?
To understand GERD, we need to understand how our digestive system works. Normally when we eat, our food is chewed into small pieces that are easy to swallow. As we swallow the food it travels down our esophagus (tube between our mouth and stomach) to the stomach.Near the top of our esophagus is an area of muscle called the upper esophageal sphincter (UES). When we swallow, the UES relaxes and allows food to pass into the esophagus. The food then travels down the esophagus to another area of specialized muscle tissue called the lower esophageal sphincter (LES). The LES is located at the junction of the esophagus and the stomach. The job of the LES is to act as a one-way valve, allowing food to enter the stomach and prevent it from coming back up into the esophagus.
GERD occurs when the LES is too relaxed and does not prevent stomach fluids (stomach acid) and food from backing up into the esophagus. The lining of our esophagus is not protected from stomach acid, unlike the stomach's lining. The acid contact with the esophagus causes inflammation, and may cause irritation of the esophageal tissue. This leads to the symptoms of GERD.
What are GERD symptoms?
Heartburn--this is a burning sensation felt under the breastbone. The frequency of this varies from person to person. It can be 1-2 times a month or even a daily occurrence. Acid regurgitation--this is the sensation that acid and food contents within the stomach is backing up into the esophagus and at times, even into the mouth, causing a bitter or sour taste.Hoarse or scratchy voice, coughing, some types of asthma, sinus problems, and dental erosions--these symptoms can be caused by the stomach acid backing up into the esophagus and traveling into the breathing tube causing irritation of the voice box (larynx) or vocal cords which can lead to changes in voice. The acid can also travel further down our airway (trachea) and cause spasms of the airways, which can cause asthma symptoms such as wheezing or coughing. The acid can even travel up into the sinuses, which can lead to sinus problems. The stomach acid can also break down tooth enamel.
Difficulty swallowing or food becoming stuck in the esophagus--this is often caused by stomach acid backing up into the esophagus. If this occurs frequently and over long periods of time, it can cause irritation and inflammation of the tissue and lead to a narrowing of the esophagus, making the passage of food difficult.
How common is GERD?
Over 60 million Americans have GERD. About one fourth of these individuals have symptoms every day. Factors contributing to the incidence of GERD include pregnancy, being overweight and older age.
How is GERD diagnosed?
There are a number of tests that are used to diagnose GERD. They include the following:
Upper endoscopy or EGD (esophagogastroduodenoscopy): is a procedure where a small lighted tube is passed through your mouth into the esophagus, stomach and first portion of the small intestine. This test allows the doctor to see the lining of your upper GI tract. Sometimes biopsies (tissue samples) may be taken.Barium swallow, and or an Upper GI x-ray: involves drinking barium, which coats the esophagus, stomach and first portion of the small intestine. X-rays are then taken to show the lining and structures of these areas. Sometimes the test will involve special x-ray video that records the actions of swallowing.
A small measuring device (Bravo capsule) can be placed (via EGD or through the mouth) in the lower esophagus to record acid events over a 48 hour period. The device has special sensors that measure how often you have acid backing up into your esophagus and how long it stays there. Alternatively, a 24-hour pH monitoring test is also available. During the 24-hour test, a thin tube is placed through the nose and into the esophagus. The tube remains in place for 24 hours and the information is recorded on a small computer monitor.
Manometry: is a test where a thin tube is placed through the nose into the esophagus. This tube has special sensors to measure pressure in the esophagus. This test is used to evaluate your swallows. It can show the strength and the coordination of your swallows. The tube is left in place for a short period of time while you are instructed to swallow, drink, and/or cough.
How is GERD treated?
Initial treatment of GERD involves lifestyle changes. Other treatments include: medications, endoscopic treatment of the esophagus, and surgery.
Avoid foods that cause symptoms, that cause the lower esophageal sphincter to relax or that are irritating to the GI tract and may cause an increase in acid production. These foods include: caffeinated drinks (coffee, some teas, colas, and other sodas high in caffeine) chocolate, tomato based products (spaghetti, lasagna, pizza, and chili), spicy foods, citrus, garlic, onions, peppers, fatty foods, and mint/peppermint.
- Avoid using tobacco products: this means no smoking or chewing tobacco.
- If you are overweight, weight loss is encouraged.
- Avoid eating for 3 hours before you go to bed or lie down.
- Avoid wearing clothing that is tight around your abdomen.
- Eat smaller meals.
- Avoid vigorous exercise within 2 hours after eating.
- Avoid alcohol.
- Avoid the use of aspirin and other non-steroidal anti-inflammatory medicines like ibuprofen.
- Elevate the head of your bed by using 4-6 inch blocks to help prevent acid from rising up at night.
- Don't bend over after eating if you are prone to regurgitation after meals.
- Antacids: There are liquid and tablet types of antacids used to neutralize the acid in your stomach. They offer relief relatively quickly, but don't last long. Some antacids can cause diarrhea while others may cause constipation. Let your doctor know if this becomes a problem. If you are using these medications frequently, you should speak to your doctor about alternative therapies.
- H2 Blockers: These include medications like cimetidine (Tagamet), ranitidine (Zantac), famotidine (Pepcid), and nizatidine (Axid). These medications come in both over the counter and prescription strengths. These drugs work by blocking some of the acid production in our stomach. It is recommended that if you need these medications for longer than a few weeks you should see your doctor.
- Proton Pump Inhibitors: These include omeprazole (Prilosec), lansoprazole (Prevacid), dexlansoprazole (Dexilant), pantoprazole (Protonix), rabeprazole (Aciphex) and sodium bicarbonate (Zegerid) and esomeprazole (Nexium). These medications work by stopping the production of acid by different types of cells in the stomach that make acid.
- Endoscopic Treatment:
If medications fail to resolve symptoms, endoscopic or surgical interventions may be necessary. New endoscopic treatment options are available to control acid reflux as an alternative to chronic medications or to avoid surgery. These options can be discussed with your gastroenterologist.
This option is reserved for when the above measures aren't working. It can also be used as an alternative to chronic medication therapy. The surgery is called "Nissen Fundoplication". This is a surgical procedure where the upper portion of the stomach is wrapped around the lower esophageal sphincter area to prevent reflux.
Are there any complications from GERD?
The main gastrointestinal complications related to GERD include Barrett's esophagus and swallowing problems.
- Barrett's esophagus is a precancerous condition where the lining of the esophagus changes. These changes can lead to cancer. It is recommended that individuals with Barrett's esophagus be followed with regular endoscopies for screening. Barrett's esophagus is found in only 10% of individuals with GERD, of those that have Barrett's esophagus, only 1% will develop esophageal cancer.
- Swallowing problems are often described as the sensation that food is getting stuck or is slow to pass through the esophagus. This may occur with liquids or solid foods. Symptoms can also include painful swallowing. Trouble swallowing usually happens as the result of acid backing up into the esophagus and causing irritation. Over time, a narrowing of the esophagus can make it difficult for food to pass. Let your doctor know if this is happening to you as correcting the problem can be done with the use of an Upper Endoscopy (EGD).
What kind of follow up will I need?
If you have GERD with no other problems, you can follow with your primary physician. Most, if not all, primary physicians are comfortable treating individuals who have GERD once the diagnosis has been made. If you wish to follow with our clinic, we will want to see you once a year to evaluate how you are doing, discuss any new treatment options as well as review lifestyle modifications. It is at this time that you will be given an updated prescription.
If you have Barrett's esophagus, we will want to see you for follow up on a yearly basis and will want to do an upper endoscopy every 1 to 3 years to evaluate for the risk of cancer.