Esophageal Reflux (GERD)
WHAT ARE THE SYMPTOMS OF GERD?— Heartburn at least two to three times a week may signify you have gastroesophageal reflux disease, or GERD. Heartburn, the most common symptom of GERD, is estimated to affect 25 million adults in the United States on a daily basis. Heartburn is experienced as a burning sensation in the center of the chest, sometimes spreading to the throat; there also may be an acid taste in the throat. Less common symptoms associated with GERD include:
WHAT IS GERD? — GERD is a disease in which stomach juices flow back (reflux) into the esophagus, causing irritation and sometimes damage to the lining of the esophagus. The reflux of stomach acid can reach high enough to affect the vocal cords or even flow into the lungs (called aspiration), causing damage to those tissues and organs as well.
Normal reflux — Some degree of reflux is normal in everyone. Episodes of normal reflux typically occur after meals, are brief and without symptoms, and rarely occur during sleep. Acid reflux becomes pathological (the disease called GERD) when symptoms develop or when the esophagus becomes damaged. Symptoms of GERD may indicate that potential injury to tissues could result from longer and more frequent acid exposure than that which occurs with normal, physiological reflux.
The amount of reflux it takes to cause these problems varies since every person is different. In general, damage occurs to the esophagus when acid is refluxed too frequently, is too acidic, and when the esophagus is unable to clear away the acid quickly. The treatments of GERD are designed to avoid one or all of these elements from occurring.
What is the esophagus? — When we eat, food is carried from the mouth to the stomach by the esophagus, a tube-like structure that is approximately 10 inches long and 1 inch wide in the average adult. The inside lining of the esophagus is different from the stomach lining, similar to that of the mouth, and was not made for frequent acid exposure. It is normal to have acid in the stomach, where it aids in digestion of food, but when acid is present in the esophagus, it can produce varying degrees of damage. The esophagus is made of tissue and muscle layers that expand and contract to propel food to the stomach through a series of wave-like movements called peristalsis. In the lower end of the esophagus, where it joins the stomach, there is a circular ring of muscle that opens up, or relaxes, when food reaches that point. That band of muscle, called the lower esophageal sphincter (LES), allows food to enter the stomach and then closes to prevent the back-up of food and acid into the esophagus. It is one of the protective mechanisms to prevent frequent acid exposure to the esophagus. If the LES is weak, or stays relaxed too long, reflux is frequently occurs.
What is a hiatal hernia? — The diaphragm is a large flat muscle at the base of the lungs that contracts and relaxes as you breath in and out. The esophagus passes through an opening in the diaphragm, called the diaphragmatic hiatus, before it joins with the stomach. With normal anatomy, diaphragmatic contraction augments the strength of the LES, especially during bending, coughing, sneezing or straining. If there is a weakening in the diaphragm muscle at the hiatus, the stomach may be able to slip through the diaphragm into the chest, forming what is called a sliding hiatal hernia.
The presence of a hiatal hernia makes reflux more likely because the herniated area of the stomach can form a pouch where acid gets trapped and is then refluxed up into the esophagus, either by increased pressure in the stomach (from coughing, bending, or too much food in the stomach) or by gravity (lying down too soon after a meal). A hiatal hernia also makes the lower esophageal sphincter relax inappropriately, releasing acid into the esophagus.
A hiatal hernia is more common in people over age 50. Obesity and pregnancy are also contributing factors. The exact cause is unknown but may be related to the loosening of the tissues around the diaphragm that occurs with advancing age. There is no known way to prevent a hiatal hernia.
HOW IS GERD DIAGNOSED? — GERD is usually diagnosed based upon symptoms and the response to treatment. Specific testing is required when the diagnosis is unclear and in people who have "alarm" symptoms (such as a low blood count or difficulty swallowing). Some doctors also recommend specific testing in people who require long-term treatment with medications to reduce stomach acid.
Your doctor will first want to rule out potentially life threatening diseases that may need to be distinguished from GERD. This is particularly true if chest pain is a symptom, since chest pain can also be a symptom of heart disease. So, in some people heart disease has to be ruled out before testing for GERD.
When the symptoms do not sound life threatening, but cannot clearly be ascribed to GERD, the following tests are available, all of which are very safe and not painful:
Endoscopy — An upper endoscopy is one of the most common tests used to evaluate the esophagus. A small, flexible tube is passed into the esophagus, stomach, and small intestine. The tube has a light source and a camera that displays magnified images that the doctor can examine. Damage to the inside lining of those structures can be evaluated and specimens of tissue (biopsies) can be taken to determine the extent and seriousness of tissue damage.
Barium swallow — A barium swallow involves ingesting a thick paste of barium while taking x-rays. The barium fills and coats the esophagus so it can be seen on the x-ray film. A barium test is good for showing obvious abnormalities, and will sometimes show inflammation of the esophagus and demonstrate how efficient the swallowing is. However, it is generally not very useful for the diagnosis of reflux.
24-hour esophageal pH study — A 24-hour esophageal pH study is the most sensitive test for diagnosing GERD. The test involves swallowing a thin tube, which is left in the esophagus for 24 hours, during which time the patient keeps a diary of symptoms. The tube is attached to a walkman-size box that measures how much stomach acid is reaching the esophagus. The data are analyzed by computer to determine the frequency of reflux and the relationship of reflux to symptoms. This test is usually reserved for patients in whom the diagnosis is unclear after an endoscopy or a trial of treatment. It is also useful for patients who continue to have symptoms despite treatment.
Esophageal manometry — Esophageal manometry involves swallowing a tube that measures the muscle contractions of the esophagus and determines if the lower esophageal sphincter is functioning properly. This test is usually reserved for patients in whom the diagnosis is unclear after other testing or in whom surgery is being considered.
WHAT ARE COMPLICATIONS FROM GERD? — The vast majority of patients with GERD will not develop serious complications, particularly when the reflux is adequately treated. However, a number of serious complications can arise in patients with severe GERD.
Ulcers — Ulcers can form in the esophagus as a result of burning from stomach acid. In some cases, bleeding occurs. Patients may not be aware of bleeding, but sometimes it is found in stool specimens the doctor analyzes for blood.
Stricture — Damage from acid can cause the esophagus to scar and narrow, causing a blockage (stricture) that can cause food or pills to get stuck in the esophagus. The narrowing is caused because the scar tissue that develops from repeated ulceration contracts over time as the esophagus is repeatedly damaged and then heals.
Lung and throat problems — Some patients reflux acid up to the throat, which results in inflammation of the vocal cords, producing sore throats or a hoarse voice. When acid is refluxed into the throat, it can get into the lungs and cause an aspiration pneumonia or asthma symptoms. Chronic acid reflux into the lungs may eventually produce permanent lung damage, called pulmonary fibrosis or bronchiectasis.
Barrett's esophagus — Barrett's esophagus occurs when the normal cell type that lines the lower part of the esophagus (squamous cells similar to those of the mouth) is replaced by a different cell type (intestinal cells). This process usually results from repetitive damage to the esophageal lining. The most common cause is longstanding GERD. Interestingly, the intestinal cells of Barrett's esophagus are more resistant to acid than squamous cells, suggesting that they may be an adaptation to the chronic acid exposure. The problem with this adaptation is that the intestinal cells have a small potential to transform into cancer cells. Because of this cancer potential, patients with Barrett's esophagus are advised to have periodic endoscopies so that early warning signs of cancer will be detected. Barrett's esophagus is much more common in white men compared to white or black women, and is usually diagnosed in patients older than 50, but can also occur in younger patients.
Esophageal cancer — There are two main types of esophageal cancer: adenocarcinoma and squamous cell carcinoma. A major risk factor for adenocarcinoma is Barrett's esophagus, which (as discussed above) is related to longstanding GERD. Squamous cell carcinoma does not appear to be related to GERD. Unfortunately, adenocarcinoma of the esophagus is on the rise in the United States and in many other countries. However, overall only a very small percentage of people with GERD will develop Barrett's esophagus and an even smaller percentage will develop adenocarcinoma.
HOW IS GERD TREATED? — How GERD is treated often depends upon its severity.
Mild symptoms — Many patients have already treated their symptoms by adjusting their diet and taking over the counter medications like antacids or acid blocking medicines (such as Pepcid AC®, Tagamet HB®, and Zantac 75®) before seeing their doctor. Your doctor may suggest additional changes to your diet or lifestyle, including recommending that you:
Moderate to severe symptoms — Patients with moderate to severe symptoms, complications of GERD, or mild symptoms that have not responded to the lifestyle modifications described above usually require treatment with prescription medications. The vast majority of patients are treated with medications that decrease stomach acid production.
Acid reducing medications can broadly be further divided into two groups: "H2 antagonists" (Zantac®, Axid®, Pepcid®, Tagamet®) and "proton pump inhibitors" (Prilosec®, Nexium®, Prevacid®, Protonix®, Aciphex®). H2 antagonists are sufficient to control symptoms in many people. However, the proton pump inhibitors are much stronger (and thus more effective) than the H2 antagonists. In fact, the degree of relief provided by proton pump inhibitors makes many patients reluctant to discontinue them. Nevertheless, many doctors recommend a trial off treatment once symptoms have been brought under control. On the other hand, many patients continue taking these medications for years. Fortunately, both the H2 antagonists and the proton pump inhibitors are very safe. The major problem with them is that they are expensive. Your doctor will recommend the course of action that is best for you based upon your symptoms, the response to therapy, and results from specific testing.
CAN GERD BE CURED? — Medications cannot cure GERD but they can alleviate symptoms and prevent damage to the esophagus. A number of different approaches have been advanced to offer a permanent, nonmedical solution.
Surgical treatment — Several surgical approaches to GERD have been developed. Currently the most popular is laparoscopic Nissen fundoplication. In general, anti-reflux surgery involves repairing the hiatal hernia and strengthening the lower esophageal sphincter. Prior to the development of the potent acid-reducing medications described above, surgery was used for severe cases of GERD that did not resolve with medical treatment. Because of the effectiveness of medical therapy, the role of surgery has become more complex. Many doctors consider surgery for relatively young patients with GERD who have demonstrated the need for permanent medical therapy. Other physicians are more cautious, noting that there are no long-term results available for current surgical approaches.
Patients in whom surgery is being considered typically undergo esophageal manometry and endoscopy to make sure that they are good candidates. Although the outcome of surgery is usually good, serious and less serious but bothersome complications can occur. Examples include persistent difficulty swallowing (occurring in about 5 percent of patients), a sense bloating and gas (known as "gas-bloat syndrome"), and diarrhea due to inadvertent injury to the nerves leading to the stomach and intestines (which fortunately is uncommon). Another factor to consider is that the effectiveness of surgery beyond two to three years is not well understood.
New and upcoming methods — A major advance in the surgical treatment of GERD was the ability to perform surgery laparoscopically. This technique involves the creation of several small incisions in the abdomen through which a camera and instruments are passed. However, the issues and complications associated with the standard conventional techniques still apply.
Experimental approaches to the treatment of GERD involve placing sutures in the lower esophageal sphincter, applying radio-frequency energy to the lower esophageal sphincter, or injecting a chemical into the lower esophageal sphincter to strengthen it. These techniques are accomplished during an upper endoscopy (and thus do not require open surgery or laparoscopy) and can be done without the need for hospitalization. Very little is known regarding the short-term efficacy, long-term efficacy, or safety of these techniques.