Gastroesophageal Reflux Disease (GERD)

What is GERD?

Reflux of contents from the stomach or doudenum into the esophagus is a normal event caused by incomplete or improper closing of the lower esophageal sphincter. The lower esophageal sphincter consists of a ring of muscle fibers which function to prevent food from moving back to the esophagus. When this sphincter does not work properly, stomach acid and possibly intestinal contents may flow backwards into the esophagus. Infants, children and adults may experience gastroesophageal reflux some time in their life due to some physiological factors such as hyperacidity or as a result of eating acidic and spicy foods. However, recurrent heartburn (2 or more days a week) and/or excessive reflux of stomach contents are abnormal and require medical attention. This condition is named gastroesophageal reflux disease (GERD) and is associated with other diseases such as esophagitis, Barrett's Esophagus and gastroesophageal tumors.

Gastroesophageal reflux disease (GERD) can affect people of all ages and occurs more often in men than in women. A recent study on the burden of chronic gastrointestinal disorders in the United States has found that gastroesophageal reflux disease was the most prevalent and expensive, affecting about one third of the population and associated with costs totaling about $10 billion per year.

What Causes GERD?

The definite cause of gastroesophageal reflux disease (GERD) is unknown, although several studies have pointed towards the existence of a genetic predisposition that may be related to weak muscular or structural problems in the esophagus.

Lifestyle and environmental factors such as cigarette smoking, eating before bedtime, intake of acidic foods and beverages, large meals, coffee and caffeinated drinks, carbonated beverages, chocolate and fatty foods have been reportedly associated with heartburn. However, direct association between these factors and development of gastroesophageal reflux disease is controversial. It is possible that none of these factors alone leads to the occurrence of the disease, but rather a combination of them. Clinical data on the link between obesity and gastroesophageal reflux disease has also shown different results. However, recent meta-analytical studies suggest that obesity (high body-mass index) increases the likelihood of this disease. Medications, such as calcium blockers, nitrates and antihistamines are also reported to increase incidence of gastroesophageal reflux disease.

Situations that increase intra-abdominal pressure can contribute to the development of gastroesophageal reflux disease (GERD). Increased pressure can alter the normal positioning and functioning of gastoesophageal valve so it cannot effectively prevent stomach contents from flowing back into the esophagus. Hiatal hernia is one of the conditions frequently associated with structural problems. Hiatal hermia causes stress on the diaphragm muscle, leading a to protrusion of the stomach, which in turn creates pressure and muscle weakness on the esophageal hiatus. People suffering from esophagitis, Barrett's esophagus, and tumor or cancer of the esophagus most commonly acquire gastroesophageal reflux disease as a symptom. Coughing, straining, vomiting and strenuous physical exercise may also make the disease worse.

Symptoms of GERD

In many cases, patients with gastroesophageal reflux disease (GERD) come to the hospital due to a burning sensation in the chest area ("heartburn") that may last for a couple of hours and can be either relieved or worsened by eating.

Some of the most common symptoms are:

• Burning sensation in the esophagus.
• Indigestion, a feeling that the food stays undigested in the stomach for a very long period.
• Hypersalivation and hyperacidity.
• Nausea, particularly after eating.

Symptoms that may indicate damage of the esophagus include:

• Coughing
• Hiccups
• Painful swallowing
• Regurgitation or vomiting
• Sore throat

Patients may also experience a worsening of symptoms while lying down bending.

Gastroesophageal reflux disease in infants and children is difficult to detect due to the unspecific nature of the symptoms:

• Irritability
• Pain recognized by sudden cry and inability to sleep.
• Frequent burping and hiccups.
• Problems with swallowing and feeding.
• Coughing
• Vomiting
• Respiratory problems

Diagnosis of GERD

History of past and present illnesses are important to accurately identify the cause of excessive reflux. Patients with recurrent or severe symptoms are candidates for esophagogastroduodenoscopy. This procedure is performed by inserting through the mouth a small tube equipped with a camera in the end, allowing detection and evaluation of any damage to the gastroesophageal mucosa. Barium swallow coupled with detection by X-ray could be used as an alternative to endoscopy. The degree of acid reflux is usually measured by esophageal pH monitoring. This is the most objective measurement of acid reflux and can be used to monitor patients for the evolution of disease and response to treatment.

Additionally, measurement of bilirubin level assesses bile reflux pattern, which is an important indicator of potential mucosal damage. On the other hand, occult blood in stool tests help to detect internal bleeding which may suggest a more advanced condition in which the mucosa is open.

Treatment of GERD

Care and treatment of the patient with gastroesophageal reflux disease (GERD) is directed towards preventing situations that may cause further irritation of the mucosa and pressure to the lower esophageal sphincter muscles.

There are many recommended lifestyle changes for the initial and continuous management of gastroesophageal reflux disease. Normally, a diet that is low in fat and calories is advised to foster weight reduction and because foods that are high in fat stay longer in the stomach, thus making it hard to digest and metabolize. The patient is also instructed to avoid caffeinated, carbonated and spicy food and beverages as well as milk and mint products because they tend to relax and weaken the lower esophageal sphincter. Alcohol intake and smoking are also not advised. The most recommended position for a patient with GERD is the sitting position, as gravity may pull intestinal contents down to the stomach and prevent them from going back up to the esophagus, thus allowing the food to stay in the duodenum and gastric area.

If the above-mentioned management and care strategies were not able to resolve acid reflux, medications are helpful in providing relief.

Proton pump inhibitors and H2 receptor antagonists are usually given to prevent or reduce the release of stomach acid. However, some physicians do not recommend the use of proton pump inhibitors, because they may increase bacterial growth and risk of infection. Prokinetic agents are also given to speed up the emptying of stomach contents.

For some cases where the above treatments, as well as medication, do not cure the symptoms, fundoplication surgery and minimally invasive radio frequency treatment could be used. Fundoplication surgery, also known as Nissen fundoplication, is a surgical procedure that consists in wrapping and stitching the upper part of the stomach around the lower end of the esophagus so that it stays in that place. The objective is to make the esophagus contract in synchrony with the stomach so that reflux will not happen again.

Alternative Treatment

Alternative treatments include changes in lifestyle such as sleeping with the head elevated, stop smoking, and losing weight. A proper meal schedule, with small and frequent meals, while avoiding meals before exercise or sleep may also have a positive impact in management of the symptoms. Try to avoid stress and prepare a calm and soothing environment during your meals, which might include turning off the television and other sources of emotional and sensorial stimulation.

Although no clinical evidence has shown effectiveness of herbal remedies, some of these agents are popular for management of symptoms from gastroesophageal reflux disease. Some of these herbal remedies include marshmallows, chamomile, licorice, and slippery elm. It is important to discuss with your doctor if these remedies are safe for you, and to ensure that they will not interact negatively with your conventional treatment.

Stress and anxiety management techniques and activities may have a positive impact in minimizing the symptoms of gastroesophageal reflux disease (GERD). Aromatherapy, guided imagery or other activities that promote relaxation might be adequate for some patients.

Prognosis of GERD

Gastroesophageal reflux disease (GERD) has a very good prognosis, with the vast majority of patients recovering after initial treatment and a substantial fraction cured without surgical measures. Treatment and recovery period for patients varies with every individual, and some people may experience recurrence of symptoms even if the disease was previously considered cured.

On the other hand, chances of complication are moderate with a long standing gastroesophageal reflux disease. Often, if not treated, it may result in Barrett's esophagus, which is thought to be a precancerous condition that may lead to adenocarcenoma of the esophagus which has a poor prognosis.

Living with GERD

Living with gastroesophageal reflux disease (GERD), can be painful due to heartburn. This discomfort brought about by the disease may prevent some normal activities. Individuals who suffer from gastroesophageal reflux disease have to follow lifestyle modifications closely in order to prevent the recurrence of the disease.

Not all gastroesophageal reflux diseases are detected at the early stages. Some may be detected during a precancerous stage (Barrett's esophagus), and unfortunately, some are discovered only at the late stage. For those who are on the late stage, surgery, radiation therapy or chemotherapy may be included in the treatment plan which may depend on the magnitude of the disease. If the surgical approach is utilized, resection is done in the thorax or abdomen depending on the location of the tumor. Surgical resection of the esophagus is a very dangerous procedure because it may lead to infection, pulmonary complication and leakage of gastroesophageal contents. Food is withheld post-operatively unless x-ray confirms that the wound has closed well. Palliative care is aimed at adequate nutritional intake, preventing aspiration and relieving pain by medication and relaxation techniques to reduce the feeling of pain. If the patient is not on parenteral nutrition, small frequent feeding is suggested rather than eating large meals.

Current Research of GERD

Research focuses on improving the understanding of the basic mechanisms of the disease and progression to changes in the cell morphology leading to cancer. The relationship of gastroesophageal reflux disease (GERD) with other conditions, namely, hiatal hernia, irritable bowel syndrome and sleep disorders is also under investigation. New drug targets such as the GABA receptors are being explored for the development of new therapeutic approaches.

Novell methods of diagnosis and monitoring are also being developed. Wireless pH monitoring is one of the methods, that potentially enables correlation of reflux with food intake, sleeping patterns and other daily activities.

Due to the expanding incidence of gastroesophageal reflux disease and its significant impact in activity levels, studies are ongoing to measure losses in productivity due to gastroesophageal reflux disease and to promote changes to reduce symptoms and increase overall activity levels.