Gastro Esophageal Reflux Disease

Introduction

Gastroesophageal reflux disease (GERD) is a chronic disease of digestive system in which the stomach acid flows backward into your food pipe. This backward flow of stomach content causes irritation in the lining of your esophagus and may feel like burning sensation in heart so called heart burn.

Signs & Symptoms

• Heartburn (Burning sensation in the chest, just behind the breastbone)• Regurgitation (Expulsion of material from the pharynx or esophagus)• Nausea (Uneasiness of stomach / feeling of vomiting)• Chest pain (Pain in the chest usually in the upper central abdomen)• Troubles swallowing food• Sensation of lump in the throat• Coughing• Sore throat

You should seek immediate medical attention if you experience chest pain along with other signs and symptoms like shortness of breath or pain radiating to left arm or jaw. These may be signs and symptoms of a heart attack.

If you experience any of these signs and symptoms for at least twice each week or interfere with your day to day life see your doctor.

Causes

GERD is caused by frequent back flow (reflux) of stomach acid or bile in to the food pipe (esophagus). There is a circular band of muscle at the lower end of esophagus where the esophagus enters the stomach which creates a valve like mechanism known as lower esophageal sphincter that prevents the back flow of stomach content in to food pipe. If this valve weakens or functions abnormally, stomach acid can flow back in to your food pipe causing the signs and symptoms of GERD and may disrupt your day to day life. If the backward flow of stomach acid persist for longer time it causes inflammation of esophagus (esophagitis) which leads to erosion of the esophagus, causing multiple complications such as bleeding or breathing difficulty.

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Risk Factors

Lifestyle and dietary habits may contribute to GERD. Certain foods and drinks can trigger back flow of stomach content such as fried or fatty foods, alcoholic drinks, coffee etc.

Following risk factors can increase your risk of GERD –

• Asthma• Pregnancy• Hiatal Hernia• Diabetes• Obesity• Smoking• Delayed stomach emptying• Zollinger Ellison syndrome

Complications

If the GERD persist for longer time, it may lead to various complications like:

Esophageal Ulcers: An open sore (ulcer) may form in the food pipe (esophagus) over time due to severe erosion of tissues in the esophagus from acid exposure. This ulcer may bleed causing pain and difficulty in swallowing.

Esophageal Strictures: The damage of esophageal cells near the junction with the stomach may leads to formation of scar tissues. This will narrows the food pathway causing dysphagia (difficulty swallowing).

Barrett’s Esophagus: The tissue lining of lower food pipe changes in color and composition which is associated with the increased risk of esophageal cancer.

Diagnosis

24 hours pH metry: The current gold standard for diagnosing GERD is 24 hours esophageal pH monitoring, in this technique a thin tube is being inserted in to the food pipe through nose at the level of lower esophageal sphincture and kept for 24 hours which records the pH. This is the most objective test to diagnose GERD.

X-ray of upper digestive tract (Barium swallow): In this procedure you have to swallow a contrast liquid and the x-ray technician visualizes the upper digestive tract. This procedure helps in detecting presence of hiatal hernia or narrowing of esophagus at lower part. However this is not very accurate in determining inflammation of esophagus or if the presence of barrett’s esophagus.

Upper Endoscopy: During endoscopy an endoscope (a thin flexible tube

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equipped with light and camera) is passed in to esophagus, stomach and small intestine through mouth. This will allow direct visualization of upper digestive tract to check for potential damage such as ulcer, inflammation of esophageal lining. This also allow the doctor to take sample tissue for further examination to determine any pre cancerous signs (Barrett’s esophagus).

Esophageal Manometry: This test helps in determining the motility and pressure in the esophagus. In this procedure a small tube is inserted down the esophagus through nose. After placing the tube, patient is asked to swallow water at regular interval. The pressure reading of the esophageal muscle contractions (motility) is recorded. This procedure helps in determining any problem with motility of esophagus or lower esophageal sphincture.

Treatment

Long term and appropriate medical therapy is usually necessary to bring the symptoms under control and to prevent various complications of GERD like esophageal stricture and Barrett’s esophagus.

Treatment options usually include lifestyle modifications, medications, surgery or combination of it.

Lifestyle Modifications: Change in lifestyle and dietary habits can help in maintaining the remission and improving quality of life. Avoidance of certain diet such as spicy foods, acidic foods, fatty foods, alcoholic drinks, coffee etc may help in reducing the signs and symptoms of GERD. Moderate exercise may help in improving the symptoms however you should avoid vigorous exercise as it may worsens the condition. Maintaining an upright posture after taking meal may help in preventing back flow of stomach acid. If you frequently experience heartburn in bed at night you should avoid lying down within 3 hours of taking meal. Avoid large meals as it will empty slowly from the stomach and exerts pressure on the lower esophageal sphincture. Take small meals at frequent intervals.

Medications: the most commonly used medications for GERD are proton pump inhibitors, H2 receptor blockers and antacids. Proton pump inhibitors (PPI) are the most effective drugs in controlling GERD symptoms. It inhibits the production of acid in stomach. H2 receptor blockers reduce the production of acid in stomach. They are less effective in controlling the GERD symptoms compared to proton pump inhibitors. Antacids provide quick relief by neutralizing stomach acid for shorter duration.

Surgery: Surgery is required when long term medical treatment is ineffective or undesirable or when certain complications of GERD are present. The most commonly used surgery for GERD is Nissen Fundoplication which involves tightening of the lower esophageal sphincture by wrapping the top portion of stomach around the outside of lower esophagus.

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