GERD

What is GastroEsophageal Reflux Disease (GERD)?
GERD is a very common condition of the gastrointestinal tract referring
to the back-flow of acid or non-acidic content into the esophagus from
the stomach. GERD is defined by its symptoms and may or may not appear
to have tissue damage due to exposure of the tissue to the acid. GERD
is further categorized as “erosive” with tissue breakdown/irritation.
Non-erosive GERD (NERD) has normal appearance to the skin, but still produces
symptoms similar to classic GERD. Even without symptoms, GERD can be discovered
as the result of complications from months or years of damage.
How does GERD occur?
The stomach is protected from acid by tall cells, called columnar epithelium,
which secrete mucous, but the esophagus has thinner plate-like cells called
squamous epithelium which is more easily killed by the caustic chemical
effects of acid and digestive enzymes like pepsin. Normally the body prevents
this with a variety of mechanisms including saliva which contains some
buffering bicarbonate. Parastalsis (muscular contraction of the esophagus)
and gravity help clearing acid.
The EGJ or esophagogastric junction, also called lower esophageal sphincter
is an area of higher pressure about 2-4 cm in the bottom of the esophagus.
It helps keep the acid in the stomach. The EGJ also works with the muscles
of the diaphragm (the muscle responsible for pulling air into the lungs)
to increase the pressure in this area.
It was originally thought that all of the damage related to GERD was due
to acid effects and enzymes, but we now know that some of the damage is
due to the immune system recruiting inflammatory cells into the region.
What symptoms are associated with GERD?
- Burning sensation behind the sternum/breastbone is the most common finding
- Regurgitation of food or sour liquid
- Bloating
- Hoarseness
- Atypical chest pain
- Difficulty with swallowing, known as dysphagia
- A lump sensation in your throat no matter how much you swallow (globus
sensation).
- Unexplained weight loss
What factors are associated with an increase in GERD symptoms?
-
Hiatal Hernia
-
If some of the stomach slides up past the diaphragm this is called a
Hiatal Hernia and makes it easier for reflux to occur.
-
Alcohol
- Makes the lower esophageal sphincter (LES) relax and increases acid production
- Eating a heavy meal and lying down within 2-3 hours of the meal
-
Obesity
- Results in external compression of the stomach, squeezing acid up when
lying flat
-
Carbonated drinks
- Expand the stomach and result in more relaxation of the LES to vent the gas
-
Pregnancy,
- Uterus pressing against the stomach
-
Fatty foods
- Slow emptying from the stomach and relax the LES
- Eating tomatoes, peppermint, caffeine, chocolate, citrus fruits, and to
a lesser extent black pepper, garlic and raw onions
-
Smoking
- Decreases saliva production and also relaxes the lower esophageal sphincter
-
Drugs
- Decrease stomach emptying (like narcotics), relax the LES or are directly
caustic to the esophagus itself—ask your physician to review your
medications.
What can I do about my GERD?
The first treatment of Gastroesophageal reflux disease starts with lifestyle
modifications, not medication.
- Try putting gravity to work for you. Raise the front posts of your bed
4-6 inches to sleep on an incline.
- Avoid bedtime snacks, and don’t eat within 3 hours of bedtime.
- If you are obese, consider weight loss.
- Avoid cigarettes, carbonated beverages and alcohol.
- Avoid trigger drugs.
- Avoid fatty foods, chocolate, peppermint, garlic and onions.
- Eat more slowly with smaller volumes at one time.
- Antacids can provide quick but non-sustained relief from GERD. They are
good for episodic heartburn, but not helpful for long-term prevention
of esophagitis.
-
Histamine (H2RA) receptor blocking agents.
- Generally safe but weak acid suppression.
- Includes drugs like Zantac (ranitidine), Pepcid (famotidine) and Tagamet
(cimetidine).
- Good for intermittent treatment but tolerance develops quickly and not
great at treating more severe erosive esophagitis.
- Relieves GERD in about ½-2/3 of patients over 12 weeks
- Sucralfate is a complex of sugar and aluminum which can bind to damaged
tissue in the stomach and esophagus. It has little absorption and toxicity,
but requires an acid environment to bind. It has little use outside of
pregnancy, but may be helpful if patients have reactions to other medications.
-
Proton Pump Inhibitors (PPIs).
- These are the most effective class of medications for treating GERD
- These include drugs like Prilosec (omprezole), Protonix (pantoprazole,
Nexium (esoprazole), and Prevacid (lansoprazole).
- Best taken prior to supper if once daily
- Heal erosive esophagitis in 80-100% in 8-12 weeks in most cases. In severe
cases may be needed twice daily.
- Ongoing treatment is required (as with all these medication) as symptoms
recur quickly with discontinuation of the medication.
- Although potential side effects have been described, these medications
are generally thought of as safe and effective. Many have been approved
for use over the counter.
-
Antireflux Surgery
- A variety of antireflux surgeries can be used to restore the diaphragm
and reduce the hiatal hernia and augment the lower esophagal tone.
- Short term about 85% of patients experience relief and are able to come
off or reduce their medication needs.
- In one Swedish study about 17.7% developed recurrence of symptoms 5 years later.
- If the patient is morbidly obese, sometimes the antireflux procedure is
combined with a roux-en-Y gastric bypass procedure for weight loss as well.
When should I be evaluated for GERD with upper endoscopy?
You can be referred to a Gastroenterologist for symptoms of your reflux
at any time. Generally, we perform evaluations for “alarm symptoms”
which include:
- New onset of symptoms at age 60 or above
- Dysphagia or food hanging up in the esophagus
- Painful swallowing
- Atypical chest pain
- Weight loss
- Recurrent vomiting
- Vomiting blood/anemia evaluation
-
Gastric cancer in a 1st degree relative
Patients will also be evaluated for
Barrett’s Esophagus if he/she has experienced reflux for at least 5-10 years, meeting several
of the following criterion:
- Age 50 or older
- Male sex
- White race
- Obesity
- Nocturnal reflux
- Tobacco use
- First degree relative with Barrett’s and or adenocarcinoma of the esophagus
Visual evaluation of the esophagus can establish if erosive esophagitis
is present, check for structures that may be dilated, assess bleeding
and look for cancer.
A Bravo pH monitoring study can be used to gauge the efficacy of treatment
of the reflux over a period of 48 hours and may be a useful test your
Gastroenterologist can order if appropriate. You might need this if you
continue to have symptoms of chest pain even after treatment with PPIs.
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