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Reflux, Gastroesophageal GERD

Definition :
GERD — gastroesophageal reflux disease — is more than just chronic heartburn. Although heartburn is the most common symptom of this disease, GERD is a condition in which stomach acid or, occasionally, bile flows back (refluxes) into your food pipe (esophagus). The constant backwash or acid reflux can irritate the lining of your esophagus and cause inflammation. Such irritation can lead to complications such as narrowing of the esophagus, ulcers and even a slightly increased risk of esophageal cancer.

Most people can manage the discomfort of heartburn with lifestyle modifications and over-the-counter medications. But if you have GERD, these remedies may offer only temporary or partial relief. If you have GERD, you may need newer, more potent medications, possibly even surgery, to reduce symptoms.

Causes:
When you swallow, the lower esophageal sphincter — a circular band of muscle around the bottom part of your esophagus — relaxes to allow food and liquid to flow down into your stomach. Then it closes again.

However, if this valve relaxes abnormally or weakens, stomach acid can flow back up into your esophagus, causing frequent heartburn and disrupting your daily life. The acid backup is worse when you bend over or lie down.

This constant backwash of acid can irritate the lining of your esophagus, causing it to become inflamed (esophagitis). Over time, the inflammation can erode the esophagus, producing bleeding, or narrow the esophagus, causing difficulty swallowing or even breathing problems. When there's evidence of esophageal irritation or inflammation, you have GERD. However, many people with GERD will have a normal-appearing esophagus despite symptoms.

GERD may be related to other conditions such as hiatal hernia. In this condition, also called diaphragmatic hernia, part of your stomach protrudes into your lower chest. If the protrusion is large, a hiatal hernia can worsen heartburn by further weakening the lower esophageal sphincter muscle.

Some factors that can make GERD worse include :

  • Certain foods, such as fatty foods, spicy foods, chocolate, caffeine, onions, tomato sauce, carbonated beverages and mint
  • Alcohol
  • Large meals
  • Lying down soon after eating
  • Certain medications, including sedatives, tranquilizers and calcium channel blockers for high blood pressure
  • Cigarette smoking

Risk factors :
Conditions that cause difficulty with digestion can increase the risk of GERD. These include :

  • Obesity. Excess weight puts extra pressure on your stomach and diaphragm — the large muscle that separates your chest and abdomen — forcing open the lower esophageal sphincter and allowing stomach acids to back up into your esophagus. Eating very large meals or meals high in fat may cause similar effects.
  • Hiatal hernia. In this condition, also called diaphragmatic hernia, part of your stomach
  • protrusion is large, a hiatal hernia can worsen heartburn by further weakening the lower esophageal sphincter muscle.
  • Pregnancy. Pregnancy results in greater pressure on the stomach and a higher production of the hormone progesterone. This hormone relaxes many of your muscles, including the lower esophageal sphincter.
  • Asthma. Doctors aren't certain of the exact relationship between asthma and heartburn. It may be that coughing and difficulty exhaling lead to pressure changes in your chest and abdomen, triggering regurgitation of stomach acid into your esophagus. Some asthma medications that widen (dilate) airways may also relax the lower esophageal sphincter and allow reflux. Or it's possible that the acid reflux that causes heartburn may worsen asthma symptoms. For example, you may inhale small amounts of the digestive juices from your esophagus and pharynx, damaging lung airways.
  • Diabetes. One of the many complications of diabetes is gastroparesis, a disorder in which your stomach takes too long to empty. If left in your stomach too long, stomach contents can regurgitate into your esophagus and cause heartburn.
  • Peptic ulcer. An open sore or scar near the valve (pylorus) in the stomach that controls the flow of food into the small intestine can keep this valve from working properly or can obstruct the release of food from the stomach. Food doesn't empty from your stomach as fast as it should, causing stomach acid to build up and back up into your esophagus.
  • Delayed stomach emptying. In addition to diabetes or an ulcer, abnormal nerve or muscle functions can delay emptying of your stomach, causing acid backup into the esophagus.
  • Connective tissue disorders. Diseases such as scleroderma that cause muscular tissue to thicken and swell can keep digestive muscles from relaxing and contracting as they should, allowing acid reflux.
  • Zollinger-Ellison syndrome. One of the complications of this rare disorder is that your stomach produces extremely large amounts of acid, increasing the risk of acid reflux.

When to seek medical advice :
Most problems with heartburn are short-term and mild. But if you have severe or frequent discomfort, or you experience any of the other symptoms of GERD for a while, you may be developing complications that need more intensive medical treatment and prescription medications. Talk to your doctor if you have :

  • Heartburn several times a week
  • Heartburn that returns soon after your antacid wears off
  • Heartburn that wakes you up at night
  • Difficulty swallowing

You may need further medical care, possibly even surgery, if you experience any of these :

  • Symptoms that persist even though you're taking prescription medications
  • Difficulty swallowing
  • Regurgitated blood
  • Stool that's black
  • Weight loss

Symptoms :
Common signs and symptoms of GERD include :

  • Heartburn — burning sensation in your chest, sometimes spreading to the throat, along with a sour taste in your mouth.
  • Chest pain, especially at night while lying down
  • Difficulty swallowing (dysphagia)
  • Coughing, wheezing, asthma, hoarseness or sore throat
  • Regurgitation of food or sour liquid

Diagnosis:
Usually a description of your symptoms will be all your doctor needs to establish the diagnosis of heartburn. However, if your symptoms are particularly severe or don't respond to treatment, you may need to undergo other tests to check for GERD and other conditions :

  • Barium X-ray. This procedure requires you to drink a chalky liquid that coats and fills the hollows of your digestive tract. The coating allows your doctor to see a silhouette of the shape and condition of your esophagus, stomach and upper intestine (duodenum). X-rays can also reveal whether a hiatal hernia may be contributing to your heartburn. They can also reveal an esophageal narrowing or stricture, or a growth, which may cause difficulty swallowing.
  • Endoscopy. A more direct test for diagnosing the cause of heartburn is esophagogastroduodenoscopy (EGD). In this test your doctor inserts a thin, flexible tube equipped with a light and camera (endoscope) down your throat. The endoscope allows your doctor to see if you have an ulcerated or inflamed esophagus (esophagitis) or stomach (gastritis). It can also reveal a peptic ulcer. During an EGD, your doctor can take tissue samples to test for Barrett's esophagus — a condition in which precancerous changes occur in cells in your esophagus — or esophageal cancer, two potential complications of severe heartburn. Your doctor also may take biopsies of the stomach that may reveal the presence of a bacterium that may cause peptic ulcers. Some of the reasons you may need an endoscopy are if medications aren't working for you, you have had GERD symptoms for a long time, you experience difficulty swallowing, weight loss, regurgitation of blood or black material, or your doctor is not sure whether you have GERD. Although endoscopy results often appear normal despite GERD, sometimes endoscopy can reveal inflammation, stricture, Barrett's esophagus or cancer.
  • Ambulatory acid (pH) probe tests. These tests use an acid-measuring (pH) probe to identify when, and for how long, stomach acid regurgitates into your esophagus. This information can help your doctor determine how best to treat your condition. In the standard tube test, a nurse or technician sprays your throat with a numbing medication while you're seated. Then a thin, flexible tube (catheter) is threaded through your nose into your esophagus to insert the probe. The probe is positioned just above the lower esophageal sphincter. A second probe may be placed in your upper esophagus. Attached to the other end of the catheter is a small computer that you wear around your waist or with a strap over your shoulder during the test. It records acid measurements. After the probe is in place, you go about your business and then come back one or two days later to have the device removed. Another ambulatory test called a Bravo pH probe may be more comfortable than the standard test, because it eliminates the need for a tube in your nose. In the Bravo test, the probe is attached to the lower portion of your esophagus during endoscopy. The probe transmits a signal to a small computer that you wear around your waist for about two days, and then the probe falls off to be passed in your stool. Another benefit of the Bravo test is that you can shower and sleep more comfortably than with the standard test. Generally, if you have symptoms of GERD your doctor will likely first treat you with medication. If the medication doesn't work or you have side effects and can't tolerate it, your doctor may order an ambulatory acid (pH) probe test.
  • Esophageal impedance. Rather than measuring acid, this test can measure whether gas or liquids reflux back into your esophagus. It's helpful for people who have regurgitation or reflux of materials in the esophagus that aren't acidic and wouldn't be detected by a pH probe. The test works by placing a catheter through your nose and into your esophagus, similar to a standard pH probe tube test. However, because the test is new, its role in helping people with GERD hasn't been clearly defined.

Complications :
In addition to irritation and inflammation of your esophagus (esophagitis), chronic reflux of stomach acid into your esophagus can lead to one or more of the following conditions if left untreated :

  • Esophageal narrowing (stricture). Strictures occur in some people with GERD. Damage to cells in the lower esophagus from acid exposure leads to formation of scar tissue. The scar tissue narrows the food pathway, causing large chunks of food to get caught up in the narrowing, and can interfere with swallowing.
  • Esophageal ulcer. Stomach acid can severely erode tissues in the esophagus, causing an open sore to form. The esophageal ulcer may bleed, cause pain and make swallowing difficult.
  • Barrett's esophagus. This is a serious, though uncommon, complication of GERD. In Barrett's esophagus, the color and composition of the tissue lining the lower esophagus change. Instead of pink, the tissue turns a salmon color. Under a microscope, the tissue resembles that of the small intestine. This cellular change is called metaplasia. Metaplasia is brought on by repeated and long-term exposure to stomach acid and is associated with an increased risk of esophageal cancer. The risk of cancer is low, but you'll need regular endoscopies to look for early warning signs of cancer if you're diagnosed with Barrett's esophagus.

Treatment:
Whether you have mild, moderate or severe heartburn, many treatment options are available. The most common treatments involve medications, but surgical and other procedures also are available.

Over-the-counter remedies
If you experience only occasional, mild heartburn, you may get relief from an over-the-counter (OTC) medication and self-care measures. OTC remedies include :

  • Antacids. Antacids, such as Maalox, Mylanta, Gelusil, Rolaids and Tums, neutralize stomach acid and can provide quick relief. But antacids alone won't heal an inflamed esophagus damaged by
  • stomach acid. Overuse of some antacids can cause side effects such as diarrhea or constipation. A liquid antacid will coat your esophagus and help reduce stomach acid.
  • H-2-receptor blockers. Over-the-counter H-2-receptor blockers, such as cimetidine (Tagamet HB), famotidine (Pepcid AC), nizatidine (Axid AR) or ranitidine (Zantac 75), are available at half the strength of their prescription versions. Instead of neutralizing the acid, these medications reduce the production of acid. They don't act as quickly as antacids, but they provide longer relief. Take these medications before a meal that you think may cause heartburn because it takes them about 30 minutes to work. They're also effective in reducing reflux at night if taken at bedtime. H-2-receptor blockers can cause infrequent side effects, including bowel changes, dry mouth, dizziness or drowsiness. In rare instances they can also react dangerously with other medications.
  • Proton pump inhibitors. These medications block acid production and allow time for damaged esophageal tissue to heal. Omeprazole (Prilosec) was previously available only by prescription, but now is available in an over-the-counter form for short-term treatment of heartburn. Do not use OTC omeprazole long term unless prescribed by your doctor. See your doctor to make sure that you don't have any complications of GERD.

Prescription-strength medications
If you have frequent and persistent heartburn leading to an inflamed esophagus, you'll likely need prescription-strength medication. It's important that you take these medications correctly, and generally 30 minutes before a meal. Prescription medications can help reduce and eliminate GERD symptoms, as well as help heal an inflamed esophagus — the result of continual exposure to stomach acid. The main types of prescription drugs are :

  • Prescription-strength H-2-receptor blockers. These significantly reduce acid production and have few side effects. They include prescription-strength Axid, Pepcid, Tagamet and Zantac.
  • Prescription-strength proton pump inhibitors. These are long-acting and are the most effective medications for suppressing acid production. They're safe and have few side effects for long-term treatment. To prevent possible side effects, such as diarrhea or headaches, your doctor will likely prescribe the lowest effective dose. Prescription-strength proton pump inhibitors include esomeprazole (Nexium), lansoprazole (Prevacid), omeprazole (Prilosec), pantoprazole (Protonix) and rabeprazole (Aciphex).
  • Prokinetic agents. These don't reduce acid production. Instead, they help your stomach empty more rapidly and may help tighten the valve between the stomach and the esophagus. Because the prokinetic agents thus far sometimes cause serious side effects, researchers are working to develop safer versions.

Surgical and other procedures
Because of the effectiveness of medications, surgery for GERD is uncommon. However, it may be an option if you can't tolerate the medications, you can't afford their long-term use or your doctor determines that the medications are ineffective. Your doctor may also recommend surgery if you have any of these complications :

  • Large hiatal hernia
  • Severe esophagitis, especially with bleeding
  • Recurrent narrowing (stricture) of the esophagus
  • Severe pulmonary problems, such as bronchitis or pneumonia, due to acid reflux
  • GERD that is not controllable by medication

Before 1991, a procedure called open Nissen fundoplication was the surgery of choice for severe GERD. Today, doctors are able to perform the same surgery with similar success laparoscopically — through a few small abdominal incisions, instead of one large one. The advantages of laparoscopic surgery are a shorter recovery time and less discomfort.

Nissen fundoplication involves tightening the lower esophageal sphincter to prevent reflux by wrapping the very top of the stomach around the outside of the lower esophagus. During laparoscopic surgery, a surgeon makes three or four small incisions in the abdomen and inserts instruments, including a flexible tube with a tiny camera, through the incisions.

People who benefit most from a Nissen fundoplication are those who gained relief from medications. If you have minimal or no relief from medications, your doctor must be certain that you have GERD before recommending surgery, which may mean additional testing. Most people who undergo Nissen fundoplication remain free of GERD symptoms for at least two years. For the majority of people, this benefit extends to five years or more. You may still require medications for GERD, but your GERD will likely be easier to control.

Other surgical procedures include Toupet fundoplication, Hill repair and the Belsey Mark IV operation. All involve restructuring the lower esophageal sphincter to improve its strength and ability to prevent reflux. These surgeries are done less often, and their success is often dependent on the skill of the surgeon.

Complications from surgery generally are mild, but may include difficulty swallowing, bloating and diarrhea. These complications generally go away within one year.

Newer, less-invasive procedures
Your doctor may suggest a procedure for tightening the lower esophageal sphincter. These procedures generally take less time to perform, they don't require any incisions, and you can go home the same day. The procedures are performed endoscopically through a long, flexible tube that's inserted into your mouth and down your esophagus. These procedures are recommended if you have a hiatal hernia or Barrett's esophagus.

  • EndoCinch endoluminal gastroplication. This procedure uses a tool that's like a miniature sewing machine. It places pairs of stitches (sutures) in the stomach near the weakened sphincter. The suturing material is then tied together, creating barriers (plications) to prevent stomach acid from washing into your esophagus. The barriers are located at and just below the junction of the esophagus and stomach. The procedure may cause a sore throat or chest pain. The long-term effectiveness of the procedure is still unknown.
  • Stretta procedure. This approach uses controlled radiofrequency energy to heat and melt (coagulate) tissues within the portion of the esophagus that contains the malfunctioning valve and at the junction of the esophagus and upper stomach. The procedure appears to work by creating scar tissue and altering the sensory nerves that respond to refluxed acid. The procedure may cause a sore throat or chest pain. The long-term effectiveness of the procedure is still unknown.
 
Please be aware that this information is provided to supplement the care provided by your physician. It is neither intended nor implied to be a substitute for professional medical advice. CALL YOUR HEALTHCARE PROVIDER IMMEDIATELY IF YOU THINK YOU MAY HAVE A MEDICAL EMERGENCY. Always seek the advice of your physician or other qualified health provider prior to starting any new treatment or with any questions you may have regarding a medical condition.
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