Gastro-esophageal Reflux Disease (GERD)

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Topic Highlights:-

• GERD is a disease of the digestive system wherein the esophagus is inflamed and irritated due to acid reflux from the stomach.
• Acid reflux causes heartburn.
• This animation helps to understand the causes of GERD, its symptoms, and treatment options.

Transcript:-
Gastro-esophageal reflux disease – or GERD – can affect any age group. The characteristic symptom of heartburn is caused by acid leaking from the stomach back into the esophagus. A certain amount of gastro-esophageal acid reflux is normal and up to 40% of people may report symptoms of heartburn. However, in about 8% of the population, the acid reflux will be severe enough to cause inflammation of the esophagus, called esophagitis.

When we eat, food passes from the mouth into the esophagus, the tube that carries food into the stomach. At the lower end of the esophagus is a specialized muscle called the lower esophageal sphincter, which is normally tightly closed. The sphincter functions as a one-way valve to prevent the back flow of stomach acid into the esophagus. It opens only to allow food and liquid into the stomach.

Sometimes the lower esophageal sphincter becomes abnormally relaxed and allows the stomach’s acidic contents to flow back or reflux into the esophagus. The reflux tendency increases when the stomach contains a lot of gastric juice or food and when there is increased pressure in or on the stomach.

GERD is caused by a combination of conditions that increase the presence of acid in the esophagus. For example, abnormal relaxation of the lower esophageal sphincter reduces its ability to prevent reflux. The sphincter may relax for short periods, lasting about 30 seconds. This is known as transient lower esophageal relaxation and is one of the most common causes of GERD. In a minority of patients, the sphincter may be constantly relaxed, which normally causes severe symptoms.

Abnormal peristalsis can also be a factor in GERD. Peristalsis is the rhythmical contraction of muscles in the esophagus that pushes food and any refluxed acid down into the stomach. If this motion is defective, the refluxed acid remains in the esophagus and causes inflammation or esophagitis.

Abnormally slow emptying of the stomach contents is a further contributor as it increases reflux. In normal conditions, the sphincter muscle is located at the same level as the diaphragm. Sometimes, a small part of the upper stomach attached to the esophagus pushes up through the diaphragm. This condition is called hiatus hernia and may cause GERD since it causes transient lower esophageal sphincter relaxation and slows the clearance of acid from the esophagus.

Several complications can arise in patients with GERD which require additional treatment. Most complications arise because of the esophagitis. For example, if severe and long term, inflammation in the esophagus can cause ulcers. The ulcers may bleed and cause scars that further narrow the esophagus, resulting in strictures. Furthermore, inflammation may cause changes in the cells lining the esophagus making them more prone to become cancerous. This condition is called Barrett’s esophagus.

Asthma and pneumonia are other complications resulting from GERD. Esophageal nerves may become irritated due to exposure with stomach acid. This irritation may produce coughing in some patients. Some esophageal nerves may stimulate the nerves that lead to the lungs resulting in asthma. The refluxed liquid may enter the lungs causing coughing and choking. Refluxed liquid may become infected and result in pneumonia.

The most common symptom of GERD is heartburn, which is a burning sensation felt under the breastbone after eating. It tends to be most severe at night. Sometimes partially digested food is regurgitated into the throat. This can irritate the esophagus leading to poor functioning of the esophageal muscles. It may also cause a scarring of the esophageal lining. Patients may also feel food trapped in their esophagus after swallowing. Some people may also experience nausea, sore throat, and a bitter taste in the back of the throat or symptoms similar to asthma.

A GERD diagnosis can usually be made from obtaining a description of symptoms. Tests may not be required. For those with severe or atypical symptoms, endoscopy is the most frequently used diagnostic test. During this test, the patient is sedated and a thin lighted, flexible tube called an endoscope is inserted into the esophagus and stomach to allow the physician to look for signs of inflammation. The test helps determine the severity of the disease and its complications. This technique is useful since a biopsy may be taken to rule out cancer.

Barium contrast studies may also be useful, if endoscopy is not available. The patient swallows the barium contrast liquid and X-rays are then taken. This technique is useful for identifying reflux and hiatus hernia. Other tests can be carried out if required, although they are not usually necessary.

In esophageal manometry, the pressure in the sphincter muscle and any abnormal muscle contractions of the esophagus are measured. The acidity of the esophagus can also be measured. A catheter is passed through the nose to the esophagus. The sensor tip of the catheter detects acid. A device records the acid reflux over several hours so it can be matched to symptoms. Stomach emptying speed can also be measured in complicated cases.

The majority of patients with GERD can be effectively treated with medications. Over-the-counter medications may be sufficient to relieve mild symptoms. Antacids neutralize stomach acids so that any gastric contents that regurgitate back into the esophagus are less damaging. Alginates form a foam barrier on top of the stomach contents to protect the esophagus.

More severe symptoms usually require proton pump inhibitors, such as omeprazole or pantoprazole. These prescription drugs reduce cell production of acid in the stomach lining. The acid reduction relieves the symptoms and allows the esophagus to heal.

Histamine H2 antagonists such as ranitidine and cimetidine are also sometimes used, although not as frequently as proton pump inhibitors. Some types can be bought over-the-counter, while stronger preparations must be prescribed. These drugs block histamine receptors in the cells of the stomach lining to reduce acid production.

Prokinetic drugs such as metoclopramide and domperidone may occasionally be used to promote gastric emptying and increase sphincter tone.

Surgery may be considered if medications are ineffective. Keyhole surgery can tighten the sphincter in a process called fundoplication. Small punctures are made in the abdomen for insertion of a telescope and surgical instruments. The top of the stomach (or fundus) is wrapped around the base of the esophagus to strengthen the problematic valve. The hiatus hernia could also be corrected during the procedure.

In addition to taking over-the-counter medications such as antacids and acid-suppressing drugs, there are various ways that you can limit symptoms of GERD. If you are overweight, try losing weight to reduce the pressure on your stomach. Avoid tight-fitting clothes. Do not lie down immediately after a meal and avoid late-night snacks. Elevating the head of your bed by six to eight inches may help. Quit smoking, as smoking can make GERD worse. Avoid foods that trigger heartburn – such as spicy foods, caffeine, chocolate, fatty foods and citrus foods – and eat small, regular meals.