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Gastroesophageal reflux disease (GERD) is a condition in which damage to the esophageal, oropharyngeal and laryngeal tissue occurs due to excessive backwashing of gastric contents into the esophagus.
The typical symptoms of GERD are burning in the chest (heartburn) and regurgitation of sour or bitter liquid, sometimes mixed with food, to the throat or mouth. Although not everyone has these symptoms, they are so indicative of reflux that testing is not usually necessary. Other relatively common symptoms include chest pain, which may simulate cardiac disease, and the feeling of food sticking in the esophagus. Less often GERD may cause throat burning, coughing, asthma, or recurrent pulmonary infections (recurrent bronchitis or aspiration pneumonia).
Polls of normal individuals reveal that a large percentage of the population has occasional symptoms of heartburn. Tests of acid reflux using pH probes placed in the esophagus suggest that a limited amount of reflux occurs daily in the majority of individuals (physiologic reflux). Reflux is only considered a disease when excessive amounts of reflux occur (pathologic reflux) causing frequent symptoms or tissue damage.
The main cause of reflux is a weak anti-reflux barrier. There are two major components of this barrier: the strength of the lower esophageal sphincter (LES) and the normal anatomic configuration of the junction of the esophagus and stomach. LES strength can be measured by esophageal manometry (pressure studies). The esophagus usually joins the stomach within the abdomen at an abrupt angle. When the esophagogastric junction is in the chest rather than the abdomen, a hiatal hernia is said to be present. A low LES pressure or a hiatal hernia predisposes individuals to abnormal amounts of reflux. Pathologic reflux is more likely when both abnormalities occur in the same individual. What other factors can contribute to the severity of reflux? Refluxed material is usually neutralized and washed out of the esophagus by saliva. Individuals who have reflux and do not produce saliva, or who are unable to swallow their own saliva due to a swallowing disorder, may develop particularly severe esophageal injury. Patients with severe esophageal weakness may also be unable to clear their esophagus after reflux occurs. This prolongs the period in which the esophagus is bathed in acid, and increases the chances of developing severe esophageal injury. Although most patients with GERD produce normal amounts of acid, those with excessive acid production are more likely to have esophageal injury when reflux occurs. Occasionally, individuals with reflux have a disorder of gastric emptying, resulting in an increased chance of reflux. In most cases, the aforementioned complications increase the severity of reflux in patients already predisposed to this condition due to a weak anti-reflux barrier. Only rarely do they create pathologic reflux in an individual not otherwise predisposed to developing reflux.
Several tests can be used to diagnose GERD. A barium esophagram is an X-ray used to evaluate structure and function of the esophagus and is indicated when there is difficulty swallowing. Esophageal manometry is a test used to determine LES pressure and the strength and coordination of muscle contraction in the esophagus. Although this test does not show reflux, it does allow placement of a thin 24-hour pH catheter in the esophagus that demonstrates frequency and direction of reflux. This is the best test for the diagnosis of GERD. Upper endoscopy allows the physician to see if there is esophageal injury and to perform biopsies to determine whether further medical or surgical management is necessary.
GERD can be treated in several ways. The first approach is dietary and lifestyle modifications, e.g., decreasing the intake of foods that increase gastric acidity or reduce the pressure at the muscle at the lower end of the esophagus (caffeinated and decaffeinated foods, chocolate, peppermint and spearmint). Coffee, alcohol and acidic liquids affect esophageal peristalsis, and fatty foods slow gastric emptying and should be avoided. Large meals increase gastric pressure and therefore increase reflux. Smoking affects esophageal motor function, stimulates acid secretion and delays gastric emptying, potentiating reflux. Air swallowed while smoking increases the need for belching and therefore increases reflux. Lying down after eating should be avoided to keep the food in the stomach from refluxing into the esophagus. The head of the bed should be elevated at night to prevent the same type of reflux. Weight reduction is also recommended for those patients who are markedly overweight to lessen the frequency of reflux. New endoscopic techniques that are being developed may be useful to treat refractory reflux.
Drug therapy is used in combination with lifestyle changes. Acid-suppressing agents and drugs that enhance upper gastrointestinal motility are often prescribed. Surgery is the other choice to manage GERD. This mode of treatment is used primarily if the patient is unwilling or unable to cope with the lifestyle changes necessary for management of reflux disease. A Nissen fundoplication is the most common procedure performed.
This is a surgical procedure in which the upper part of the stomach is wrapped around the entire circumference of the lower esophagus. Any existing hiatal hernia is reduced. This procedure has been reported to produce relief of reflux in 80 to 85 percent of patients.
Complications that may occur from a Nissen "wrap" are dysphagia (difficulty swallowing) and abdominal distention. The dysphagia is usually mild and temporary but occasionally can be severe or persistent. Another post-operative problem is the "gas bloat" syndrome, in which patients develop bloating and abdominal pain after urgery. Some degree of this syndrome is not uncommon after surgery but is usually a minor nuisance. However, "gas bloat" can be severe and difficult to treat. Three major complications of GERD are esophagitis, esophageal strictures and Barrett’s esophagus. Esophagitis is an inflammation of the esophagus and can range from inflamed mucosa to erosive ulcers occurring in a minority of GERD patients. GI bleeding may occur in ulcerated and eroded areas. Reflux-induced strictures are areas of thickened esophageal wall that narrow the lumen (the channel through which food must pass). Strictures occur in patients who have had relatively severe esophagitis. Barrett’s esophagus is a condition resulting from the abnormal healing of erosive esophagitis. The risk of developing Barrett’s is greater in patients with more severe and long-standing reflux symptoms. The significance of this condition is its tendency to develop into cancer of the esophagus. I have GERD.
Barrett’s esophagus develops in about 10 to 20 percent of patients with chronic GERD or inflammation of the esophagus. It occurs more often in men than in women (3:1 ratio) and is more common in Caucasian Americans than African Americans. The prevalence of Barrett’s esophagus increases with age; the average age at diagnosis is 55 years