HEARTBURN--gastroesphageal reflux disease
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            Gastroesophageal reflux disease, also known as GERD or just "reflux", occurs when stomach acid regurgitates or backwashes into the esophagus or swallowing tube.  Typically this causes heartburn or indigestion, but can cause additional symptoms or alternatively, no symptoms at all.  Symptoms associated with reflux include a sour or bitter taste in the mouth, bad breath, chronic cough, sore throat, asthma, chest pain or abdominal pain, and painful or difficult swallowing.  Reflux in the absence of symptoms is termed silent reflux.

            GERD is quite common.  About 40% of adults have some degree of reflux, although most are quite mild.  One person in twenty has fairly severe reflux. If symptoms occur rarely, then there is typically no cause for concern and over-the-counter antacids can be taken as needed.  However, if symptoms occur more frequently than once or twice a week, or if there is unexplained weight loss, chest pain, trouble swallowing or bleeding, then you should seek medical attention.

            GERD is most often due to an incompetent or leaky valve at the bottom of the esophagus.  This valve is actually a muscular ring called the lower esophageal sphincter.  This sphincter acts as a trap door, keeping stomach acid out of the esophagus most of the time.  However, in some people it opens too often, allowing excess acid to reflux into and irritate the esophagus.  Factors affecting reflux include obesity as well as diet, eating habits, smoking and alcohol use.  All of these things cause the esophageal sphincter to relax more frequently and thus contribute to reflux.  Specific foods that increase reflux include fatty foods, carbonated and caffeinated beverages, coffee (even decaffeinated), chocolate and peppermint.   Some medications, including a number of heart medications, can also increase reflux in the same way.  Large meals and lying down within an hour or two of eating can also worsen symptoms.  Often, patients will describe awakening at night with symptoms.  This occurs because when you are lying flat gravity cannot help to clear the acids in the esophagus, and acid exposure is increased.  Reflux can also develop or worsen during pregnancy due to pressure from the enlarging uterus on the stomach.

            Hiatal hernia can also contribute to reflux, but it is rarely the primary cause of GERD.  Normally the diaphragm (or breathing muscle) that separates the chest from the abdomen has a small opening, allowing the esophagus to pass into the abdominal cavity and join the stomach.  The stomach thus is entirely inside the abdominal cavity.   Hiatal herniation occurs when this opening is enlarged and allows some of the top of the stomach to push up into the chest.  This actually occurs fairly commonly, but usually the stomach protrudes only slightly and does not in and of itself cause significant difficulty.  Rarely, a large portion of the stomach may herniate and cause symptoms primarily.

            Additional factors that may contribute to GERD include motility or motor disorders of the esophagus or stomach.  Coordinated esophageal contraction or peristalsis is required to clear the esophagus of refluxed stomach contents.  Diminished esophageal peristalsis thus can increase esophageal acid exposure and potential reflux.  Poor stomach emptying, or gastroparesis, may also exacerbate GERD by allowing the accumulation of stomach contents and increased opportunity for a volume of reflux.  If motility problems are present, there are medications available that facilitate esophageal and stomach emptying.  These include metoclopramide (Reglan) and cisapride (Propulsid).   These medications may also be prescribed in cases of GERD where there is a primary supine or nocturnal component to reflux, or if symptoms are refractory to standard antacid therapy.

            The reason for concern about GERD is of course to alleviate symptoms but also to prevent complications from chronic reflux.  These complications include esophagitis or irritation of the esophagus, esophageal ulcers, strictures or scarring of the esophagus leading to problems with swallowing and something called Barrett's esophagus. 

            Barrett's esophagus in and of itself does not cause symptoms, but signifies a 30- to 50-fold increased risk of developing a type of esophageal cancer, esophageal adenocarcinoma, in the future. The incidence of esophageal adenocarcinoma has increased alarmingly over the past few decades, and it has now become the most common type of esophageal cancer.  Barrett's esophagus describes a change in the appearance of the lining of the bottom of the esophagus, due to chronic acid exposure.  The cells that normally reside there are replaced by different cells that are more tolerant of acid.  The detection of Barrett's esophagus and other complications of reflux, and the prevention of future cancer, is the reason that most gastroenterologists recommend a one-time examination, or index endoscopy, to check the esophagus in patients with chronic reflux symptoms, or symptoms suggestive of a reflux complication.  Patients with Barrett's esophagus are further advised to undergo additional examinations of the esophagus every two years or so to check for cancer or pre-cancerous changes within Barrett's esophagus called dysplasia.  If high-grade dysplasia is present, this indicates a high likelihood of esophageal cancer developing imminently, or having already developed but having eluded detection.   In that eventuality, surgical resection of the esophagus (the standard treatment for esophageal adenocarcinoma) is frequently advised.

            The best examination for reflux is an upper endoscopy.  This examination allows your doctor to directly visualize the lining of the esophagus.  It is the only way to make a diagnosis of esophagitis or Barrett's esophagus and to perform a biopsy.   The examination is performed with a flexible fiberoptic instrument under sedation, so that there is no pain involved.  As well, the medication typically results in the patient having no recollection of the procedure.  An upper GI series or a barium x-ray of the esophagus can show some abnormalities, but is of limited usefulness.  Additionally, if a significant abnormality is suggested by upper GI series, then upper endoscopy is typically required in any event to make a definitive diagnosis.

            Treatment for GERD should always begin with lifestyle modifications to minimize reflux.  This includes dietary change, as well as smoking and alcohol cessation.  At times, elevation of the head of the bed may be suggested.  Currently, there are many effective medications for reflux.  Most of these act to reduce stomach acid.  This group of medications includes antacids and histamine antagonists including cimetidine (Tagamet), ranitidine (Zantac), famotidine (Pepcid), or nizatidine (Axid).  There are newer, more potent medications, termed proton pump inhibitors, including omeprazole (Prilosec), lansoprazole (Prevacid) and rabeprazole (Aciphex).  These are all generally well tolerated, but effectiveness varies significantly based on medication dose and frequency.  Again, you should see your doctor for guidance if symptoms are occurring frequently or if over-the-counter medications are not controlling symptoms. As noted previously, there are also medications that can improve reflux by helping the esophagus and stomach to empty.


            Finally, there are surgical options for reflux that recreate an anatomic barrier to reflux by wrapping the top of the stomach around the bottom of the esophagus.  This procedure is termed a "fundoplication" and can be performed laparoscopically.  Surgery is generally reserved for individuals with severe GERD or with complications of GERD.  Patients should be carefully selected for this operation to minimize the likelihood of post-operative symptoms or complications.  Specifically, abnormalities of esophageal or stomach emptying should be excluded prior to referral for surgery.  Surgery is also a viable alternative to medication for young patients who require life-long, aggressive treatment for GERD.  Recently, two new, less invasive techniques for the treatment of GERD have become available, for more information, click here.


            Standard treatment for Barrett's esophagus includes aggressive acid suppression, surveillance endoscopy to check for the development of dysplasia and consideration of antireflux surgery.  A newly developed treatment for Barrett's esophagus is termed "photodynamic therapy" or "PDT."  This involves passing a light probe into the esophagus to burn away and necrose the abnormal or Barrett's lining of the distal esophagus.  After this procedure, typically normal cells will then regrow and repopulate the bottom of the esophagus.  Although great strides have been made in improving this technique, many physicians still view this as investigational and remain concerned about the persistence of abnormal cells and the inability to screen for dysplasia and cancer after this procedure has been performed.


Update Article By Dr. Antony Maniatis