Gastroesophageal Reflux Disease (GERD)

What is GERD (Gastro-Esophageal Reflux disease)?

To understand GERD, we need to understand how our digestive system works.  Normally when we eat, our food is chewed into small pieces that are easy to swallow.  As we swallow the food it travels down our esophagus (tube between our mouth and stomach) to the stomach.

Near the top of our esophagus is an area of muscle called the Upper Esophageal Sphincter (UES).  When we swallow, the UES relaxes, allowing food to pass into the esophagus.  The food then travels down the esophagus where it passes another area of specialized muscle tissue called the Lower Esophageal Sphincter (LES).  The LES is located at the junction of the esophagus and the stomach.  The job of the LES is to act as a one way valve, allowing food to enter the stomach and prevent it from coming back up into the esophagus.

GERD occurs when the Lower Esophageal Sphincter (LES) is too relaxed and does not do its job of preventing stomach fluids (stomach acid) and food from backing up into the esophagus.  The lining of our esophagus is not protected from stomach acid, unlike the stomach’s lining.  The acid contact with the esophagus causes inflammation, and may cause irritation of the esophageal tissue.  This leads to the symptoms of GERD.

You may be familiar with the symptoms of GERD.  They include:

• Heartburn.  This is a burning sensation felt under our breastbone.  The frequency of this varies from person to person.  It can be 1-2 times a month, or even a daily occurrence.   
• Acid regurgitation. This is the sensation that the acid and food contents in our stomach are backing up into our esophagus and at times even into our mouths, causing a bitter or sour taste.
• Hoarse or scratchy voice, coughing, some types of asthma, sinus problems, and dental erosions These can be caused by the stomach acid backing up in our esophagus and traveling into our breathing tube causing irritation of our voice box (larynx) or vocal cords which can lead to changes in our voice.  The acid can also travel further down our airway (trachea) and cause spasm of our airways that can cause asthma symptoms such as wheezing or coughing.  The acid can even travel up into our sinuses, which can lead to sinus problems.   The stomach acid can also break down the enamel of our teeth.
• Difficulty swallowing or food becoming stuck in our swallowing tube (esophagus). This is often caused by our stomach acid backing up into our esophagus.  If this occurs frequently and over long periods of time it can cause irritation and inflammation of the tissue which can lead to a narrowing of the esophagus, making the passage of food difficult.

How common is GERD?

Over 60 million Americans have GERD.  About one fourth of these individuals have symptoms every day.   Factors contributing to the incidence of GERD include pregnancy, being overweight and older age.

How do you know if you have GERD?

There are a number of tests that are used to diagnose GERD.  They include the following:

• Upper Endoscopy or EGD (Esophagogastroduodenoscopy): is a procedure where a small lighted tube is passed through your mouth into you esophagus, stomach and first portion of your small intestine.  This test allows the doctor to see the lining of your esophagus, stomach and first portion of your small intestine.  Pictures can be taken, and can be part of your medical record.  After the study, the physician will tell you what they saw.    Sometimes biopsies (tissue samples) may be taken.  There is no pain associated with taking biopsies.   Getting results of biopsies can take 1-2 weeks. 
• Barium Swallow, and or an Upper GI x-ray:  involves drinking barium which coats the esophagus, stomach and first portion of the small intestine.  X-rays are then taken to show the lining and structures of these areas.  Some times the test will involve special x-ray video  that records the actions of swallowing 
• 24-hour pH monitoring is a test where a very thin tube is placed through your nose into your esophagus.  This is done in a GI clinic.  The tube has special sensors that measure how often you have acid backing up into your esophagus and how long it stays there.   The tube remains in place for 24 hours, and the information is recorded on a small computer monitor. 
• Manometry:  is a test where a thin tube is place through your nose into your esophagus.  This tube has special sensors to measure pressure in the esophagus.  This test is used to evaluate your swallows.  It can show the strength and the coordination of your swallows.  This test is also done in our Endoscopy clinic .  The tube is left in place for a short period of time.  While it is in place you will be asked to swallow, drink, and/or cough.

How is GERD treated?

Initial treatment of GERD involves Life-style changes.  Other treatments include: Medications, Endoscopic treatment of the esophagus, and Surgery.

Lifestyle Changes:

• Avoid foods that cause symptoms; or that cause the lower esophageal sphincter to relax, or that are irritating to the GI tract and may cause increase in acid production. These foods include: Caffeinated drinks (coffee, some teas, colas, and other sodas high in caffeine) chocolate, tomato based products (i.e. spaghetti, lasagna, pizza, and chili), spicy foods, garlic, onions, peppers, fatty foods, and mint/peppermint.  Avoid Citrus products. 
• Avoid using tobacco products: this means no smoking, or chewing tobacco.
• If you are over weight try to lose some of the excess weight.
• Avoid eating for 3 hours before you go to bed.
• Avoid wearing clothing that is tight around your abdomen.
• Avoid alcohol.
• Avoid the use of aspirin and other non-steroidal anti-inflammatory medicines.
• Elevate the head of your bed up on 4-6 inch blocks to help prevent acid from rising up.

Medications:

Antacids:  There are liquid and tablet types of antacids used to neutralize the acid in your stomach. They offer relief relatively quickly, however don’t last long.  Some antacids can cause diarrhea others may cause constipation.  Let your doctor know if this becomes a problem.  If you are using these medications frequently, you should speak to your doctor.

• H2 Blockers: These include medications like: cimetadine (Tagamet), ranitidine (Zantac), famotidine (Pepcid), and nizatidine (Axid).  These medications come in both over the counter and prescription strengths.  These drugs work by blocking some of the acid production in our stomach.  It is recommended that if you need these medications for longer then a few weeks you should see your doctor. 
• Proton Pump Inhibitors: These include: omeprazole (Prilosec), lansoprazole (Prevacid), pantoprazole (Protonix), rabeprazole (Aciphex), and esomeprazole (Nexium).  These medications work by stopping the production of acid by different types of cells in our stomach that make acid.
• Prokinetic medications such as metoclopramide (Reglan) and Erythromycin are used as they aid the stomach in emptying which decreases the chances of reflux.

Surgery: 

This option is reserved for when the above measures aren’t working.  It can also be used as an alternative to chronic medication therapy.  The surgery is called “Nissen Fundoplication”.  This is a surgical procedure where the upper portion of the stomach is wrapped around the lower esophageal sphincter area to prevent reflux.

Endoscopic Treatment: Recently the FDA approved the use of a polymer called “Enteryx”.  This is a solution that is injected into the esophagus at the area of the lower esophageal sphincter.  The liquid becomes spongy after injected in the tissue.  It creates something like a collar around the lower esophageal sphincter that helps to prevent reflux.

Are there any complications to GERD?

The main gastrointestinal complications that are related to GERD include Barrett’s Esophagus and swallowing problems.

• Barrett’s Esophagus is a precancerous condition of the esophagus, where the lining of the esophagus changes.  These changes can lead to cancer.  It is recommended that individuals with Barrett’s Esophagus be followed with regular endoscopies for screening.   Barrett’s Esophagus is found in only 10% of individuals with GERD, of those that have Barrett’s esophagus 1% will develop esophageal cancer.
• Swallowing problems are often described as the sensation that the food is getting stuck or is slowing up in the esophagus instead of going into the stomach. Symptoms can also include painful swallowing.   It can happen with solid food and or liquids.  If this is happening to you let your doctor know.  Most often it happens as the result of acid backing up into our esophagus causing irritation, and over time a narrowing of our esophagus making it difficult for food to pass.  Let your doctor know if this is happening to you as correcting the problem can be done with the use of Upper Endoscopy.

What kind of follow up will I need?

If you have GERD with no other problems, you can follow with your primary physician.  Most if not all primary physicians are comfortable treating individuals who have GERD once the diagnosis has been made.  If you wish to follow with our clinics, we will want to see you once a year to see how you are doing, discuss any new treatment options as well as reviewing lifestyle modifications.  It is at this time that you will be given an updated prescription.

If you have Barrett’s Esophagus, we will want to see you for follow up on a yearly basis and will want to do an upper endoscopy every 2 years to evaluate for the risk of cancer.

If you are having swallowing problems, we ask that you call our office and speak with the patient coordinator that works with your Gastroenterologist.

If you have any questions, please call our office at 612-871-1145.

 

11/18/2007