Ohio GI [G.E.R.D.]

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INTRODUCTION Gastroesophageal reflux disease (GERD) is a disease in which acid from the stomach flows back (refluxes) into the esophagus, causing irritation and sometimes damage to the lining of the esophagus. The reflux of stomach acid can adversely affect the vocal cords or even be inhaled into the lungs (called aspiration).

CAUSES The exact cause of reflux is complex and not completely understood. Many factors are probably involved.

Normal digestion When we eat, food is carried from the mouth to the stomach through the esophagus, a tube-like structure that is approximately 10 inches long and 1 inch wide in adults ( show figure 1 ). The esophagus is made of tissue and muscle layers that expand and contract to propel food to the stomach through a series of wave-like movements called peristalsis.

At the lower end of the esophagus, where it joins the stomach, there is a circular ring of muscle that relaxes and opens when food reaches that point. This ring of muscle is called the lower esophageal sphincter (LES), which allows food to enter the stomach and then closes to prevent the back-up of food and acid into the esophagus. Reflux can occur if the LES is weak or stays relaxed too long.

It is normal to have acid in the stomach, where it aids in digestion of food. It is not normal to have acid in the esophagus; the lining of the esophagus is different from that of the stomach, and it cannot tolerate frequent acid exposure. When acid is present in the esophagus, it can cause varying degrees of damage.

Reflux Some degree of reflux is normal in everyone. Episodes of normal reflux typically occur after meals, are brief and without symptoms, and rarely occur during sleep. Acid reflux becomes GERD when a person has frequent symptoms or the esophagus becomes damaged. The amount of reflux required to cause injury varies. In general, damage to the esophagus occurs when acid refluxes frequently, the pH of the acid is less than 4, or the esophagus is unable to clear away the acid quickly. The treatments of GERD are designed to prevent one or all of these elements from occurring.

Hiatal hernia The diaphragm is a large flat muscle at the base of the lungs that contracts and relaxes as a person breathes in and out. The esophagus passes through an opening in the diaphragm called the diaphragmatic hiatus before it joins with the stomach. Normally, the diaphragm contracts, which improves the strength of the LES, especially during bending, coughing, or straining. If there is a weakening in the diaphragm muscle at the hiatus, the stomach may be able to partially slip through the diaphragm into the chest, forming a sliding hiatal hernia. There is no way to prevent a hiatal hernia.

The presence of a hiatal hernia makes reflux more likely. A hiatal hernia is more common in people over age 50. Obesity and pregnancy are also contributing factors. The exact cause is unknown but may be related to the loosening of the tissues around the diaphragm that occurs with advancing age.

SYMPTOMS People who experience heartburn at least two to three times a week may have gastroesophageal reflux disease, or GERD. The most common symptom of GERD, heartburn, is estimated to affect 10 million adults in the United States on a daily basis. Heartburn is experienced as a burning sensation in the center of the chest, which sometimes spreads to the throat; there also may be an acid taste in the throat. Less common symptoms include:

Stomach pain (pain in the upper abdomen)
Non-burning chest pain
Difficulty swallowing (called dysphagia), or food getting stuck
Painful swallowing (called odynophagia)
Persistent laryngitis/hoarseness
Persistent sore throat
Chronic cough, new onset asthma, or asthma only at night
Regurgitation of foods/fluids; taste of acid in the throat
Sense of a lump in the throat
Worsening dental disease
Recurrent pneumonia
Chronic sinusitis
Waking up with a choking sensation

The following signs and symptoms may indicate a more serious problem, and should be reported to a healthcare provider immediately:

Food getting stuck in the esophagus
Unexplained weight loss
Chest pain
Choking
Bleeding (vomiting blood or dark-colored stools)

DIAGNOSIS GERD is usually diagnosed based upon symptoms and the response to treatment. Specific testing is required when the diagnosis is unclear or if there are more serious signs or symptoms as described above.

It is important to rule out potentially life threatening diseases that can cause signs and symptoms similar to those of GERD. This is particularly true with chest pain, since chest pain can also be a symptom of heart disease ( See "Patient information: Chest pain" ). When the symptoms are not life threatening, but cannot clearly be ascribed to GERD, one or more of the following tests may be recommended.

Endoscopy An upper endoscopy is commonly used to evaluate the esophagus. A small, flexible tube is passed into the esophagus, stomach, and small intestine. The tube has a light source and a camera that displays magnified images. Damage to the lining of these structures can be evaluated and specimens of tissue (biopsies) can be taken to determine the extent of tissue damage. ( See "Patient information: Upper endoscopy" ).

24-hour esophageal pH study A 24-hour esophageal pH study is the most sensitive test for the diagnosis of GERD, although it is usually reserved for patients whose diagnosis is unclear after endoscopy or a trial of treatment. It is also useful for patients who continue to have symptoms despite treatment.

The test involves swallowing a thin tube, which is left in the esophagus for 24 hours. During this time the patient keeps a diary of symptoms. The tube exits the esophagus through the nose, and is attached to a small device that measures how much stomach acid is reaching the esophagus. The data are then analyzed to determine the frequency of reflux and the relationship of reflux to symptoms.

An alternate method for measuring pH uses a device that is attached to the esophagus and broadcasts pH information to a monitor worn outside of the body. This avoids the need for a tube in the esophagus and nose. The main disadvantage is that an endoscopy procedure is required to place the device (it does not require removal, but simply passes on its own in the stool). The device is not used by all gastroenterologists.

Esophageal manometry Esophageal manometry involves swallowing a tube that measures the muscle contractions of the esophagus to determine if the lower esophageal sphincter is functioning properly. This test is usually reserved for patients in whom the diagnosis is unclear after other testing or in whom surgery is being considered.

COMPLICATIONS The vast majority of patients with GERD will not develop serious complications, particularly when reflux is adequately treated. However, a number of serious complications can arise in patients with severe GERD.

Ulcers Ulcers can form in the esophagus as a result of burning from stomach acid. In some cases, bleeding occurs. Patients may not be aware of bleeding, but it may be detected in a stool sample with a test called hemoccult. This test is performed by putting a small amount of stool on a chemically coated card.

Stricture Damage from acid can cause the esophagus to scar and narrow, causing a blockage (stricture) that can cause food or pills to get stuck in the esophagus. The narrowing is caused by scar tissue that develops as a result of ulcers that repeatedly damage and then heal in the esophagus.

Lung and throat problems Some patients reflux acid into the throat, causing inflammation of the vocal cords, a sore throat, or a hoarse voice. The acid can be inhaled into the lungs and cause a type of pneumonia (aspiration pneumonia) or asthma symptoms. Chronic acid reflux into the lungs may eventually cause permanent lung damage, called pulmonary fibrosis or bronchiectasis.

Barrett's esophagus Barrett's esophagus occurs when the normal cells that line the lower esophagus (squamous cells) are replaced by a different cell type (intestinal cells). This process usually results from repeated damage to the esophageal lining, and the most common cause is longstanding GERD. The intestinal cells have a small risk of transforming into cancer cells. As a result, patients with Barrett's esophagus are advised to have a periodic endoscopy to monitor for early warning signs of cancer. ( See "Patient information: Monitoring and treatment of Barrett's esophagus" ).

Esophageal cancer There are two main types of esophageal cancer: adenocarcinoma and squamous cell carcinoma. A major risk factor for adenocarcinoma is Barrett's esophagus, discussed above. Squamous cell carcinoma does not appear to be related to GERD. Unfortunately, adenocarcinoma of the esophagus is on the rise in the United States and in many other countries. However, only a small percentage of people with GERD will develop Barrett's esophagus and an even smaller percentage will develop adenocarcinoma. ( See "Patient information: Monitoring and treatment of Barrett's esophagus" ).

TREATMENT GERD is treated according to its severity.

Mild symptoms Initial treatments for mild reflux include dietary changes and using non-prescription medications, including antacids or acid blocking medicines (such as famotidine [Pepcid ACÿ], cimetidine [Tagamet HBÿ], nizatidine [Axid ARÿ] and ranitidine [Zantac 75ÿ]). Additional changes to the diet or lifestyle may also be helpful. For people with mild symptoms, these treatments can be tried before seeking medical attention. However, anyone with more serious symptoms should speak to their healthcare provider before using any treatment ( see "Symptoms" above ).

Weight loss In significantly overweight people, losing weight may help reduce reflux. In addition, weight loss has a number of other health benefits, including a decreased risk of type 2 diabetes and heart disease. ( See "Patient information: Weight loss treatments" ).

Raise the head of the bed six to eight inches Although most patients only have heartburn for the two- to three-hour period after meals, some wake up at night with heartburn. People with nighttime heartburn can elevate the head of their bed, which raises the head and shoulders higher than the stomach, allowing gravity to prevent acid from refluxing.

Raising the head of the bed can be done with blocks of wood or a foam wedge under the mattress. However, it is not helpful to use additional pillows; this can cause an unnatural bend in the body that increases pressure on the stomach, making reflux more likely. Several manufacturers have developed commercial products for this purpose (for one example, see www.bedge.com ).

Avoid reflux inducing foods Some foods also cause relaxation of the lower esophageal sphincter, promoting reflux. Excessive caffeine, chocolate, alcohol, peppermint, and fatty foods may cause bothersome reflux in some people.

Quit smoking Saliva helps to neutralize refluxed acid, and smoking reduces the amount of saliva in the mouth and throat. Smoking also lowers the pressure in the lower esophageal sphincter and provokes coughing, causing frequent episodes of acid reflux in the esophagus. Quitting smoking can reduce or eliminate symptoms of mild reflux. ( See "Patient information: Smoking cessation" ).

Avoid large and late meals Lying down with a full stomach may increase the risk of reflux. By eating three or more hours before bedtime, reflux may be reduced. In addition, eating smaller meals may prevent the stomach from becoming overdistended, which can cause reflux.

Avoid tight fitting clothing At a minimum, tight fitting clothing can increase discomfort, but it may also increase pressure in the abdomen, forcing stomach contents into the esophagus.

Chew gum or use oral lozenges Chewing gum or using lozenges can increase saliva production, which may help to clear stomach acid that has entered the esophagus.

Although these suggestions have been recommended for many years, their effectiveness has not been extensively evaluated in well-designed clinical trials. A review of the published literature concluded that there was evidence supporting the effectiveness of weight loss and head of bed elevation, but no evidence for the other measures described above [ 1 ]. Thus, these recommendations may be helpful in some, but not all people with mild symptoms of reflux.

Moderate to severe symptoms Patients with moderate to severe symptoms, complications of GERD, or mild symptoms that have not responded to the lifestyle modifications described above usually require treatment with prescription medications. Most patients are treated with medications that decrease stomach acid production.

Acid reducing medications can broadly be further divided into two groups:

H2 antagonists include famotidine (Pepcidÿ), cimetidine (Tagametÿ), ranitidine (Zantacÿ), and nizatidine (Axidÿ), which and are sufficient to control symptoms in many people.

Proton pump inhibitors include omeprazole (Prilosecÿ), esomeprazole (Nexiumÿ), lansoprazole (Prevacidÿ), pantoprazole (Protonixÿ), and rabeprazole (Aciphexÿ), which are stronger and more effective than the H2 antagonists. Most clinicians recommend a stopping treatment for a trial period once symptoms are under control, although many patients continue taking these medications for years.

Both the H2 antagonists and the proton pump inhibitors are safe, although they may be expensive, especially if taken for a long period of time.

Surgical treatment Prior to the development of the potent acid-reducing medications described above, surgery was used for severe cases of GERD that did not resolve with medical treatment. Because of the effectiveness of medical therapy, the role of surgery has become more complex. In general, anti-reflux surgery involves repairing the hiatal hernia and strengthening the lower esophageal sphincter. The most common surgical treatment used currently is the laparoscopic Nissen fundoplication.

Patients in whom surgery is being considered typically require esophageal manometry and endoscopy to confirm the diagnosis and decide which surgical treatment will be most effective. Although the outcome of surgery is usually good, complications can occur. Examples include persistent difficulty swallowing (occurring in about 5 percent of patients), a sense of bloating and gas (known as "gas-bloat syndrome"), breakdown of the repair (1 to 2 percent of patients per year), and uncommonly, or diarrhea due to inadvertent injury to the nerves leading to the stomach and intestines.

New and upcoming methods Several new methods for treatment of GERD are being developed. At present, none can be recommended routinely.

SUMMARY

Gastroesophageal reflux disease (GERD) is a disease in which acid from the stomach flows back (refluxes) into the esophagus, causing irritation and sometimes damage to the lining of the esophagus. The reflux of stomach acid can adversely affect the vocal cords or even be inhaled into the lungs (called aspiration), causing damage.

The exact causes of reflux are complex and not completely understood. Many factors are probably involved ( see "Causes" above ).

The most common symptom of GERD is heartburn, which feels like a burning sensation in the center of the chest and sometimes spreads to the throat; there also may be an acid taste in the throat ( see "Symptoms" above ).

GERD is usually diagnosed based upon symptoms and the response to treatment. Specific testing is required when the diagnosis is unclear or if there are more serious signs or symptoms ( see "Diagnosis" above ).

The vast majority of patients with GERD will not develop serious complications, particularly when reflux is adequately treated. However, a number of serious complications can arise in patients with severe GERD, including ulcers, scarring and narrowing or the esophagus, lung and throat problems, a precancerous condition known as Barrett's esophagus, and rarely esophageal cancer ( see "Complications" above ).

Initial treatments for mild reflux include dietary changes and using non-prescription medications, including antacids or acid blocking medicines (such as famotidine [Pepcid ACÿ], cimetidine [Tagamet HBÿ], nizatidine [Axid ARÿ] and ranitidine [Zantac 75ÿ]). Additional changes to the diet or lifestyle may also be helpful. For people with mild symptoms, these treatments can be tried before seeking medical attention. However, anyone with more serious symptoms should speak to their healthcare provider before using any treatment ( see "Mild symptoms" above ).

Patients with moderate to severe symptoms, complications of GERD, or mild symptoms that have not responded to the lifestyle modifications usually require treatment with prescription medications. Most patients are treated with medications that decrease stomach acid production, such as acid blockers or proton pump inhibitors (omeprazole (Prilosecÿ), esomeprazole (Nexiumÿ), lansoprazole (Prevacidÿ), pantoprazole (Protonixÿ), and rabeprazole (Aciphexÿ) ( see "Moderate to severe symptoms" above ).

Surgical treatment, such as laparoscopic Nissen fundoplication, may be an option for a person who has longstanding symptoms and is seeking an alternative to long-term medical therapy ( see "Surgical treatment" above ).