GASTROESOPHAGEAL REFLUX OVERVIEW
Gastroesophageal reflux,
also known as acid reflux, occurs when the stomach contents reflux or back up
into the esophagus and/or mouth. Reflux is a normal process that occurs in
healthy infants, children, and adults. Most episodes are brief and do not cause
bothersome symptoms or complications.
In contrast, people with
gastroesophageal reflux disease (GERD) experience bothersome symptoms as a
result of the reflux. Symptoms can include heartburn, regurgitation, vomiting,
and difficulty or pain with swallowing. The reflux of
stomach acid can
adversely affect the vocal cords causing hoarseness or even be inhaled into the
lungs (called aspiration).
WHAT IS GASTROESOPHAGEAL REFLUX?
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.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 called the lower esophageal
sphincter (LES). After swallowing, the LES relaxes to allow food to enter the
stomach and then contracts to prevent the back-up of food and acid into the
esophagus. However, sometimes the LES is weak or becomes relaxed because the
stomach is distended, allowing liquids in the stomach to wash back into the
esophagus. This happens occasionally in all individuals. Most of these episodes
occur shortly after meals, are brief, and do not cause symptoms. Normally, acid
reflux should occur only rarely during sleep.
Acid reflux
- Acid reflux becomes gastroesophageal reflux disease (GERD) when it causes
bothersome symptoms or injury to the esophagus. The amount of acid reflux
required to cause GERD varies.
In general, damage to the esophagus is
more likely to occur when acid refluxes frequently, the reflux is very acidic,
or the esophagus is unable to clear away the acid quickly. The most common
symptoms associated with acid reflux are heartburn, regurgitation, chest pain,
and trouble swallowing. The treatments of GERD are designed to prevent one or
all of these symptoms from occurring.
Hiatus 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 hiatus hernia. The
presence of a hiatus hernia makes acid reflux more likely. A hiatus 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. There is no way to
prevent a hiatus hernia.
ACID REFLUX 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 lung infections (called pneumonia)
= Chronic sinusitis
= Waking up with a choking sensation
When to seek
help - The following signs and symptoms may indicate a more serious problem, and
should be reported to a healthcare provider immediately:
= Difficulty or pain
with swallowing (feeling that food gets "stuck")
= Unexplained weight loss
= Chest pain
= Choking
= Bleeding (vomiting blood or dark-colored stools).
ACID REFLUX DIAGNOSIS
Acid reflux is usually diagnosed
based upon symptoms and the response to treatment. In people who have symptoms
of acid reflux but no evidence of complications, a trial of treatment with
lifestyle changes and in some cases, a medication, are often recommended,
without testing. 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 problems that can cause
symptoms similar to those of gastroesophageal reflux disease. This is
particularly true with chest pain, since chest pain can also be a symptom of
heart disease. When the symptoms are not life threatening and the diagnosis of
gastroesophageal reflux disease is not clear, 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 a small sample of tissue (biopsy) can be taken to determine
the extent of tissue damage.
24-hour esophageal pH study
- A 24-hour esophageal pH study is the most direct way to measure the frequency
of acid reflux, although the study is not always helpful in diagnosing
gastroesophageal reflux disease or refluxassociated problems. It is usually
reserved for people whose diagnosis is unclear after endoscopy or a trial of
treatment. It is also useful for people who continue to have symptoms despite
treatment. The test involves inserting a thin tube through the nose and into the
esophagus. The tube is left in the esophagus for 24 hours. During this time the
patient keeps a diary of symptoms. The tube is attached to a small device that
measures how often 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).
Esophageal manometry
- Esophageal manometry involves
swallowing a tube that measures the muscle
contractions of the esophagus. This can help to
determine if the lower esophageal sphincter is
functioning properly. This test is usually
reserved for people in whom the diagnosis is
unclear after other testing or in whom surgery
for reflux disease is being considered.
ACID REFLUX COMPLICATIONS
The vast majority of patients with
gastroesophageal reflux disease will not develop
serious complications, particularly when reflux
is adequately treated. However, a number of
serious complications can arise in patients with
severe
gastroesophageal reflux disease.
Ulcers - Ulcers can form in
the esophagus as a result of burning from
stomach acid. In some cases, bleeding occurs.
You may not be aware of bleeding, but it may be
detected in a stool sample to test for traces of
blood that may not be visible. 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 people
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
gastroesophageal reflux disease. The intestinal
cells have a small risk of transforming into
cancer cells. As a result, people with Barrett's
esophagus are advised to have a periodic
endoscopy to monitor for early warning signs of
cancer.
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.
REFLUX
TREATMENT
Gastroesophageal reflux
disease is treated according to its severity.
Mild symptoms - Initial
treatments for mild acid reflux include dietary
and using non-prescription medications,
including antacids or histamine antagonists.
Lifestyle changes - Changes
to the diet or lifestyle have been recommended
for many years, although their effectiveness has
not been extensively evaluated in well-designed
clinical trials. A review of the literature
concluded that weight loss and elevating the
head of your bed may be helpful, but other
dietary changes were not found helpful in all
patients. Thus, these recommendations may be
helpful in some, but not all people with mild
symptoms of acid reflux.
For people with mild
acid reflux, 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.
Weight loss –
Losing weight may help people who are overweight
to reduce acid reflux. In addition, weight loss
has a number of other health benefits, including
a decreased risk of type 2 diabetes and heart
disease. Raise the head of the bed six to eight
inches – Although most people 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 under the legs of the bed or a
foam wedge under the mattress. Several
manufacturers have developed commercial products
for this purpose. However, it is not helpful to
use additional pillows; this can cause an
unnatural bend in the body that increases
pressure on the stomach, worsening acid reflux.
Avoid acid reflux-inducing foods
– Some foods also cause relaxation of the lower
esophageal sphincter, promoting acid reflux.
Excessive caffeine, chocolate, alcohol,
peppermint, and fatty foods may cause bothersome
acid 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.
Avoid large and late meals –
Lying down with a full stomach may increase the
risk of acid 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 acid reflux.
Avoid
tight fitting clothing – At 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.
Antacids
- Antacids are commonly used for short-term
relief of acid reflux. However, the stomach acid
is only neutralized very briefly after each
dose, so they are not very effective. Examples
of antacids include Tums, Maalox, and
Mylanta.
Histamine antagonists
- The histamine antagonists reduce production of
acid in the stomach. However, they are somewhat
less effective than proton pump inhibitors
(PPIs).
Examples of histamine antagonists
available in the United States include
ranitidine (Zantac), famotidine (Pepcid),
cimetidine (Tagamet), and nizatidine (Axid).
These medications are usually taken by mouth
once or twice per day. Cimetidine,
ranitidine, and famotidine are available in
prescription and nonprescription strengths.
Moderate to severe symptoms
- Patients with moderate to severe symptoms of
acid reflux, complications of gastroesophageal
reflux disease, or mild acid reflux symptoms
that have not responded to the lifestyle
modifications and the medications described
above usually require treatment with
prescription medications. Most patients are
treated with a proton pump inhibitor.
Proton pump inhibitors - PPIs
include omeprazole (Prilosec), esomeprazole (Nexium),
lansoprazole (Prevacid), dexlansoprazole (Kapidex),
pantoprazole (Protonix), and rabeprazole (AcipHex),
which are stronger and more effective than
the H2 antagonists. Once the optimal dose and
type of PPI is found, you will probably be kept
on the PPI for approximately eight weeks.
Depending upon your symptoms after eight weeks,
the medication dose may be decreased or
discontinued. If symptoms return within three
months, long-term treatment is usually
recommended. If symptoms do not return within
three months, treatment may be needed only
intermittently. The goal of treatment for GERD
is to take the lowest possible dose of
medication that controls symptoms and prevents
complications. Proton pump inhibitors are safe,
although they may be expensive, especially if
taken for a long period of time. Long-term risks
of PPIs may include an increased risk of gut
infections, such as Clostridium difficile (C.
diff), or reduced absorption of minerals and
nutrients. In general, these risks are small.
However, even a small risk emphasizes the need
to take the lowest possible dose for the
shortest possible time.
If
symptoms are not controlled - If your
symptoms of gastroesophageal reflux disease are
not adequately controlled with one = PPI, one or
more of the following may be recommended:
=
An alternate PPI may be prescribed or the dose
of the PPI may be increased
= The PPI may be
given twice per day instead of once
= Further
testing may be recommended to confirm the
diagnosis and/or determine if another problem is
causing symptoms
= Surgical treatment may be
considered
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 hiatus hernia and strengthening the lower
esophageal sphincter.
The most common
surgical treatment is the laparoscopic Nissen
fundoplication. This procedure involves wrapping
the upper part of the stomach around the lower
end of the esophagus.
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), or diarrhea due
to inadvertent injury to the nerves leading
to the stomach and intestines..