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August 28, 2015

Gastroesophageal Reflux Disease

Gastroesophageal Reflux Disease, commonly called GERD, is due to back-up of stomach juices into the esophagus. It occurs normally briefly in most of us from time to time. It becomes a disorder or disease (the D in GERD) when it occurs much of the time, causes symptoms that are bothersome or causes damage to the esophagus. GERD is the disease of having these reflux events so often that symptoms or actual tissue damage to the esophagus results from repeated exposure to acid juices.

Causes

GERD is caused by disorders of the contractions that move food along push food down to the stomach, and along the way two sphincters (muscular valves) open—at the top of esophagus and the Lower Esophageal Sphincter (LES) at the bottom. These function automatically when a food swallow is started. When the LES doesn’t close properly, is too loose or opens up too much of the time, then it takes very little pressure within the stomach for stomach juices, or partly digested food, to back up into the esophagus.

The lining of the esophagus is delicate and has nerve endings that sense various degrees of pressure, acidity and other events. Stomach juices contain extremely strong acid (called hydrochloric acid) (20 to 100 times stronger than anything acid you take in your food!) and digestive enzymes (such as bile and pepsin) that have roles in food digestion.

People who have reflux symptoms don’t make too much acid; it’s simply that too much of the normal acid backs up across the LES into the esophagus. Reflux occurs commonly as a result of over-eating or from foods that result in the LES opening up or staying relaxed longer than it should. GERD is the disease of having these reflux events so often that symptoms or actual tissue damage to the esophagus results from repeated exposure to acid juices. Sometimes nausea and regurgitation of stomach contents into the throat and mouth will occur (without vomiting). That may often be followed by foul-smelling breath. Bending over or lying down may aggravate pain from reflux.

In some people the LES pressure is too low during much of the night, so reflux occurs a lot and wakes people from sleep. Failure of the valve-like lower esophageal sphincter (LES) to close effectively may occur with normal anatomy, and it can be responding inappropriately to food, nervous stress, and/or by the effects of excessive weight where abdominal fat tissues are dense and compress the stomach.

Also, reflux can be caused by structural abnormalities such as hiatal hernia. Hiatal hernia is the pushing up of the stomach into the chest cavity through a weakening of the diaphragm. The presence of a hiatal hernia may weaken the LES. Many persons who have hiatal hernias will experience some degree of gastroesophageal reflux, thus it is a common finding in GERD patients. If the LES is strong though, a hiatal hernia is not itself a problem.

Risk Factors

Factors that induce GERD are alcohl excess, obesity, pregnancy, and smoking.

High Risk Foods: “rich” foods (high fat content, oily/greasy foods & sauces), sometimes chocolate, sweets/pastries; acidic juices can cause heartburn symptoms.

Signs & Symptoms

The commonest symptom of reflux is a feeling of burning and/or pressure in the chest spreading upwards toward the throat, or at the lower tip of the breastbone area, called heartburn. Regurgitation or “burping-up” of sour stomach contents may occur due to the loose sphincter valve. Indeed, strong pressure feelings from reflux can’t be easily told apart from angina so sometimes heart evaluation must be done to distinguish one cause from the other.

Other symptoms may include a sense of food backup (regurgitation), excessive belching if it accompanies other reflux symptoms; rarely nausea; and a sense of difficult swallowing called “dysphagia”, where food hesitates or stops on the way. Persistent cough, sore throat occur sometimes. Hoarseness is RARELY related to GERD.

Screenings & Diagnostic Tests

A detailed history—discussing the details of your symptoms, habits and past treatments-- helps us diagnose whether reflux is present, if reflux is GERD or just minor heartburn, and decide if it is more probable that complications of GERD are present.

We may recommend that you have an endoscopic examination to assess for complications, contributing causes of reflux, and to guide treatment. During endoscopy, usually done with intravenous sedation for comfort, we can see the esophagus, stomach and duodenum up close, take photos and tissue samples, watch the peristaltic contractions to see if they function, look at the LES and for hiatal hernia.

Note that typical cases of GERD can be diagnosed and treated without endoscopy, & that there is no “routine” need to do endoscopy. If endoscopy is done, it is often just the once, and then long-term treatment can be carried out without new exams. At times we will do a barium Xray test where dye is swallowed to get pictures of esophagus and UGI tract; sometimes we will use naso-esophageal probes to examine the level of acid in the esophagus over 24 hours or measure the peristalsis and LES functions & a test to see if fluid backing up correlates with symptoms (pain, cough, heartburn) that a person experiences.

Treatment

Once reflux is diagnosed, an anti-reflux program can be started. Some patients have to maintain a strict program to relieve symptoms, while others with less severe symptoms, may not have to alter their usual routine very much. Treatment of esophageal reflux consists of two major components, lifestyle changes and medication.

Diet & Lifestyle

  • Don’t smoke! If you can’t stop completely, cut down. Cigarettes (and other types of tobacco products) cause lower LES pressure and increased acid secretion that can aggravate reflux and contribute to ulcer formation. In addition, it has been proven that patients who use tobacco products have a more difficult time healing complications.
  • Avoid large meals. Try to eat smaller, more frequent meals. Also, avoid eating fast.
  • Don’t lie down immediately after eating. Wait at least 3 hours after meals before going to bed or activities like exercise, bending that raise pressure on the stomach and may force acid back into the esophagus.
  • Elevate the head of your bed. Elevating the head of your bed four inches or more (depending on your doctor’s recommendation) will help keep acid and stomach contents in your stomach instead of backing up into your esophagus. This is mainly useful for people with night-time reflux symptoms and chronic cough from reflux. A wedge of foam (usually 4 inches) from a mattress supply store, or wooden/brick blocks or books under the upper feet of the bed raising it 4 inches, are often used for this purpose.
  • Avoid excess weight. If you are overweight, try to shed pounds—EVEN 8-10 POUNDS can cause major improvement in reflux symptoms. Being overweight contributes to the problem.
  • Don’t bend or stoop forward after eating. This may force stomach contents upward.
  • Avoid tight, restrictive clothing. Do not wear anything that fits tightly around your waist or stomach. Loose comfortable clothing will help minimize your reflux problem.
  • Avoid some foods. Some foods will aggravate reflux. Try to avoid the following:
  • Alcohol in excess, more so beer than others; excess coffee, greasy/high fat content foods. Normal herbs and spices don’t usually create reflux though raw onion, garlic may aggravate.

Medications

If you have GERD symptoms or damage, the goal is to help you feel better but also to reverse and prevent damage even when symptoms aren’t active. Diet and lifestyle are important, no matter how well drugs may seem to help. There are three main types of medications that neutralize or prevent acid; and a few other types of medications sometimes used.

 

  • Acid neutralizers: Antacids, such as Tums, Digel and Gaviscon, are usually the first drugs recommended to relieve sporadic heartburn and other mild GERD symptoms; or to treat breakthrough symptoms which can occur despite taking acid blocker medications. They work almost immediately since they don’t need to be absorbed to work! Many brands on the market use different combinations of three basic salts--magnesium, calcium, and aluminum--with hydroxide or bicarbonate ions to neutralize the acid in your stomach. Antacids, however, have side effects. Magnesium salt can lead to diarrhea, and aluminum salts can cause constipation. Aluminum and magnesium salts are often combined in a single product to balance these effects. Calcium carbonate antacids, such as Tums, Titralac, and Alka-2, can also be a supplemental source of calcium. They seldom can cause constipation. Foaming antacid agents, such as Gaviscon, work by covering your stomach contents with foam to prevent reflux.
  • H2 blockers, such as cimetidine (Tagamet HB), famotidine (Pepcid AC) and ranitidine (Zantac 75), reduce acid production by the stomach. They are available in prescription strength and over the counter; generics are reliable. These drugs provide short-term relief, but over-the-counter H2 blockers should not be used for more than a few weeks at a time if symptoms are not well controlled. They are effective for about half of those who have GERD symptoms. They are commonly used at dinnertime to prevent evening reflux symptoms, nighttime to prevent waking, or twice a day. Some products are combined in one pill with an antacid (e.g. Pepcid Complete).
  • Proton pump inhibitors (PPI’s) include omeprazole (Prilosec, Zegerid), lansoprazole (Prevacid), pantoprazole (Protonix), rabeprazole (Aciphex), esomeprazole (Nexium) and eslansoprazole (Dexilant), which are all available by prescription, and most now in lower strength OTC as generics. PPI’s are much stronger at blocking acid production than H2 blockers and one dose typically lasts 24 hours in the effect, so can relieve symptoms and heal damage in almost everyone who has GERD. Most all patients find that ANY ONE of these drugs is equivalent in benefit to all the others, but there can be major cost differences, depending on insurance coverage; and this changes a lot!! PPI’s are best taken within the 30 minutes before the FIRST meal or may be less effective!

Surgical Options

Though we don’t recommend it often, there are some people who are better off with surgical treatment of their GERD. This is primarily when heartburn can be controlled but where intermittent regurgitation remains troublesome; or if for some reason an individual objects strongly to longterm use of medications but is willing to have an operation. Operations do two things: pulls the hiatal hernia part of the stomach back down into the abdomen, and wraps the upper end of the stomach around the lower end of the esophagus. Both aspects help create a better-functioning lower sphincter zone, so that reflux diminishes greatly.

Presently, the procedures are mostly done by laparoscopy, using a scope from within the abdomen via a small incision, to avoid large incisions in abdomen or chest. Relatively few surgeons are both well-trained to do this and do it often enough to be very skilled with it. These are mostly called Nissen Fundoplication or “wrap” operations. While newer technology may discover a method through an endoscope, which is effective, without an abdominal operation, at present only one such method appears effective and is fairly new as of 2015.

An operation to constrict the loose valve with magnetic beads (“LINX”) appears promising also. How good is surgery? In good hands, results 5 to 10 years later are comparable to the results of medication and diet—not better, not worse. About 1/3-2/3 of patients have to go back to some degree of regular medication! Side effects—swallowing problems, gas bloat—occur in a small percent but can be troublesome. Risks of death and serious complications are small.

Treatment Outlook for GERD

Science is looking for more answers and treatment options for GERD. Scientists are looking for medications that make the lower esophageal sphincter to tighten to prevent acid reflux into the esophagus. Fortunately, available medications when needed are extremely safe for longterm use and your clinician can guide you as far as what is best for your situation.

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