Gastroesophageal Reflux Disease

Symptoms

View Slide ShowAfter food passes from the mouth, it enters the esophagus, which is the tube that carries it to the stomach. In the stomach, digestion begins when the food is mixed with gastric acid.

After softening into a liquid in the stomach, it is then passed on into the small intestine for digestion. The stomach has specially designed cells lining it to protect it from the effects of the gastric acid. In the small intestines, gastric acid is neutralized with a base solution produced in the pancreas. The esophagus, however, has no such protective devices. The lower esophageal sphincter is a muscular valve designed to keep gastric acid from washing up into the esophagus. When this is not functioning properly, acid passes into the esophagus.

Symptoms of gastroesophageal reflux disease are commonly described as "heartburn", which is a burning type pain below the breast bone. While this has nothing to do with the heart or cardiovascular system, the heart is in a similar location, so it has falsely been named heartburn.

Indigestion is another term given for the symptoms produced by gastric secretions washing up into the esophagus, especially when they reach the back of the throat causing irritation, and the need to swallow the secretions back down into the stomach. Acid produces a bitter taste when it reaches the mouth, which can also be a symptom of GERD. Having acid in the back of the throat near the windpipe can also cause upper airway infections and hoarseness when damage is caused to the voice box (larynx) or windpipe (trachea). If acid is allowed to damage the esophagus for a long period of time, it can cause poor functioning of the muscular contractions of the esophagus, scarring, or narrowing, producing difficulty swallowing.

Causes

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There are a number of different causes for Gastroesophageal Reflux Disease. Abnormal esophageal movement or motility will prevent the esophagus from clearing itself of food and gastric secretions. Over production of gastric acid in the stomach can produce an overflow of gastric acid washing up into the esophagus. Dysfunction of the muscular contractions of the stomach producing poor gastric emptying can also produce the build up of gastric secretions in the stomach, which overflows into the esophagus. A weak or poorly functioning lower esophageal sphincter (valve) will not accomplish its normal function of closing the lower esophagus preventing gastric acid from emptying. This also results in acid leaking up into the esophagus.

An incompetent lower esophageal sphincter is the most common cause of reflux symptoms.

Hiatal Hernias occur when the stomach bulges up through the diaphragm into the chest. While this alone does not necessarily cause gastroesophageal reflux symptoms, it will often lead to incompetency of the lower esophageal sphincter, and thus is associated with reflux.

Complications

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Microaspiration occurs when small amounts of gastric fluid trickle from the esophagus into the windpipe (trachea). This can happen slowly and insidiously, and even be unsuspected. Gastric acid inside the airways then leads to bronchitis and pneumonia in some patients. After repeated injury and scarring, the flexibility of the esophagus becomes limited or scar tissue builds up to produce a blockage, which results in stricture of the esophagus. This prevents the normal passage of food and can lead to difficulty swallowing.

Barrett's Esophagus is a pre-cancerous abnormality of the cells of the lower esophagus that occurs from constant irritation and injury from gastric acid. In cases of prolonged reflux, this can then lead to esophageal cancer.

Diagnosis

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The diagnosis of Gastroesophageal Reflux Disease is based on the history of symptoms characteristic for reflux as described previously. Physical examination may show redness orirritation of the throat (pharynx) or voice box (larynx). Esophageal Manometry testing is performed to measure the muscular contractions of the esophagus to see if they are normal. The most definitive test is a 24-hour pH probe test, which measures the pH (acidity) of the secretions in the lower esophagus over a 24-hour period while the patient records their symptoms. A correlation is then made between the symptoms and the presence of acid in the esophagus. Endoscopy is frequently used to visualize the lining of the esophagus to identify damage caused by exposure to acid such as inflammation of the esophagus (esophagitis) or narrowing of the esophagus (stricture).

Treatment

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The initial treatment for Gastroesophageal Reflux Disease is lifestyle changes. Avoiding foods such as caffeine and alcohol can be useful at decreasing reflux. Since most of the damage to the esophagus occurs while lying flat at night while sleeping, elevating the head of the bed can help use gravity to keep gastric secretions in the stomach. Losing weight can decrease intra-abdominal pressure, and help prevent reflux.

Medical therapy has been shown to be very effective, and includes antacid medications, such as Tums or Maalox, which neutralize some of the acid produced by the stomach.

Histamine blocking medications such as Axid, Pepcid, Zantac, and Tagamet, help reduce the amount of acid produced by the stomach. These medications are available over the counter at pharmacies or in prescription strength doses from your physician.

Hydrogen pump blocking medications such as Prilosec or Prevacid inhibit nearly all of the acid production by the stomach, and are useful especially in patients who have developed esophageal ulceration.

Other medications such as Propulsid or Reglan help stimulate the contractions of the stomach, and therefore, help gastric secretions to be emptied into the small intestines so they do not wash up into the esophagus.

Surgical Treatment

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For patients who do not improve on medical therapy, or who require medication long term, surgical therapy has been shown to be very effective at relieving symptoms. In the past, the surgery required large incisions and long hospital stays, and patients were generally discouraged from undergoing surgery.

However, new, less invasive, surgical techniques recently have been perfected that allow the surgical treatment of gastroesophageal reflux disease using only small punctures rather than a standard surgical incision. Hospitalization following the new procedure is short, generally one or two days.

The procedure performed is called a Laparoscopic Fundoplication. The most common types of this operation are the Nissen or Toupet variations. Both are designed to change the angle of the lower esophagus to help restore the function of the lower esophageal sphincter.

The surgery has been well tested, and shown to have low complication rates. It also has been shown to be very effective at relieving the gastroesophageal reflux symptoms.

Summary

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  1. Gastroesophageal reflux disease is a serious disease requiring treatment.
  2. When lifestyle changes and medical therapy fail, or if long term medication is required, surgical therapy is recommended.
  3. Laparoscopic treatment of gastroesophageal reflux disease is safe and effective at relieving reflux.