Gastroesophageal Reflux Disease
Reflux disease affects almost 60 million Americans each month, with one quarter of the population experiencing symptoms of this disease weekly. Often referred to as acid reflux, heartburn, indigestion, or dyspepsia, gastroesophageal reflux disease (GERD) ranges in severity from a mild inconvenience for millions of people to a severe and debilitating condition for chronic sufferers. In normal individuals, a ring of muscle called the lower esophageal sphincter (LES) forms a one-way valve between the esophagus and the stomach, preventing stomach contents from flowing back into the esophagus. Failure of the LES allows corrosive liquid from the stomach to leak back into esophagus, which has no protection against it. The backward movement of stomach contents is called reflux. Over time, the acid and digestive juices in the stomach contents cause irritation and damage to the esophagus wall and are responsible for the familiar burning pain that most people experience as heartburn. For most people, periodic heartburn is little more than an inconvenience and they are able to control it with lifestyle changes or over-the-counter medications. However, chronic gastroesophageal reflux disease is a serious condition in which prolonged exposure of the esophagus to stomach acids causes debilitating symptoms and may lead to conditions such as ulceration, strictures, esophagitis, Barrett’s esophagus, and in rare cases, cancer.
Causes of Reflux Disease
There are several factors that can combine to increase the likelihood that you will suffer from acid reflux or that will increase the severity of your symptoms: Increased stomach pressure: This may be overeating or from conditions that alter stomach contractions and emptying. Acidic Foods: Some foods increase the acidity or the amount of acid produced by the stomach. These foods include alcohol, acidic juices, tomato products, peppermints, chocolate, and soda. Medications: Certain medications can affect stomach acid production and gastric motility or can interfere with the normal opening and closing of the LES. Smoking: Makes reflux worse and causes peptic ulcers, esophagitis, and gastritis. Hiatal Hernia: A hiatal or diaphragmatic hernia often accompanies gastroesophageal disease. The region of the muscular diaphragm through which the esophagus passes may enlarge and allow part of the stomach to move up through it. This alters the pressure at the end of the esophagus and allows reflux to occur. Obesity: Stomach pressure increases with abdominal girth. As stomach pressure increases, it becomes more difficult for the LES to prevent reflux. Nerve and Muscle abnormalities: Opening and closing of the LES relies on normal muscular function and nerve conduction.
Acidic stomach contents leaking through the one-way valve at the top of the stomach into the esophagus is called reflux. Gastroesophageal reflux disease (GERD) is a chronic form of reflux affecting millions of people in the United States. Frequent reflux of acid and digestive juices from the stomach causes a variety of symptoms, and long-term exposure to this corrosive liquid can cause serious damage to tissue and structures in the esophagus, throat, mouth, and even lungs. The most common symptom of GERD is pain in the chest often referred to as heartburn or acid indigestion. This pain, which is located behind the sternum or breastbone, usually comes on after eating and is made worse by bending over or lying down.
Common Symptoms of Acid Reflux
- Sour taste
- Difficulty swallowing
- Intolerance of certain foods
- Pain or discomfort in the chest
- Hoarseness, especially in the morning
- Sore throat or feeling the need to clear the throat
- Sleep disruption (unable to sleep lying down)
- Regurgitation of food
- Gum inflammation
- Tooth enamel erosion
- Waterbrash (an excess of saliva)
- Vomiting blood
- Nausea and vomiting
- Asthma or asthma-like symptoms
- Bad breath
- Persistent cough
In most cases, diagnosis of gastroesophageal reflux disease can be made following a medical examination and a review of symptoms. When symptoms are not typical, or conservative treatment has been unsuccessful, additional testing is required to identify the underlying cause of acid reflux disease.
The most frequently used diagnostic tests for GERD are:
An esophagogastroduodenoscopy or upper endoscopy allows Dr. Ihde to examine the esophagus and stomach using a long flexible tube housing a tiny camera. This outpatient procedure does not require incisions or anesthesia, and most people tolerate it well. After you receive medication to help you relax, the endoscope is passed into the esophagus, stomach, and first part of the small intestines. The camera in the endoscope transmits an image to a video screen so that Dr. Ihde can see areas that may be damaged by reflux disease. Evidence of vocal cord irritation, inflammation and scarring of the esophagus, hiatal hernia, gastritis, gastric ulcers, polyps, duodenal ulcers, and duodenitis can be evaluated with the endoscope.
The strength of an acid is measured by its pH. During a pH study, a thin catheter is passed through the nose and down into the esophagus. Over a 24-hour period, the patient goes about his or her normal activities, while keeping a log of meals and any reflux symptoms. The catheter measures the pH or acidity of any liquid in the esophagus and can detect when acid refluxes into the esophagus, helping to determine the severity of the reflux.
Manometry is used to measure the effectiveness of the lower esophageal sphincter (LES) at preventing reflux. A manometer measures pressure at various points in the esophagus and stomach. The results of this test help identify muscular abnormalities and nerve conduction problems that interfere with normal LES function. Manometry can identify when laparoscopic fundoplication or Transesophageal Incisionless Fundoplication are viable treatment options for GERD and which type of procedure is the best option.
The treatment options for gastroesophageal reflux disease (GERD) fall into three broad categories: conservative, medications, and surgical.
- Conservative methods include changing lifestyle and eating behaviors that contribute to acid reflux.
- Medication therapy uses both over-the-counter and prescription medications to reduce the production of acid in the stomach, protect the esophagus from acid damage, and help keep pressure at the esophageal junction low.
- Surgical intervention is necessary when other methods of controlling GERD fail
Conservative and medication-based therapies help to reduce the severity and frequency of your GERD symptoms, but they do not correct the underlying anatomical issues that cause most GERD. The disease is progressive and surgery has proven to be the most effective long-term solution available. Using advanced, minimally invasive surgery and the newer incisionless procedures such as EsophyX TIF, Dr. Ihde can correct the underlying cause of GERD and dramatically reduce or eliminate symptoms, allowing you to return to a normal lifestyle.
Conservative therapy for Acid Reflux
In almost all cases, lifestyle and diet change are the first steps in reducing the frequency and severity of heartburn and GERD-related symptoms. These changes focus on food choices, modifying intake, and taking steps to reduce pressure within the stomach.
Taking the first steps to control GERD
- Control alcohol and tobacco use: Apart from the irritant effect of alcohol and tobacco on the esophagus, both act on the lower esophageal sphincter (LES) to reduce its ability to stay closed.
- Reduce trigger foods: Foods that stimulate acid production or relax the LES are called “trigger foods.” Eliminating these foods from your diet can alleviate many symptoms of GERD.
- Adjust medications: Prescription and non-prescription medications change acidity, LES pressure, and stomach emptying. Review medications with your doctor to ensure they are not making your GERD worse.
- Get active: Activity helps gastric emptying and assists with weight control. Reducing your weight by as little as 10 pounds can have a dramatic effect on stomach pressure and prevent reflux through the LES.
- Stay upright: Reclining increases the pressure of stomach contents on the LES and promotes reflux, especially when your stomach is full. Staying upright for a minimum of 2 hours after eating can reduce symptoms.
- Adjust sleeping position: Raising the head of your bed about 6 inches using blocks under the front legs can decrease pressure on the LES while you sleep, reducing nighttime heartburn.
- Loosen clothing: Tight-fitting clothes such as pants, belts, and back support belts increase abdominal pressure and make it more difficult for the LES to do its job. In many cases, weight gain is responsible for tight-fitting clothing, so weight loss can help tremendously.
Medications for reflux
Both over-the-counter and prescription medication have been the mainstay of GERD treatment for many years. Medications are designed to reduce symptoms by reducing stomach pressure, decreasing stomach acid production, and protecting the esophagus from acid damage. Because GERD is a progressive disease, however, medication doses will adjust upward as a reflux disease worsens.
Types of medications for Acid Reflux
Antacids: Reducing stomach acidity with over-the-counter antacids is the most frequent remedy for infrequent and mild heartburn. H2 Blockers: Histamine turns on acid production at a cellular level in the stomach. Histamine blockers are frequently used to stop acid production as part of stomach ulcer treatment. Reducing stomach acid production also reduces the severity of acid reflux symptoms. Proton Pump Inhibitors (PPIs): More powerful than H2 blockers, PPIs reduce acid production in the stomach by up to 80%. They have quickly become the most important class of drugs used in GERD treatment and are usually part of a lifelong drug therapy regimen to control chronic acid reflux. Coating Agents: These types of prescription drugs protect damaged tissue in the stomach and esophagus from exposure to acid, reduce pain, and allow damaged tissues to heal. Motility-promoting drugs: Improving the rate at which stomach contents empty into the intestines with motility drugs can reduce stomach pressure and prevent reflux through the LES.
Surgical Treatment for Reflux Disease
Minimally invasive surgery and natural orifice or incisionless procedures have increased the popularity of surgery as a long-term solution for chronic GERD. Surgical intervention focuses on strengthening the lower esophageal sphincter, correcting hiatal hernias, and in some cases, helping obese patients reduce their weight. Surgical repair of the LES is considered when:
- Conservative and medication-based therapies are ineffective at controlling GERD symptoms
- Complications are developing from GERD, despite medication treatment
- Atypical symptoms such as asthma, sinus problems and chronic cough are uncontrolled
- GERD medication side effects are not tolerated by the patient
- Lifelong therapy with medications is cost prohibitive or too disruptive to the patient’s lifestyle