GASTRO-ESOPHAGEAL REFLUX DISEASE (GERD) Causes symptoms risk factors treatment management and complications

GASTRO-ESOPHAGEAL REFLUX DISEASE (GERD)

WHAT IS GASTROESOPHAGEAL REFLUX DISEASE (GERD)?

Gastro-esophageal reflux disease develops when stomach and duodenal (first part of the esophagus) contents and acid irritates the lining of the food pipe (esophagus) for a prolonged period of time. Stomach contents backflow from time to time and residual acid is neutralized by saliva but if it occurs for a prolonged period of time it produces symptoms and causes irritation and inflammation of the food pipe (esophagitis).

CAUSES OF GASTROESOPHAGEAL REFLUX DISEASE (GERD)

Gastro-esophageal reflux disease occurs when stomach acidic or non-acidic contents backflow and irritate the lining of the food pipe (esophagus). There is a band of muscles at the lower the bottom of food pipe (lower esophageal sphincter) which relaxes and allows food to enter the stomach. It is tonically contracted normally and relaxes only when food passes through it. If the tone of these muscles (lower esophageal sphincter) is reduced food and there is increased intra-abdominal pressure then acid repeatedly flows into the esophagus and irritates its lining.

RISK FACTORS OF GASTROESOPHAGEAL REFLUX DISEASE (GERD)

The following condition can increase the risk of GERD:

• Increased abdominal pressure – Obesity, pregnancy
• Delayed or Defective Gastric Emptying
• Delayed Esophageal Clearance -                
• Dietary and Environment factors - Fatty and Fried food, alcohol, tea and coffee, Smoking, and Chocolate as these foods have been shown to decrease lower esophageal sphincter tone and increase symptoms of GERD
• Connective Tissue Disorder – Scleroderma
• Eating large meals
• Eating late at night
• Medications – Aspirin

SYMPTOMS AND CLINICAL FEATURES OF GASTROESOPHAGEAL REFLUX DISEASE (GERD)

• Heartburn and backwash (regurgitation) which is usually worst at night, and increased on bending, straining, and lying down.
• Excessive salivation due to stimulation of salivary glands when acid enters the oral cavity.
• Chocking at night time when food and acid backwash during sleeping and irritates the larynx.
• Upper abdominal and chest pain
• The feeling of lump in the throat
• Difficulty in swallowing or painful swallowing
• Atypical symptoms such as chest pain, laryngitis (inflammation of vocal cords), cough, recurrent chest infections, and asthma.

DIAGNOSIS OF GASTROESOPHAGEAL REFLUX DISEASE (GERD)

Investigations are usually not required in young people with typical symptoms of GERD or with without worrying features such as weight loss, anemia, or dysphagia. Investigations are required for patients over the age of 50 or younger persons with atypical symptoms, worrying features, or complications.

• Upper GI Endoscopy – Your food pipe and stomach is visualized with a flexible tube that has a camera and light. It is the investigation of choice. It is done to look for any inflammation, exclude other gastrointestinal diseases and complications, and for taking tissue for biopsy.
• 24-hour pH monitoring also called an Ambulatory acid (pH) probe test – is done when the diagnosis is unclear or surgical intervention is needed. In this procedure, a catheter with a terminal radio-telemetry is tethered above the gastr0-esophageal junction and the pH of the esophagus is recorded for 24 hours and episodes of symptoms are recorded and related to pH. A pH of less than 4 for more than 6-7% of study time is diagnostic of reflux disease.
• X-Ray of Upper Gastro-intestinal Tract with barium swallow – Done in patients to look for narrowing of the esophagus.
• Esophageal Manometry – Done in patients who have trouble swallowing to measure the rhythmic muscle contractions, coordination, and force exerted by the muscles of the esophagus
• Transnasal Esophagoscopy – To look for any defect in the lining of the esophagus through a tube and camera.

MANAGEMENT AND TREATMENT OF GASTRO-ESOPHAGEAL REFLUX DISEASE (GERD)

MANAGEMENT

You can manage your GERD symptoms and sometimes simple management is the only intervention you need. You can treat your GERD by following the given below steps

• Modify lifestyle – weight loss, avoidance of dietary items that worsen your symptoms, reduce the consumption of coffee, tea, alcohol, fatty and spicy foods especially avoid these items at bedtime.
• Elevate your bed at the head-side especially if you have increased symptoms at night.
• Cessation of smoking
• Avoid large meals or meals at night

TREATMENT

If your symptoms do not improve with these above measures your doctor will put you on

• Antacids that neutralize stomach acid – these provide quick relief but do not heal an inflamed esophagus
• Medications that reduce the production of acid in the stomach – such as Histamine H-2 Blockers
• Medications that block the production of acid in the stomach and heal damaged esophagus – include PROTON PUMP INHIBITORS (PPIs)

Prolonged therapy with PROTON PUMP INHIBITORS (PPIs) is associated with reduced absorption of Iron, Vit. B12 and Magnesium. These are also some risks of osteoporosis and fractures. There is also an increased risk of gut infection.

SURGICAL PROCEDURES 

These are performed on patients who do not respond to medications or do not want to take long-term medications and those who have increased symptoms and severe regurgitation

• Laparoscopic Anti-Reflux Surgery 
• Fundoplication
• LINX Device
• Transoral Incisionless Fundoplication

COMPLICATIONS OF GASTRO-ESOPHAGEAL REFLUX DISEASE (GERD)

• Esophagitis – inflammation of the esophagus, ranging from mild redness to severe ulceration and with stricture formation
• Narrowing of the esophagus due to fibrosis as the result of inflammation - esophageal strictures
• Barrett esophagus - Pre-cancerous changes of the esophagus in which it is replaced by a lining like that of the intestine 
• Anemia – from occult blood loss or subtle erosion from the sac of the hiatus hernia
• Gastric Volvulus – if happens when the hiatal hernia twists upon itself that cause esophageal or stomach obstruction and chest pain, vomiting, and dysphagia (inability to swallow).