Gastro-esophageal reflux disease (GERD) is a digestive disorder that affects the lower esophageal sphincter (LES)- the muscle connecting the esophagus with the stomach. Many people, including pregnant women, suffer from heartburn or acid indigestion caused by GERD. Doctors believe that some people suffer from GERD due to a condition called hiatal hernia. In most cases, heartburn can be relieved through diet and lifestyle changes; however, some people may require medication or surgery.

"Gastroesophageal" refers to the stomach and esophagus. Reflux means to flow back or return. Therefore, gastro-esophageal reflux is the return of the stomach's contents back into the esophagus.

In normal digestion, the LES opens to allow food to pass into the stomach and closes to prevent food and acidic stomach juices from flowing back into the esophagus. Gastro-esophageal reflux occurs when the LES is weak or relaxes inappropriately allowing the stomach's contents to flow up into the esophagus.

The severity of GERD depends on LES dysfunction as well as the type and amount of fluid brought up from the stomach and the neutralizing effect of saliva.

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What is the role of hiatal hernia?

Some doctors believe a hiatal hernia may weaken the LES and cause reflux. Hiatal hernia occurs when the upper part of the stomach moves up into the chest through a small opening in the diaphragm (diaphragmatic hiatus). The diaphragm is the muscle separating the stomach from the chest. Recent studies show that the opening in the diaphragm acts as an additional sphincter around the lower end of the esophagus. Studies also show that hiatal hernia results in retention of acid and other contents above the opening. These substances can reflux easily into the esophagus.

Coughing, vomiting, straining, or sudden physical exertion can cause increased pressure in the abdomen resulting in hiatal hernia. Obesity and pregnancy also contribute to this condition.

Many otherwise healthy people age 50 and over have a small hiatal hernia. Although considered a condition of middle age, hiatal hernias affect people of all ages.

Hiatal hernias usually do not require treatment. However, treatment may be necessary if the hernia is in danger of becoming strangulated (twisted in a way that cuts off blood supply, i.e., paraesophageal hernia) or is complicated by severe GERD or esophagitis (inflammation of the esophagus). The doctor may perform surgery to reduce the size of the hernia or to prevent strangulation.

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What does heartburn feel like?

Heartburn, also called acid indigestion, is the most common symptom of GERD and usually feels like a burning chest pain beginning behind the breastbone and moving upward to the neck and throat. Many people say it feels like food is coming back into the mouth leaving an acid or bitter taste.

Heartburn pain can be mistaken for the pain associated with heart disease or a heart attack, but there are differences. Exercise may aggravate pain resulting from heart disease, and rest may relieve the pain. Heartburn pain is less likely to be associated with physical activity.

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How common is reflux?

It has been estimated that about 1/3 of the North American population has GERD, and about 10% will experience the symptoms (mainly heartburn and regurgitation) on a daily basis. Twenty-five percent of pregnant women experience daily heartburn, and more than 50% have occasional distress. Recent studies show that GERD in infants and children is more common than previously recognized and may produce recurrent vomiting, coughing and other respiratory problems, or failure to thrive.

Adults with GERD may also experience symptoms other than acid-reflux, including persistent cough, dysphagia (difficulty swallowing), and hoaseness.

Factors contributing to GERD

Dietary and lifestyle choices may contribute to GERD. Certain foods and beverages, including chocolate, peppermint, fried or fatty foods, coffee, or alcoholic beverages, may weaken the LES causing reflux and heartburn. Studies show that cigarette smoking relaxes the LES. Obesity and pregnancy can also cause GERD.

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Treatment for GERD

Lifestyle changes
Doctors recommend lifestyle and dietary changes for most people with GERD. Treatment aims at decreasing the amount of relfux or reducing damage to the lining of the esophagus from refluxed materials.

Avoiding foods and beverages that can weaken the LES is recommended. These foods include chocolate, peppermint, fatty foods, coffee and alcoholic beverages. Foods and beverages that can irritate a damaged esophageal lining, such as citrus fruits and juices, tomato products, and pepper, should also be avoided.

Decreasing the size of portions at mealtime may also help control symptoms. Eating meals at least 2 to 3 hours before bedtime may lessen reflux by allowing the acid in the stomach to decrease and the stomach to empty partially. In addition, being overweight often worsens symptoms. Many overweight people find relief when they lose weight.

Cigarette smoking weakens the LES. Therefore, stopping smoking is important to reduce GERD symptoms.

Elevating the head of the bed on 6-inch blocks or sleeping on a specially designed wedge reduces heartburn by allowing gravity to minimize reflux of stomach contents into the esophagus.


Medications
Antacids taken regularly can neutralize acid in the esophagus and stomach and stop heartburn. Many people find that nonprescription antacids provide temporary or partial relief. An antacid combined with a foaming agent such as alginic acid helps some people. These compounds are believed to form a foam barrier on top of the stomach that prevents acid reflux from occurring.

Long-term use of antacids, however, can result in side-effects, icluding diarrhea, altered calcium metabolism (a change in the way the body breaks down and uses calcium), and buildup of magnesium in the body. Too much magnesium can be serious for patients with kidney disease. If antacids are needed for more than 3 weeks, a doctor should be consulted.

For chronic reflux and heartburn, the doctor may prescribe medications to reduce acid in the stomach. These medicines include H2 blockers, which inhibit acid secretion in the stomach. Currently, four H2 blockers are available: cimetidine, famotidine, nizatidine, and ranitidine. Another type of drug, the proton pump (or acid pump) inhibitors omeprazole (Prilosec, Losec, Antra), and lansoprazole (Prevacid) and pantoprazole (Pantaloc) inhibit an enzyme (a protein in the acid-producing cells of the stomach) necessary for acid secretion. Proton Pump Inhibitors (PPI's) have been shown to be highly effective in the treatment of heartburn, and safe for long-term use. Initially, your physician may have to adjust your dose to control your symptoms, but once your optimal dose has been established it can likely remain steady over many years. Those taking PPI medication usually experience relief of symptoms quickly, often within 1-2 weeks.

Other approaches to therapy will increase the strength of the LES and quicken emptying of stomach contents with motility drugs that act on the upper gastrointestinal (GI) tract. These drugs include cisapride, bethanechol, and metoclopramide.

Surgery
When ulcers have resulted in complications and pharmaceutical treatments have been ineffective surgery can be an option. A vagotomy involves cutting the vagus nerve, which is the nerve that transmits messages from the brain to the stomach. Interrupting the messages sent through the vagus nerve reduces acid secretion. This surgery may also interfere with the stomach emptying. The newest variation of the surgery involves cutting only those parts of the nerve that control the acid-secreting cells of the stomach, and avoiding those that control stomach emptying. An antrectomy involves removing the lower part of the stomach (antrum) which produces a hormone that stimulates the stomach to secrete digestive juices, and sometimes an adjacent part of the stomach which secretes pepsin and acid. This procedure is usually done in conjunction with a vagotomy. Pyloroplasty is also sometimes done along with a vagotomy and involves enlarging the (pylorus) opening into the duodenum and small intestine enabling contents to pass more freely from the stomach.

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Diagnostic tests for GERD

An upper GI series may be performed during the early phase of testing. This test is a special x-ray that shows the esophagus, stomach, and duodenum (the upper part of the small intestine). While an upper GI series provides limited information about possible reflux, it is used to rule out other diagnoses, such as peptic ulcers.

Endoscopy is an important procedure for individuals with chronic GERD. By placing a small lighted tube with a tiny video camera on the end (endoscope) into the esophagus, the doctor may see inflammation or irritation of the tissue lining the esophagus (esophagitis). If the findings of the endoscopy are abnormal or questionable, biopsy (removing a small sample of tissue) from the lining of the esophagus may be helpful.

The Bernstein test (dripping mild acid through a tube placed in the mid-esophagus) is often performed as part of a complete evaluation. This test attempts to confirm that symptoms result from acid in the esophagus. Esophageal manometric studies- pressure measurements of the esophagus- occasionally help identify critically low pressure in the LES or abnormalities in esophageal muscle contraction.

For patients in whom diagnosis is difficult, doctors measure the acid levels inside the esophagus through pH testing. Testing pH monitors the acidity level of the esophagus and is used to assess the episodes of reflux and type of activity associated with the symptoms.

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Long-term complications of GERD

Sometimes GERD results in serious complications. Esophagitis can occur as a result of too much stomach acid in the esophagus. Esophagitis may cause esophageal bleeding or ulcers. In addition, a narrowing or stricture of the esophagus may occur from chronic scarring. Some people develop a condition known as Barrett's esophagus, which is severe damage to the skin-like lining of the esophagus. Doctors believe this condition may be a precursor to esophageal cancer.

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