Gastroesophageal Reflux Disorder

What is Gastroesophageal Reflux Disorder

You’ve just eaten a big meal and leaned back in your favorite chair. Then it happens. Your chest starts to hurt so much it feels like it’s on fire.

Every day, more than 15 million Americans experience heartburn, which produces a burning sensation behind the breastbone. You may also experience a sour taste and the sensation of food re-entering your mouth (regurgitation). It results from gastroesophageal reflux, a condition in which stomach acid or, occasionally, bile salts back up into your food pipe (esophagus). When there’s also evidence of esophageal irritation or inflammation, you have gastroesophageal reflux disease (GERD).

Normally, the lower esophageal sphincter blocks most acid from coming up into the esophagus. This circular band of muscle at the lower end of the esophagus doesn’t open except when you swallow. If the sphincter relaxes abnormally or weakens, stomach acid can back up and cause heartburn.

Most people can manage the discomfort of heartburn with lifestyle modifications, such as improved diet, over-the-counter antacids and weight loss. But if heartburn is severe, these remedies may offer only temporary or partial relief. You may need newer, more potent medications to reduce symptoms.

Signs and symptoms of Gastroesophageal Reflux

If you experience heartburn, you may also experience these signs and symptoms:

• Chest pain, especially at night while lying down
• Difficulty swallowing (dysphagia)
• Coughing, wheezing, asthma, hoarseness or sore throat
• Regurgitated blood
• Stool that’s black, which may mean it contains partially digested blood

When you swallow, the lower esophageal sphincter  a circular band of muscle around the bottom part of your esophagus  relaxes to allow food and liquid to flow down into your stomach. When it relaxes at any other time, stomach acid flows back up into your esophagus, even if you’re in an upright position. The acid backup is worse when you’re bent over or lying down. Some factors that can cause the sphincter to relax abnormally include:

• Fatty foods
• Chocolate, caffeine, onions, spicy foods, mint and some medications
• Alcohol
• Large meals
• Lying down soon after eating
• Tranquilizers, such as benzodiazepines including diazepam (Valium) and alprazolam (Xanax)
• Theophylline (Elixophyllin), an asthma medication

Risk factors of Gastroesophageal Reflux

Conditions that cause difficulty with digestion can increase the risk of heartburn. These include:

• Obesity. Excess weight puts extra pressure on your stomach and diaphragm, the large muscle that separates your chest and abdomen, forcing open the lower esophageal sphincter and allowing stomach acids to back up into your esophagus. Eating very large meals or meals high in fat may cause similar effects.
• Hiatal hernia. In this condition, also called diaphragmatic hernia, part of your stomach protrudes into your lower chest. If the protrusion is large, a hiatal hernia can worsen heartburn by further weakening the lower esophageal sphincter muscle.
• Pregnancy. Pregnancy results in greater pressure on the stomach and a higher production of the hormone progesterone. This hormone relaxes many of your muscles, including the lower esophageal sphincter.
• Asthma. Doctors aren’t certain of the exact relationship between asthma and heartburn. It may be that coughing and difficulty exhaling lead to pressure changes in your chest and abdomen, triggering regurgitation of stomach acid into your esophagus. Some asthma medications that widen (dilate) airways may also relax the lower esophageal sphincter and allow reflux. Or it’s possible that the acid reflux that causes heartburn may worsen asthma symptoms. For example, you may inhale small amounts of the digestive juices from your esophagus and pharynx, damaging lung airways.
• Diabetes. One of the many complications of diabetes is gastroparesis, an uncommon disorder in which your stomach takes too long to empty. Left in your stomach too long, stomach contents can regurgitate into your esophagus and cause heartburn.
• Peptic ulcer. An open sore or scar near the valve (pylorus) in the stomach that controls the flow of food into the small intestine can keep this valve from working properly or can obstruct the release of food. Food doesn’t empty from your stomach as fast as it should, causing stomach acid to build up and back up into your esophagus.
• Delayed stomach emptying. In addition to diabetes or an ulcer, abnormal nerve or muscle functions can delay emptying of your stomach, causing acid backup into the esophagus.
• Connective tissue disorders. Diseases such as scleroderma that cause muscular tissue to thicken and swell can keep digestive muscles from relaxing and contracting as they should, allowing acid reflux.
• Zollinger-Ellison syndrome. One of the complications of this rare disorder is that your stomach produces extremely high amounts of acid, increasing the risk of acid reflux.

Screening and diagnosing Gastroesophageal Reflux

Usually a description of your symptoms will be all your doctor needs to establish the diagnosis of heartburn. However, if your symptoms are particularly severe or don’t respond to treatment, you may need to undergo other tests:

• Barium X-ray. This procedure requires you to drink a chalky liquid that coats and fills the hollows of your digestive tract. The coating allows your doctor to get a clear silhouette of the shape and condition of your esophagus, stomach and upper intestine (duodenum). X-rays can then reveal whether a hiatal hernia may be contributing to your heartburn. They can also reveal an esophageal narrowing or stricture, or a growth, which may cause difficulty swallowing.
• Endoscopy. A more direct test for diagnosing the cause of heartburn is esophagogastroduodenoscopy (EGD). In this test your doctor inserts a thin, flexible tube equipped with a light and camera (endoscope) down your throat. The endoscope allows your doctor to see if you have an ulcerated or inflamed esophagus or stomach (esophagitis or gastritis, respectively). It can also reveal a peptic ulcer. During an EGD your doctor can take tissue samples to test for Barrett’s esophagus  a condition in which precancerous changes occur in cells in your esophagus  or esophageal cancer, two potential complications of severe heartburn. Analysis of these samples may also reveal the presence of a bacterium that may cause peptic ulcers.
• Ambulatory acid (pH) probe test. This test measures acid levels in your upper and lower esophagus, and can help determine the frequency and duration of acid reflux. While you’re sitting, a nurse or technician sprays your throat with a numbing medication. Then a thin, flexible tube (catheter) is threaded through your nose into your esophagus. This probe is positioned just above the lower esophageal sphincter. A second probe may be placed in your upper esophagus. Attached to the other end of the catheter is a small computer, which you wear around your waist and which records acid measurements. Once the device is attached, you go about your business and then come back the next day to have the device removed. Knowing the frequency and duration of acid reflux can help your doctor determine how best to treat the condition.

Complications for Gastroesophageal Reflux

In addition to irritation and inflammation of your esophagus (esophagitis), chronic reflux of stomach acid into your esophagus can lead to one or more of the following conditions if left untreated:

• Esophageal narrowing (stricture). Strictures occur in some people with GERD. Damage to cells in the lower esophagus from acid exposure leads to formation of scar tissue. The scar tissue narrows the food pathway, causing large chunks of food to get caught up in the narrowing, and can interfere with swallowing.
• Esophageal ulcer. Stomach acid can severely erode tissues in the esophagus, causing an open sore. The esophageal ulcer may bleed, cause pain and make swallowing difficult.
• Barrett’s esophagus. This is a serious, though uncommon, complication of GERD. In Barrett’s esophagus, the color and composition of the tissue lining the lower esophagus change. Instead of pink, the tissue turns a salmon color. Under a microscope, the tissue resembles that of the small intestine. This cellular change is called metaplasia. Metaplasia is brought on by repeated and long-term exposure to stomach acid and is associated with an increased risk of esophageal cancer.

Treating Gastroesophageal Reflux

Whether you have mild, moderate or severe heartburn, many treatment options are available. The most common treatments involve medications, but surgical and other procedures also are available.

Over-the-counter remedies

If you experience only occasional, mild heartburn, you may get relief from an over-the-counter (OTC) medication. OTC remedies include:

• Antacids. Antacids, such as Maalox, Mylanta, Gelusil, Rolaids and Tums, neutralize stomach acid and can provide quick relief. But antacids alone won’t heal an inflamed esophagus damaged by stomach acid. Overuse of some antacids can cause side effects such as diarrhea or constipation.
• H-2-receptor blockers. H-2-receptor blockers, such as cimetidine (Tagamet HB), famotidine (Pepcid AC), nizatidine (Axid AR) or ranitidine (Zantac 75), are available at half the strength of their prescription versions. Instead of neutralizing the acid, these medications reduce the production of acid. They don’t act as quickly as antacids, but they provide longer relief. Take these medications before a meal that you think may cause heartburn because it takes them about 30 minutes to work. They’re also effective in reducing reflux at night if taken at bedtime. H-2-receptor blockers cause infrequent side effects, including bowel changes, dry mouth, dizziness or drowsiness. In rare instances they can also react dangerously with other medications.
• Proton pump inhibitors. These medications block acid production and allow time for damaged esophageal tissue to heal. Omeprazole (Prilosec) was previously available only by prescription, but now is available in an over-the-counter form for treatment of heartburn.

Prescription-strength medications

If you have frequent and persistent heartburn, you may have GERD, leading to an inflamed esophagus (esophagitis). GERD usually requires prescription-strength medication. Prescription medications can help reduce and eliminate GERD symptoms, as well as help heal an inflamed esophagus the result of continual exposure to stomach acid. The main types of prescription drugs are:

• Prescription-strength H-2-receptor blockers. These significantly reduce acid production and have few side effects. They include prescription-strength Axid, Pepcid, Tagamet and Zantac.
• Prescription-strength proton pump inhibitors. These are long acting and are the most effective medications for suppressing acid production. They’re safe and have few side effects for long-term treatment (at least 10 years). To prevent possible side effects, such as stomach or abdominal pain, diarrhea or headaches, your doctor will likely prescribe the lowest effective dose. Prescription-strength proton pump inhibitors include esomeprazole (Nexium), lansoprazole (Prevacid), omeprazole (Prilosec), pantoprazole (Protonix) and rabeprazole (Aciphex).
• Prokinetic agents. These don’t reduce acid production. Instead, they help your stomach empty more rapidly and may help tighten the valve between the stomach and the esophagus. Because the prokinetic agents thus far sometimes cause serious side effects, researchers are working to develop safer versions.

Surgical and other procedures

Because of the effectiveness of medications, surgery for GERD is uncommon. However, it may be an option if you can’t tolerate the medications, the medications are ineffective, or you can’t afford their long-term use. Your doctor also may recommend surgery if you have any of these complications:

• Large hiatal hernia
• Severe esophagitis, especially with bleeding
• Recurrent narrowing (stricture) of the esophagus
• Barrett’s esophagus, especially with progressive precancerous or cancerous changes
• Severe pulmonary problems, such as bronchitis or pneumonia, due to acid reflux

Before 1991, a procedure called open Nissen fundoplication was the surgery of choice for severe GERD. Today, doctors are able to perform the same surgery with similar success laparoscopically through a few small abdominal incisions, instead of one large one. The advantages of laparoscopic surgery are a shorter recovery time and less discomfort.

Nissen fundoplication involves tightening the lower esophageal sphincter to prevent reflux by wrapping the very top of the stomach around the outside of the lower esophagus. During laparoscopic surgery, a surgeon makes three or four tiny incisions in the abdomen and inserts small instruments, including a flexible tube with a tiny camera, through the incisions. To provide more space for your surgeon to see and work, your abdomen is inflated with carbon dioxide. The surgery takes about 2 hours and typically requires an overnight hospital stay.

More than 90 percent of the people who undergo Nissen fundoplication remain free of GERD symptoms for at least 1 year. At least 60 percent are symptom-free for several years. This success rate applies to both the laparoscopic and open procedures.

Other surgical procedures include Toupet partial fundoplication, Hill repair and the Belsey Mark IV operation. All involve restructuring the lower esophageal sphincter to improve its strength and ability to prevent reflux. These surgeries are done less often, and their success is often dependent on the skill of the surgeon.

Complications from surgery generally are mild, but may include difficulty swallowing, bloating, diarrhea and a sense of feeling full after eating only a moderate amount (early satiety).

Newer, less invasive procedures

Your doctor may suggest one of several procedures for tightening the lower esophageal sphincter. The procedures generally take an hour or less to perform, they don’t require any incisions, and you can go home the same day. The procedures are performed endoscopically through a long, flexible tube that’s inserted into your mouth and threaded through your esophagus. None of the procedures are recommended if you have a hiatal hernia or Barrett’s esophagus.

• EndoCinch endoluminal gastroplication. This procedure uses a tool that’s like a miniature sewing machine. It places pairs of stitches (sutures) in the stomach near the weakened sphincter. The suturing material is then tied together, creating barriers (plications) to prevent stomach acid from washing into your esophagus. The barriers are located at and just below the junction of the esophagus and stomach. The procedure may cause a sore throat or chest pain. The long-term effectiveness of the procedure is still unknown.
• Stretta procedure. This approach uses controlled radiofrequency energy to heat and melt (coagulate) tissues within the portion of the esophagus that contains the malfunctioning valve and at the junction of the esophagus and upper stomach. The procedure appears to work by creating scar tissue and altering the sensory nerves that respond to refluxed acid. The procedure may cause a sore throat or chest pain. The long-term effectiveness of the procedure is still unknown.
• Enteryx. This procedure involves the injection of a compound called ethylene polyvinyl alcohol into the lower esophageal sphincter, just within the stomach. The injection is done with guidance from real-time X-ray. The compound is in liquid form outside the body, but when it comes into contact with the tissues inside the body, it turns into an expanding, spongy material. The procedure may cause a sore throat or chest pain, and the long-term effectiveness of the procedure is still unknown.

Preventing Gastroesophageal Reflux

You may eliminate or reduce the frequency of heartburn by making the following lifestyle changes:

• Control your weight. Being overweight is one of the strongest risk factors for heartburn. Excess pounds put pressure on your abdomen, pushing up your stomach and causing acid to back up into your esophagus.
• Eat smaller, more frequent meals. Three smaller meals a day, with small snacks in between, will help you stop overeating. Continual overeating leads to excess weight, which aggravates heartburn.
• Loosen your belt. Clothes that fit tightly around your waist put pressure on your abdomen and the lower esophageal sphincter.
• Eliminate heartburn triggers. Everyone has specific triggers. Common triggers such as fatty or fried foods, alcohol, chocolate, peppermint, garlic, onion, caffeine and nicotine may make heartburn worse.
• Avoid stooping or bending. Tying your shoes is OK. Bending over for longer periods to weed your garden isn’t, especially soon after eating.
• Don’t lie down after a meal. Wait at least three to four hours after eating before going to bed, and don’t lie down right after eating.
• Raise the head of your bed. An elevation of about 6 inches puts gravity to work for you. You can do this by placing wooden or cement blocks under the feet at the head of your bed. If it’s not possible to elevate your bed, you can insert a wedge between your mattress and box spring to elevate your body from the waist up. Wedges are available at drugstores and medical supply stores. Raising your head only by using pillows is not a good alternative.
• Don’t smoke. Smoking may increase stomach acid. The swallowing of air during smoking may also aggravate belching and acid reflux. In addition, smoking and alcohol increase your risk of esophageal cancer.