Gastroesophageal Reflux Disease or GERD is a chronic condition that occurs when acid or stomach contents move back up into the esophagus. Because of its increasing number of cases over the past few years, GERD is now being described as an epidemic that continues to affect millions all over the world. According to the Journal of Clinical Gastroenterology and Hepatology, global numbers that cover Europe, Asia, South America, and the United States continue to rise annually, with an alarming 46.5% increase in the past three years, 60% of which were women.
Anatomically speaking, several factors that affect the lower esophageal sphincter may cause stomach contents to move back up into the esophagus (as seen in the illustration). Common conditions include lower esophageal sphincter abnormalities, hiatal hernias, abnormal esophageal contractions, and slowed or prolonged emptying time of the stomach.
When it comes to abnormalities, a weakened sphincter can be one of the causes. Factors that can attribute to this include overeating, obesity or being overweight, pregnancy, smoking, and even something as simple as wearing tight clothing that can compress the stomach. According to the Lancet Journal, obesity and smoking are the most closely related factors, while genetics has recently been studied as a contributing factor.
Other aggravating factors of reflux are the different types of food that can increase acid secretion and affect lower esophageal function. Some of them are chocolates, citrus fruits, oily food, caffeinated and carbonated drinks, and alcohol, as well as anti-inflammatory medications.
So how does one know that it’s GERD? The presenting symptoms often indicate the presence of the condition. Common signs and symptoms include heartburn or a burning sensation in the mid-chest area, which can sometimes be described as chest pain or a sensation of something going up the throat. This symptom is often observed after meals and worsens or progresses when lying down. According to the Journal of Digestion, approximately 20 to 40% of those with GERD report heartburn as their main symptom. Other common but not so definitive symptoms of GERD include:
Difficulty in swallowing;
Regurgitation of food or liquid;
Nausea with or without vomiting;
Chronic or persistent cough; and
Voice hoarseness or ear pain.
Aside from the symptoms mentioned above, diagnostic procedures are often recommended to determine the presence of reflux disease. Upper gastrointestinal endoscopy or esophago-gastro-duodenoscopy or EGD is a procedure used to diagnose GERD. The patient is sedated while a small tube containing an optical system for visualization is introduced through the mouth and is made to travel down the gastrointestinal tract, while the walls of the esophagus, stomach, and duodenum are being examined. Inflammation, ulcers, or erosions are visualized during this procedure and biopsy may be performed on suspicious-looking lesions found within the tract.
In the past, an esophagogram or x-ray of the esophagus was usually performed in order to diagnose GERD. Patients were made to swallow a contrast material called barium, after which an x-ray was taken. Sadly, lesions within its walls would only be detected in severe cases, which made it a very poor tool for early diagnosis and treatment.
Acid reflux tests are also performed in order to diagnose GERD. A test known as esophageal pH test is done to determine how much acid is found in the esophagus. In this test, a small tube with a sensor that detects acid is passed through the nose and positioned in the esophagus. The other end of the tube exits through the nose and is attached to a recorder that hangs by the waist. The recorder takes down all episodes of acid reflux into the esophagus within a period of 24 hours. This test is able to not only diagnose but monitor the effectiveness of treatment as well. A newer method of prolonged pH testing of 48 hours makes use of a wireless capsule that acts as a sensor and receiver of information that is transmitted to a computer and analyzed. This capsule is passed out in the stools later on.
Aside from pH testing, motility tests can also be performed to determine how well the muscles of the esophagus are working. These also help identify abnormalities that fall under esophageal motility disorder since almost 20% of those diagnosed with GERD have slow gastric or stomach emptying time. Gastric emptying studies are done by labeling the food with radioactive substance. A sensor is then placed over the stomach to measure how quickly or how slowly the radioactive substance in the food empties from the stomach.
Once a diagnosis is made, treatment should be started immediately in order to avoid complications. Since it is considered a chronic disease, complications are not uncommon. Among others, ulcers are the most frequently reported complication. When the acid from the stomach moves back up into the esophagus, the lining is damaged which leads to inflammation and ulcer formation. When not addressed, this can lead to more severe complications such as esophageal bleeding and stricture formation later on. Strictures usually result from healed ulcers that lead to scar formation and narrowing of the esophageal cavity. This can later cause difficulty in swallowing.
The American Society of Gastrointestinal Endoscopy describes a condition that results from long-standing GERD known as Barrett’s esophagus. Severe GERD usually causes changes in the lining of the esophageal wall that can be pre-malignant and later develop to esophageal cancer.
This condition occurs in approximately 10% of patients with GERD and is advised regular follow up and evaluation through endoscopy to observe any changes or progression to pre-malignant cells.
Because of the irritation brought about by acid reaching all the way up to the other areas of the gastrointestinal tract, inflammation of the throat and larynx are also common and usually reported as a sore throat and voice hoarseness. Since the liquid can pass from the throat into the larynx, and consequentially into the lungs, this can result in coughing and accumulation of fluid in the lungs leading to infection or pneumonia. In cases where there is a severe cough caused by marked irritation of the nerves found in the gastrointestinal tract, asthma can be triggered in those who are at risk for or have a history of it. In a study published in the Journal of Pediatrics, GERD was associated with recurrent pneumonia and chronic asthma in children, with a resolution of symptoms in 92% of the cases studied once effective treatment for reflux was administered. In a similar study released in the CHEST Journal, they discovered that in children with a chronic cough who were unresponsive to treatment, GERD was apparently present. With the treatment of the reflux disease, there was also noted resolution of the cough.
Fortunately, these complications can be prevented through adequate treatment and management. Prior to taking any medication, diet modification is often advised in those with reflux disease. Small and frequent meals are preferred over large meals to help decrease pressure in the stomach that can aggravate reflux. Since reflux is more commonly experienced at bedtime, those with GERD are often advised to keep their body elevated when sleeping.
Medications will almost always alleviate the symptoms of GERD. Commonly prescribed drugs include antacids, proton pump inhibitors, histamine antagonists, and promotility drugs or drugs that encourage faster gastric emptying. Since the type of treatment will depend on the cause of reflux, it is best to consult your doctor prior to taking any medication.
In cases wherein there is no relief despite effective treatment, surgery may be advised. According to the Journal of Gastrointestinal Surgery, laparoscopic fundoplication or anti-reflux surgery helped resolve heartburn by as much as 91% of the patients who were part of their study with a resolution in regurgitation in 90% of the patients. Cough and wheezing were also markedly reduced in the patients. Although the relief and resolution of symptoms are best observed after surgery, not all those who suffer from GERD are advised to undergo surgery. Seeking medical advice from a specialist or a gastroenterologist can help work out an effective treatment plan that best suits you.