Gastroesophageal reflux disease

What is gastroesophageal reflux disease?

Gastroesophageal reflux disease (GERD) is a common condition in which the stomach contents move up into the esophagus. Reflux becomes a disease when it causes frequent or severe symptoms or injury. Reflux may damage the esophagus, pharynx or respiratory tract.

How common is GERD?

Researchers estimate that about 20 percent of people in the United States have GERD. 

What is GERD also commonly known as?

• Acid indigestion
• Acid reflux
• Acid regurgitation
• Heartburn
• Reflux 

Who is more likely to get GERD?

People who are

• Overweight or obese
• Pregnant
• Take certain medications for e.g. benzodiazepines, calcium channel blockers
• Smokers or those exposed to secondhand smoking (https://www.niddk.nih.gov/health-information/digestive-diseases/acid-reflux-ger-gerd-adults/definition-facts) 

The lower esophageal sphinchter (LES)  is a 3-4 cm tonically contracted smooth muscle segment located at the esophagogastric junction (EGJ) and, along with the crural diaphragm forms the physiological EGJ barrier, which prevents the retrograde migration of acidic gastric contents into the esophagus. In otherwise healthy individuals, LES maintains a high-pressure zone above intragastric pressures with transient relaxation of the LES that occurs physiologically in response to a meal facilitating the passage of food into the stomach. Patients with symptoms of GERD may have frequent transient LES relaxations (TLESRs) not triggered by swallowing, resulting in exceeding the intragastric pressure more than LES pressures permitting reflux of gastric contents into the esophagus. The exact mechanism of increased transient relaxation is unknown, but TLESRs account for 48-73% of GERD symptoms. The LES tone and TLESRs are influenced by factors such as alcohol use, smoking, caffeine, pregnancy, certain medications like nitrates, and calcium channel blockers. (https://www.ncbi.nlm.nih.gov/books/NBK441938/)  

What are the symptoms of GERD?

The main symptom of GERD is heartburn, often described as a fiery feeling in one's chest, and regurgitating sour or bitter liquid to the throat or mouth. The combination of heartburn and regurgitation is such a common characteristic of GERD that formal testing may be unnecessary. Other symptoms of GERD may include:

• Non-burning chest pain, which is usually located in the middle of the chest and radiates to the back
• Difficulty swallowing (dysphagia)
• Atypical reflux symptoms relating to the throat, larynx or lungs: 
  • Sore throat
  • Coughing
  • Increased salivation
  • Shortness of breath (https://www.hopkinsmedicine.org/health/conditions-and-diseases/gastroesophageal-reflux-disease-gerd) 
• GERD symptoms may be worse:
  • At night or while lying down.
  • After a large or fatty meal.
  • After bending over.

After smoking or drinking alcohol. 

How is GERD diagnosed?

A gastroenterologist will evaluate your esophagus to diagnose GERD. Tests may include:

• Esophagram is a type of moving X-rays (fluoroscopy) of your esophagus while you swallow barium. 
• Upper endoscopy involves looking inside your esophagus while you’re asleep under light sedation.
• Esophageal pH test measures the acid content inside your esophagus through a small wireless receiver.
• Esophageal manometry measures the muscle activity in your esophagus, using pressure sensors embedded in a nasogastric tube. It can confirm if your LES or other muscles aren’t working right. (https://my.clevelandclinic.org/health/diseases/17019-acid-reflux-gerd) 

How is GERD treated?

Lifestyle changes and non-prescription medications are the first line of treatment.

Non-prescription medication include: 

• Antacids containing calcium carbonate for example, Mylanta, Rolaids and Tums. 
• Histamine (H-2) blockers don't act as quickly as antacids, but they provide longer relief and may decrease acid production from the stomach for up to 12 hours.
• Proton pump inhibitors (PPI) are stronger acid blockers than H-2 blockers and allow time for damaged esophageal tissue to heal. Nonprescription proton pump inhibitors include lansoprazole (Prevacid), omeprazole (Prilosec OTC) and esomeprazole (Nexium).

If non-prescription medication don`t work, then prescription medication or surgery are other options to be considered. 

Prescription medication include:

• Prescription-strength PPI for example, esomeprazole (Nexium), lansoprazole (Prevacid), omeprazole (Prilosec), pantoprazole (Protonix), rabeprazole (Aciphex) and dexlansoprazole (Dexilant).

Although generally well tolerated, these medicines might cause diarrhea, headaches, nausea or, in rare instances, low vitamin B-12 or magnesium levels.

• Prescription strength H-2 blockers include famotidine and nizatidine. Side effects from these medicines are generally mild and well tolerated.

Surgery and other procedures: 

• Fundoplication is a minimally invasive laparoscopic procedure where the top part of the stomach can be partially or completely wrapped. 
• LINX device is a ring of tiny magnetic beads is wrapped around the junction of the stomach and esophagus. The magnetic attraction between the beads is strong enough to keep the junction closed to refluxing acid, but weak enough to allow food to pass through. The LINX device can be implanted using minimally invasive surgery. The magnetic beads do not affect airport security or magnetic resonance imaging.
• Transoral incisionless fundoplication involves tightening the lower esophageal sphincter by creating a partial wrap around the lower esophagus using polypropylene fasteners. TIF is performed through the mouth by using an endoscope and requires no surgical incision. Its advantages include quick recovery time and high tolerance. (https://www.mayoclinic.org/diseases-conditions/gerd/diagnosis-treatment/drc-20361959)