gerd

GERD is a very common condition of the gastrointestinal tract referring to the back-flow of acid or non-acidic content into the esophagus from the stomach. GERD is defined by its symptoms and may or may not appear to have tissue damage due to exposure of the tissue to the acid. GERD is further categorized as “erosive” with tissue breakdown/irritation.

Non-erosive GERD (NERD) has normal appearance to the skin, but still produces symptoms similar to classic GERD. Even without symptoms, GERD can be discovered as the result of complications from months or years of damage.

The stomach is protected from acid by tall cells, called columnar epithelium, which secrete mucous, but the esophagus has thinner plate-like cells called squamous epithelium which is more easily killed by the caustic chemical effects of acid and digestive enzymes like pepsin. Normally the body prevents this with a variety of mechanisms including saliva which contains some buffering bicarbonate. Parastalsis (muscular contraction of the esophagus) and gravity help clearing acid.

The EGJ or esophagogastric junction, also called lower esophageal sphincter is an area of higher pressure about 2-4 cm in the bottom of the esophagus. It helps keep the acid in the stomach. The EGJ also works with the muscles of the diaphragm (the muscle responsible for pulling air into the lungs) to increase the pressure in this area.

It was originally thought that all of the damage related to GERD was due to acid effects and enzymes, but we now know that some of the damage is due to the immune system recruiting inflammatory cells into the region.

• Burning sensation behind the sternum/breastbone is the most common finding
• Regurgitation of food or sour liquid
• Bloating
• Hoarseness
• Atypical chest pain
• Difficulty with swallowing, known as dysphagia
• A lump sensation in your throat no matter how much you swallow (globus sensation).
• Unexplained weight loss

• Hiatal Hernia
  • If some of the stomach slides up past the diaphragm this is called a Hiatal Hernia and makes it easier for reflux to occur.
• Alcohol
  • Makes the lower esophageal sphincter (LES) relax and increases acid production
• Eating a heavy meal and lying down within 2-3 hours of the meal
• Obesity
  • Results in external compression of the stomach, squeezing acid up when lying flat
• Carbonated drinks
  • Expand the stomach and result in more relaxation of the LES to vent the gas
• Pregnancy,
  • Uterus pressing against the stomach
• Fatty foods
  • Slow emptying from the stomach and relax the LES
• Eating tomatoes, peppermint, caffeine, chocolate, citrus fruits, and to a lesser extent black pepper, garlic and raw onions
• Smoking
  • Decreases saliva production and also relaxes the lower esophageal sphincter
• Drugs
  • Decrease stomach emptying (like narcotics), relax the LES or are directly caustic to the esophagus itself—ask your physician to review your medications.

The first treatment of Gastroesophageal reflux disease starts with lifestyle modifications, not medication.

1. Try putting gravity to work for you. Raise the front posts of your bed 4-6 inches to sleep on an incline.
2. Avoid bedtime snacks, and don’t eat within 3 hours of bedtime.
3. If you are obese, consider weight loss.
4. Avoid cigarettes, carbonated beverages and alcohol.
5. Avoid trigger drugs.
6. Avoid fatty foods, chocolate, peppermint, garlic and onions.
7. Eat more slowly with smaller volumes at one time.
8. Antacids can provide quick but non-sustained relief from GERD. They are good for episodic heartburn, but not helpful for long-term prevention of esophagitis.
9. Histamine (H2RA) receptor blocking agents.
   1. Generally safe but weak acid suppression.
   2. Includes drugs like Zantac (ranitidine), Pepcid (famotidine) and Tagamet (cimetidine).
   3. Good for intermittent treatment but tolerance develops quickly and not great at treating more severe erosive esophagitis.
   4. Relieves GERD in about ½-2/3 of patients over 12 weeks
10. Sucralfate is a complex of sugar and aluminum which can bind to damaged tissue in the stomach and esophagus. It has little absorption and toxicity, but requires an acid environment to bind. It has little use outside of pregnancy, but may be helpful if patients have reactions to other medications.
11. Proton Pump Inhibitors (PPIs).
    1. These are the most effective class of medications for treating GERD
    2. These include drugs like Prilosec (omprezole), Protonix (pantoprazole, Nexium (esoprazole), and Prevacid (lansoprazole).
    3. Best taken prior to supper if once daily
    4. Heal erosive esophagitis in 80-100% in 8-12 weeks in most cases. In severe cases may be needed twice daily.
    5. Ongoing treatment is required (as with all these medication) as symptoms recur quickly with discontinuation of the medication.
    6. Although potential side effects have been described, these medications are generally thought of as safe and effective. Many have been approved for use over the counter.
12. Antireflux Surgery
    1. A variety of antireflux surgeries can be used to restore the diaphragm and reduce the hiatal hernia and augment the lower esophagal tone.
    2. Short term about 85% of patients experience relief and are able to come off or reduce their medication needs.
    3. In one Swedish study about 17.7% developed recurrence of symptoms 5 years later.
    4. If the patient is morbidly obese, sometimes the antireflux procedure is combined with a roux-en-Y gastric bypass procedure for weight loss as well.

You can be referred to a Gastroenterologist for symptoms of your reflux at any time. Generally, we perform evaluations for “alarm symptoms” which include:

• New onset of symptoms at age 60 or above
• Dysphagia or food hanging up in the esophagus
• Painful swallowing
• Atypical chest pain
• Weight loss
• Recurrent vomiting
• Vomiting blood/anemia evaluation
• Gastric cancer in a 1^st degree relative

Patients will also be evaluated for Barrett’s Esophagus if he/she has experienced reflux for at least 5-10 years, meeting several of the following criterion:

• Age 50 or older
• Male sex
• White race
• Obesity
• Nocturnal reflux
• Tobacco use
• First degree relative with Barrett’s and or adenocarcinoma of the esophagus

Visual evaluation of the esophagus can establish if erosive esophagitis is present, check for structures that may be dilated, assess bleeding and look for cancer.

A Bravo pH monitoring study can be used to gauge the efficacy of treatment of the reflux over a period of 48 hours and may be a useful test your Gastroenterologist can order if appropriate. You might need this if you continue to have symptoms of chest pain even after treatment with PPIs.

• GERD from the American Gastroenterology Association bsite: 
  https://gastro.org/practice-guidance/gi-patient-center/topic/gastroesophageal-reflux-disease-gerd/
• Cleveland Clinic website: 
  https://my.clevelandclinic.org/health/diseases/17019-gerd-or-acid-reflux-or-heartburn-overview
• Webmd.com website: 
  https://www.webmd.com/heartburn-gerd/default.htm