Gastroenterology

Gastroesophageal Reflux Disease (GERD)

What is Gastroesophageal Reflux Disease

Gastroesophageal reflux disease or better known as GERD is a chronic disease where the acidic content of stomach refluxes into the esophagus due to dysfunction of lower esophageal sphincter.  Small amounts of refluxes are common and normal, as the lower esopahgeal spincter relaxes occasionally to allow passage of food.  The disease starts producing symptoms when the mucosal lining of the esophagus is damage by highly acidic stomach content in larger amount.

Patients with GERD will experience heartburn, reflux, nausea, epigastric pain and belching. While the symptoms are similar for adult and children, most children are undiagnosed because they do no complaint the symptoms to their parents.

GERD can be diagnosed clinically, but there are a series of investigations to confirm the diagnosis and to detect the complications.

Gerd

  • Cause of GERD
  • Diagnosis and Investigation of GERD
  • Complications of GERD
  • Treatment
  • Conclusion

 

Symptoms of GERD

In adult, the most common symptoms are heartburn, reflux and nausea. The symptoms may be one or multiple present at the same time. Most symptoms are after a meal.

Heartburn

Heartburn is a burning sensation from the epigastric region to the central of chest, with some up to the neck region or to the back. As the acidic content refluxes to the esophagus, the nerve fibres are stimulated resulting in burning sensation or sharp pain. It is often aggravated by bending, stooping or lying flat as this positions increase the reflux of acidic content to the lower esophagus. This is because of the gravity effect, as we sit, the gravity pulls the reflux quickly back to stomach. But when we lie down, due to loss of some gravity effect, the refluxed content stays in the esophagus for a longer period of time.

Sometimes, it is very difficult to distinguish between heartburn or chest pain as the pain regions are almost similar. This could mimic a heart attack. So, for older patient, it is advisable to seek medical help from hospital or clinic and have a electrocardiogram done.

Reflux

In most patients with GERD, small amount of stomach content often reflux into the esophagus. They can be just at the lower end of esophagus or even up to the mouth.  The amount of reflux and the site may vary from patient to patient and from time to time.

Waterbrash usually comes together with a reflux. Waterbrash is the regurgitation of excessive saliva accumulation with acidic content from the stomach.

Belching

Some people will experience frequent belching, also known as burping. This is due to the gas released from the process of digestion. An acidic stomach content releases more gas during digestion which causes a very uncomfortable stomach distension. Belching or burping is the way to relieve the distension by release of air.

 Epigastric pain

Most patients will have epigastric pain ranging from mild to severe pain that could disable the patient. This is mainly cause by the erosion of the esophageal mucosa by the highly acidic stomach content called esophagitis. Severe esophagitis could also cause hematemesis, vomitus containing blood.

 

Nausea

Most patients will have nausea ranging from very mild to severe symptoms that might cause repeated vomiting. This symptom is due to the combination of abdominal distension, gas and reflux of acidic content.

 

Others

Patients who have pre-existing asthma will have more night symptoms and exacerbations as GERD can cause small amounts of acidic gastric contents being inhaled to the airways. In older frail patients, aspiration pneumonia might occur.

 

In children

In young children and infants, the symptoms are very different and subtle. This makes it more difficult to diagnose GERD in young children. Mothers play the most important role for early detection in their children especially infants by observing them.

Children with GERD will have many bouts of vomiting especially after feeding, usually in small amount. They are often the colicky babies and meal time is always a battle as they always refuse food. They often have inconsolable cry as they have gas, yet they are hungry and at the same time very uncomfortable abdominal distension. Very often, they effortlessly vomit of spit out their food. This is because their digestive system have not matured fully yet.

By 9-12 months, most infants will be asymptomatic.

The more severe GERD babies will larger size of vomitus, more frequent vomiting with poor weight gain. The frequent vomiting especially in very young children who can’t sit up well may cause aspiration pneumonia. They may also have recurrent cough and wheezing.

 

Cause of GERD

There are many contributing factors for a person to end up with GERD. Some individuals may have only one factor while others may have multiple. Sometimes, as time goes by, the factors may vary as lifestyle and body conditions change. The common contributing factors are dysfunctional lower esophageal sphincter, hiatus hernia, slow emptying of stomach and abnormal contraction of esophagus. Other important factors are associated to lifestyle of a person that plays a major role.

Lower Esophageal Spincter

As the bolus of food pass from esophagus to the stomach, there is a sphincter that surrounds the end of esophagus where it connects to the stomach called lower esophageal spincter (LES). This sphincter is made up of muscular ring controlled by our nervous system. The sphincter relaxes to allow passage of food bolus or saliva and it contracts to prevent regurgitation of stomach content to the esophagus.

The LES can be dysfunctional by weak contractions or prolonged relaxations. These conditions are intermittent and transient but can be bad enough to cause the symptoms.

When the LES relaxes, stomach content that is rich in acid and pepsin, occasionally with bile regurgitates into the esophagus. These acidic fluids will injure the esophagus and cause inflammations to happen that produces GERD symptoms.

Hiatus hernia

This is a condition where the proximal portion of stomach herniates through the diaphragm into the thoraxic cavity. There are 2 types of hiatus, 80% is the sliding hiatus hernia where the gastroesophageal junction with the LES slides up into the thoraxic cavity. Another 20% is the rolling hiatus hernia where the fundus of the stomach herniates into the thoraxic cavity along the esophagus but gastroesophageal junction remains in the abdomen.

A sliding hiatus hernia impairs the contraction of LES and also the contraction of crural diaphragm around it to prevent reflux because the LES is in the thoraxic cavity instead of abdomen. It is important to have both the LES and diaphragm to contract to produce an effective antireflux mechanism.  This condition is common as it presents in 30% of population above 50 years old.

A rolling hiatus hernia do causes GERD, but not as common as the other counterpart. This is because the LES remains in the abdomen.

 

Other factors

Pregnancy and obesity predispose to GERD as they both have very large abdomen, filled with fetus or fats that increases the intra-abdominal pressure, causing the lower esophageal sphincter to relax further. During pregnancy, the elevated hormones causes lower LES pressure that makes reflux easier.

Similarly, a large hearty meal often causes severe symptoms.  A distended stomach also slows down the process of stomach emptying and gives more time for the acidic content to reflux.

Other medical conditions of connective tissue disease particularly scleroderma predisposes to GERD as their LES pressure is lowered.

A spicy and sour meal often exacerbates the symptoms as it causes the gastric content to be more acidic, to a lower pH which worsens the condition. Other associated foods are chocolate, coffee and alcohol.

Cigarette smoking that contain nicotine and various other chemicals also worsen GERD by irritation to the mucosal lining and also the lower the pH of digestive tract.

Other than the above symptoms, some medications can also cause GERD by delaying gastric emptying. Anti-hypertensive such as Beta blocker, Calcium channel blocker, nitrates and theophylline are known to cause these symptoms when taken in a long duration.

Diagnosis and Investigation of GERD

Clinical Diagnosis

Usually, clinical diagnosis can be made without investigation. This is made by the presenting symptoms of heartburn, reflux, nausea, epigastric pain and belching.  Most symptoms occur after a hearty meal and worsen on lying down. The further history of cigarette smoking, obesity, spicy and sour food and list of medications strengthens the diagnosis.

In most common practice, the physician will prescribe medications for GERD and advices the patient for lifestyle modification. If the symptoms are relieved, then GERD is confirmed.

However, clinical diagnosis often depends on how the patient describes the symptoms and also the interpretation of the physicians. GERD could be a distractor for a diagnosis of more severe conditions. For that, there are a few red flags that must be determined during a diagnosis for further investigations to rule out ischemia heart disease, peptic ulcer and gastric or duodenal carcinoma.

The red flags are :

  • Dysphagia
  • Significant loss of weight
  • Loss of appetite
  • Malaenic stool (black in colour)
  • Altered bowel habit
  • Central chest pain or heaviness on exertion
  • Pain radiating to left arm and neck
  • Profuse sweating
  • Prolonged usage of pain killers

There is also the placebo effect where patient’s symptoms are relieved after medication by placebo,(inactive pill). With this, patient will continue to be treated for GERD even though he does not have GERD.

Endoscopy

OGDS ( Oesophageal-gastro-duodeno-scopy) is another way to diagnose GERD. By OGDS, the physician can have a direct visualization of the gastrointestinal tract from the mouth, to esophagus, stomach and finally the duodenum.

This is a simple daycare procedure where the patient is required to fast at least 8 hours. After giving a mild sedative which does not requires intubation, a flexible tube is slowly guided into the patient’s mouth and slowly advances down the gastrointestinal tract and end in the duodenum. During the procedure, visualization of the lining is important for the diagnosis.

By OGDS, esophagitis and hiatal hernia can be confirmed.  In GERD, there will be inflammations or small superficial ulcers in the esophagus or stomach. The physician can also identify the complications of GERD such as peptic ulcers, strictures and Barrett’s esophagus.

By the biopsies taken during endoscopy(OGDS), malignancy can also be diagnosed. Barrett’s esophagus is also a diagnosis by microscopic examination of a biopsied piece. In some centres, a small piece of stomach is biopsied and tested for H.pylori infection.

24 hour esophageal pH test

This test is the gold standard for GERD. A small catheter with pH sensor is placed into the esophagus via the nostril. Another end of the tube is attached to a recorder placed at the waist that records every episode of reflux. The device is removed after 24hours and the records are analysed to diagnose GERD. This test can also be used to monitor the effectiveness of medication to control GERD.

This method is often used for pediatric age group as they are less cooperative for OGDS, which will require them to be deeply sedated and intubated. This is usually the method of investigation for young children who do not improve with medical therapies. It is preferred because it is less invasive and accurate.

However, there are a few disadvantages to this method such as dislodgment of catheter and discomfort to the throat and nostril. Some patients experience severe sore throat after the procedure.

The alternative to this is pH testing with capsule. There are no catheters or protruding devices. The patient would need to swallow the capsule and retrieve it later from the feces after bowel output. Unfortunately, not many centres provide this investigation routinely.

Complications of GERD

Peptic Ulcers

The acidic content of stomach can damage the delicate lining of esopahgus. This is because the esophagus lining are not armed with cells that can withstand a low pH environment. Peptic ulcers are formed when there is a breakage of lining in the areas of inflammation. This causes small bleedings,  but over a long period of time it causes severe anemia which could require blood transfusion.

Peptic Strictures

Peptic strictures usually occur in patient over the age of 60 years old. The could experience mild intermittent dysphagia( pain on swallowing). This symptom could be for a long period of time and worsens gradually.

These strictures are caused by healed ulcers of the esophagus. The tissues heal by fibrosis, forming scar tissues that narrow the lumen of esophagus.

Barrett’s esophagus

Normal lining of the esophagus is by the squamous epithelium. With long standing GERD, the normal squamous epithelium is replaced by metaplastic columnar cells to form a segment of columnar lined esophagus. These cells are pre-cancerous cells where 0.5% – 1.0% of patient with Barrett’s esophagus develops esophageal adenocarcinoma per year. Barrett’s pregression to adenocarcinoma increases with the severity of dysplasia.

However, not all GERD patients develop Barrett’s esophagus and not all develop esophageal adenocarcinoma. The only way to diagnose this condition is by OGDS and microscopic examination of a biopsied esophageal lining.

Throat Inflammation

Sometimes, the stomach content refluxes through the LES and goes beyond the upper esophageal sphincter into the throat. This results in inflammation of the throat causing sore throat and hoarseness of voice.

Lungs Inflammation and Aspiration Pneumonia

Other than that, the content of reflux can also enter the lungs. This usually happen in young children where their system is not well matured yet. And, this also usually happen in older patients where their systems and mechanism have deteriorated. Both result in aspiration pneumonia that ranges from mild to severe requiring hospital stay or even intubation due to respiratory failure.

 

Treatment

Lifestyle Modification

Most GERD patients improve and have lesser symptoms with a simple lifestyle changes. Weight loss and eating smaller meals and on time have significantly reduced the symptoms. This is due to lesser stomach distension which lowers the frequency of LES relaxation after eating.

Elevating the upper body during sleep raises the esophagus. So, this aids the gravity effect to pull the refluxes content back to stomach thus reducing the symptoms of GERD.

Modification of diet, with less spicy, sour, fatty food and caffeine reduced the symptom by reducing the acidity of stomach content.

Smoking also reduces GERD symptoms greatly.

 

Medications

Antacids

Antacids are most cost effective treatment for GERD. They provide almost immediate and long term relieve. Antacids form a foam-raft with gastric content to reduce reflux and also neutralizes the acidic content.

There are many antacids available over the counter, ranging from aluminum, magnesium, or calcium based. Aluminium antacids tend to cause constipation while Magnesium antacids tend to cause diarrhea. Calcium antacids are least recommended due to the rebound increase of stomach acid.

It is advisable to take antacids during GERD symptoms or 1 hour after food.

Dopamine antagonist

Dopamine antagonist are pro-motility drugs such as domperidone and metoclopramide. These agents stimulate the gastrointestinal tract muscles to increase motility and also strengthen the LES. This will reduce the events of reflux and so reduces GERD symptoms.

It is advisable to take these drugs 30 minutes before meal and just before sleep.

H2 receptor antagonist

If antacids fail, most physicians will prescribe a H2 receptor antagonist such as ranitidine, cimetidine or famotidine. They are similar to antacids, which is used for acid suppression but they have longer effects.

It is advisable to take these drugs 30 minutes before meal.

Proton pump inhibitors

Proton pump inhibitors or well known as PPIs are omeprazole, pantoprazole, esomeprazole, rabeprazole and lansoprazole. They reduce the secretion of acid by binding to the proton pumps of stomach. The effect of PPIs are longer and much more effective than H2 receptor antagonist.

PPIs are the preferred drug due to the longer action of drugs, quick relieve of symptoms and also its protection of the esophagus from acidic content.

It is advisable to take these drugs 1 hour before meal.

 

Surgery

While not many people opt for surgery, this treatment is indicated for hiatus hernia and severe GERD. Severe symptoms even after lifestyle modifications and medical treatments will often be offered surgery.

Laparascopic Nissen fundoplication has high satisfaction of 80% after 10 years and 90% after 5 years. There will only be 3 small incisions done using special surgical instrument ans a viewing devie. This procedure corrects the hiatus hernia by pulling the sac below the diaphragm and securing it there. Then, the upper part of stomach is pulled around the LES to create an artificial sphincter.

Another indication for surgery is for esophageal stricture


 

Conclusion

GERD is a common condition with a wide range of symptoms and severity. It can be a mild disease or it can be very disabling. GERD is also easy to treat as most symptoms resolve with lifestyle modifications and many over the counter drugs available. There are fast relieving drugs and also some for prevention.

While most GERD are benign, it is important to watch out for red flags or serious diseases and the complications.

We will be expanding on this important topic in future articles. While I recommend you to register to download an e-book: “Adult Prevention Guide” for better health, a FREE

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The Team Manager Web Diseases

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