Gastroesophageal Reflux Disease Symptoms: In gastroesophageal reflux disease, stomach acid and enzymes flow back from the stomach into the esophagus, causing esophageal inflammation and chest pain.
- Reflux occurs when the ring-shaped muscle that normally prevents gastric contents from refluxing into the esophagus (called the lower esophageal sphincter) does not work properly.
- The most typical symptom is heartburn (burning pain behind the breastbone).
- The diagnosis is based on symptoms, and sometimes esophageal pH tests.
- Initial treatment consists of avoiding triggering substances (e.g. alcohol and fatty foods) and taking medicines to reduce stomach acid. However, if these measures fail, surgery may also be necessary.
The esophagus (esophagus) is a hollow tube that runs from the throat (pharynx) to the stomach. The lower esophageal sphincter is a ring of muscles that hold the lower part of the esophagus closed to keep food and stomach acid from flowing back up the esophagus. When people swallow, this sphincter usually relaxes to allow food to enter the stomach. (See also Overview of the Esophagus .)
Gastroesophageal reflux disease (GERD) is a common condition. It occurs in 10 to 20% of adults. In addition, it often occurs in young children and sometimes begins with birth ( gastroesophageal reflux in children ).
The stomach lining protects the stomach from the effects of its own acid. Since the esophagus does not have a similar protective lining, stomach acid and bile that flow back into the esophagus (reflux) can cause symptoms and sometimes damage.
The acid and biliary reflux into the esophagus can occur when the lower esophageal sphincter is not working properly. When you stand and sit, gravity prevents the gastric contents from refluxing into the esophagus. This explains why reflux can worsen when you lie down. Also, soon after meals, when the volume and acidity of the stomach are higher and the sphincter is less likely to work properly, reflux is more likely to occur. The factors that promote reflux include:
- Weight gain
- Fatty foods
- Caffeinated and carbonated drinks
- Tobacco use
- Certain medicines
Medicines that adversely affect the lower esophageal sphincter function include anticholinergic drugs (e.g., many antihistamines and some antidepressants), calcium channel blockers, progesterone, and nitrates. Delayed gastric emptying (e.g., with diabetes or due to the use of opioids) can also make reflux worse.
Gastroesophageal Reflux Disease Symptoms:
The most noticeable symptom of gastroesophageal reflux is heartburn (burning pain behind the breastbone). Heartburn can be accompanied by regurgitation , with stomach contents reaching the mouth. If the contents of the stomach get into your mouth it can cause a sore throat, hoarseness, cough or a feeling of lump in your throat (globus feeling). Sometimes small amounts of stomach contents enter the lungs, causing coughing and / or wheezing. People with chronic heartburn sometimes develop difficulty swallowing ( dysphagia ).
Complications of Gastroesophageal Reflux:
Long-term acid reflux in the lower part of the esophagus can lead to the following complications:
- Inflammation of the gullet (esophagitis)
- Ulcers (open wounds) in the gullet (erosive esophagitis)
- Narrowing of the esophagus (esophageal stricture)
- Malformed cells in the esophagus that can degenerate (see esophageal cancer)
Inflammation of the esophagus (esophagitis or erosive esophagitis) causes symptoms that are typical, but potentially more serious, of gastroesophageal reflux disease. It can also cause pain when swallowing (odynophagia). Some people have bleeding, which is usually light but can also be heavy. The blood may be vomited or passed through the digestive tract, and then excreted as black, tarry stools (melena) or, if the bleeding is profuse, as bright red blood. Light bleeding that continues for a long time can cause iron deficiency anemia.
Esophagitis Caused by Gastroesophageal Reflux:
Repeated reflux can cause ulcers (arrows) to form in the esophagus.
Esophageal ulcers are painful, open sores in the wall of the esophagus. They can cause chest pain, often behind or just below the sternum, where the heartburn is felt.
A narrowing (stricture) in the esophagus caused by reflux makes it increasingly difficult to swallow solid food.
Narrowing (stricture) of the Esophagus:
Reflux can cause the esophagus to narrow. This picture also shows ulcers or open wounds (arrows) over a narrowing (stricture) of the esophagus.
Prolonged irritation causes the cells in the wall of the esophagus to change, causing a condition called Barrett’s syndrome. There may be changes without symptoms. These altered cells are degenerate and can develop into cancer in some people.
Repeated reflux can cause the cells in the esophagus to change and become precancerous (precancerous disease). In this photo the red tongue-shaped areas (arrows) show these changes.
- Endoscopy with biopsy
- Sometimes pH test
- Sometimes manometry
If symptoms suggest a diagnosis of GERD, treatment can be started without extensive diagnostic evaluations. Investigations are usually reserved for situations where the diagnosis is ambiguous, where treatment has not brought symptoms under control, or where symptoms have persisted for a long time.
If tests are needed, the esophagus is usually examined first with a flexible viewing tube ( endoscope ). Endoscopy is the best way to diagnose esophagitis, erosive esophagitis, esophageal ulcers, narrowing of the esophagus, esophageal cancer, and Barrett’s syndrome. With endoscopy, the doctor can also remove tissue in order to examine it under the microscope (biopsy).
If endoscopy and biopsy results are normal in people whose symptoms are highly suggestive of GERD, doctors usually do an esophageal pH test (the pH test measures acidity – see Catheter-based Monitoring). For this test, a thin, flexible tube with a sensor on the tip is inserted over the nose into the lower esophagus. The hose remains there for 24 hours. The other end of the hose is attached to a monitor that the person wears on their clothing.
The monitor records the acid level in the esophagus, usually over 24 hours. This exam determines not only how much reflux is occurring, but also the relationship between the symptoms and the reflux. It is also helpful for people with symptoms that are not typical of reflux. Measurement of pH in the esophagus is recommended for all individuals who are considering surgery to correct gastroesophageal reflux. In people who cannot tolerate a tube in their nose,wireless monitoring ).
Pressure measurements on the lower esophageal sphincter using manometry indicate how well the sphincter is working and also provide information about the strength of the esophageal muscles. The information obtained through this examination will help the doctor decide whether surgery is appropriate for treatment.
Several Measures can be Taken to Relieve Gastroesophageal Reflux:
- Raise the headboard of the bed
- Avoid drugs and foods that cause symptoms or stimulate acid formation
- Do not eat anything 3 hours before going to bed
- Weight loss
Raising the headboard about six inches can prevent acid from flowing into the esophagus while you sleep. Medications that cause symptoms and smoking should be avoided. Coffee, alcohol, acidic drinks such as orange juice, cola drinks, salad dressings with vinegar and other substances that strongly stimulate gastric acid production or delay gastric emptying should also be avoided. Affected people should stop eating about 3 hours before going to bed. Obese people and people who have recently gained weight should lose weight.
- Proton pump inhibitors or sometimes histamine-2 blockers
- Stretching of the narrowed areas
Proton pump inhibitors, the most powerful drugs used to reduce gastric acid production, are usually the most effective treatment for gastroesophageal reflux, esophagitis, and erosive esophagitis due to gastroesophageal reflux. The drugs usually have to be taken for 4 to 12 weeks to heal. These drugs are also suitable for long-term use, but doctors will try to use a lower dose if necessary. H2 receptor antagonists (histamine-2 blockers) are other acid-lowering drugs that are effective in patients with mild symptoms of GERD. Drugs that stimulate the movement of food through the esophagus, stomach and intestines (so-called promotional drugs) are less effective than proton pump inhibitors,
A narrowing of the esophagus is treated by stretching the narrowed area several times with balloon tubes or tubes. If the expansion is successful, the constriction does not mean a serious restriction in eating.
Surgery is a way to treat gastroesophageal reflux in patients who cannot tolerate drugs, who have large amounts of reflux that are not acidic but cause symptoms, or who have ulcers, bleeding, large hernias, or severe esophagitis. In addition, surgery may be the preferred treatment for those who do not plan to take medication for years. The operation can be performed minimally invasively with a laparoscope (so-called fundoplication). Some people experience side effects after this procedure, the most common being difficulty swallowing, gas, and abdominal pain after eating.
The Barrett’s syndrome rarely disappears by treatment with a proton pump inhibitor, and typically does not change. If the cells are degenerate (precancerous), Barrett’s syndrome can be treated as part of an endoscopy with methods that destroy the changed tissue using radio waves (radio frequency ablation), extreme cold (cryotherapy) or a laser beam (laser ablation). Optionally, the tissue can also be surgically removed. However, the defective cells may persist even if symptoms have been alleviated after treatment. Therefore, all people with Barrett’s syndrome should have regular endoscopic exams to make sure that cancer does not develop.