Reflux Disease (GERD)
Gastroesophageal reflux disease (GERD) is the most common gastrointestinal disorder in the United States, affecting 18 million to 20 million people, including infants and children. GERD occurs when the stomach’s acidic contents rise up into the esophagus, the tube that carries food from the mouth to the stomach. GERD typically causes heartburn (pain behind the sternum or in the abdomen, often accompanied by a sour taste in the throat), belching, dysphagia (pain or difficulty with swallowing), and other serious problems. Almost everyone experiences acid reflux at some time, but a doctor’s visit is warranted if reflux occurs two to three times or more per week for a period of three months.
GERD typically is caused by a malfunctioning lower esophageal sphincter (LES), a ringed muscle that acts as a valve between the esophagus and stomach. The stomach produces acids to digest food, and the LES normally keeps those acids out of the esophagus.
GERD can have multiple contributing factors:
- a malformed or dysfunctional LES or esophagus
- a hiatal hernia, in which the stomach slips upward, out of the abdominal cavity through an enlarged hole in the diaphragm, repositioning the LES
- obesity, in which excess fat pushes on the stomach, repositioning or pressuring the LES
- inadequate emptying of acid and bile by the stomach
Physicians diagnose GERD through a detailed patient history and medical tests, including barium swallows, manometry (measuring pressure in the esophagus) and an endoscopic exam of the patient’s esophagus and stomach through a flexible tube inserted in the patient’s mouth.
Physicians’ first line of treatment typically includes antacids and prescribed changes to diet and lifestyle – such as eating smaller meals, not eating near bedtime, and elevating the head-end of the bed. With the advent of laparoscopic surgery, more patients are choosing this course not only to treat the failures of medication, but also as an alternative to it.
When acid reaches the esophagus, heartburn is the predominant symptom, with accompanying bad breath. Patients also might experience regurgitation of food, difficulty or pain with swallowing, chest pain, coughing, throat-clearing, hoarseness, voice changes, nausea, and ear or sinus pain.
Chronic reflux can cause other health problems. Esophagitis – inflammation harmful to the esophagus’ sensitive mucosal lining – can develop and, over time, lead to esophageal ulcers or change the esophagus’ cell structure to that of the stomach and intestinal wall. This condition, called Barrett’s esophagus, is associated with higher risk of esophageal adenocarcinoma (cancer), particularly in older adults. Chronic inflammation also can cause scarring that shortens the esophagus, which could contribute to development of a hiatal hernia by pulling the stomach upward through the esophageal hiatus, a passageway in the diaphragm. (A hiatal hernia also, conversely, is a risk factor for developing GERD.)
GERD occurs most often because of a malfunctioning lower esophageal sphincter (LES), a ringed muscle that acts as a valve between the esophagus and stomach. The LES might not work properly because it is malformed or dysfunctional, or because of a hiatal hernia, in which the stomach slips partially or entirely out of the abdominal cavity and into the thoracic (chest) cavity through an enlarged passageway in the diaphragm. Obesity and pregnancy also can cause GERD, as extra weight puts pressure on the stomach and can change the position or orientation of the LES.
Other factors contributing to GERD’s onset include diet (spicy/fatty/citrus foods, caffeine and chocolate); lifestyle (eating large meals, eating too near bedtime; tobacco and alcohol intake); medications; and restrictive clothing.
Excessive secretion of acid in the stomach and, perhaps surprisingly, insufficient secretion of acid both can contribute to GERD.
Diabetes and asthma also are both associated with GERD, though asthma’s connection is not well documented. Diabetes can cause a delay in the emptying of the stomach, called gastroparesis.
Women are slightly more prone to develop GERD than men, research suggests, and the average patient is in his/her early to mid-50s. GERD can emerge in people of all ages but its prevalence rises sharply in people over 40 due to their reduced saliva production and peristalsis (contractions that move food through the esophagus). Diet and lifestyle choices play important roles in likelihood of developing acid reflux. Obesity, pregnancy, hiatal hernia and diabetes are other potential risk factors.
Patients can be grouped by those with typical symptoms (heartburn and regurgitation) and those with atypical ones (airway symptoms, chest pain, etc.). For both groups, an adequate diagnostic evaluation includes upper endoscopy, manometry, 24-hr esophageal pH monitoring, and a series of images of the upper gastrointestinal tract.
These tests can help evaluate people with symptoms and establish a diagnosis of GERD, as well as detect corresponding medical issues. The tests are performed with instruments inserted into the patient’s mouth or nose.
This test gives the best information regarding structure of the esophagus and stomach. The contour of the lower esophageal sphincter (LES) correlates well with its function as an anti-reflux valve. Complications of reflux, such as esophagitis and Barrett’s Esophagus, are diagnosed with endoscopy and can be biopsied appropriately. Endoscopy may identify unexpected findings that change the patient’s treatment focus, such as cancer in the esophagus, stomach or duodenum. Endoscopy also can detect a hiatal or paraesophageal hernia and evaluate whether the LES is blocked or twisted.
Manometry evaluates the esophagus’ muscular contractions – their amplitude and wave action – and the pressure, location and relaxation of the LES. Surgeons need to know whether the motility of the esophagus is poor when considering a fundoplication.
24-hr pH esophageal and pharyngeal pH monitoring
Esophageal monitoring is the gold standard for the detection and quantification of GERD. It measures acid exposure in the upper and lower esophagus, helping to rule out other causes. This test also can be used to correlate reflux episodes with symptom events to confirm or cast doubt on the clinical association. Pharyngeal pH monitoring detects acid in the pharynx, which is a good surrogate for aspiration events. This is particularly important in patients with laryngeal and respiratory disorders and may be a better predictor of successful surgical therapy than esophageal pH monitoring in some patients.
In the last several years we have gained a better understanding of the role of non-acidic things refluxing from the stomach into the esophagus, and even beyond, into the lungs. Until recently physicians had only the pH test to detect reflux, thus were measuring only acid. With strong medicine to decrease acid secretion (PPIs), it is important to understand why patients with GERD still have symptoms, despite taking these medications. Impedance measures electrical resistance between two electrodes. When multiple pairs of electrodes are placed within the esophagus with a catheter, physicians can detect acid and non-acid reflux. This technology was first introduced to the Pacific Northwest seven years ago at the University of Washington Medical Center, and we have been on the forefront of research to determine the utility of impedance in the workup of GERD.
Upper Gastrointestinal Series (Barium Swallow)
A group of X-rays yields information about the anatomy of the esophagus and stomach, as well as the relation between these structures and the diaphragm. It may detect a short esophagus, strictures or a hiatal or paraesophageal hernia, each of which may affect a surgical strategy.
Like endoscopy of the esophagus, laryngoscopy can identify injury to the larynx caused by acid. Typical findings include erythema, ulcers, swelling, nodules, etc. None of these lesions pinpoints reflux but laryngoscopy remains an important test in evaluating patients with possible reflux laryngitis. This test is performed by a laryngologist.
Complications of chronic GERD include esophagitis, Barrett’s esophagus, narrowing or shortening of the esophagus, scarring of the lungs, cancer of the esophagus or larynx, and asthma.