Heartburn and Reflux

Gastroesophageal Reflux Disease (GERD)

Gastroesophageal reflux disease (GERD) is a common cause of heartburn and reflux symptoms. This condition occurs when acid from the stomach (which is usually located in the abdomen) flows upward into the esophagus (which is located in the chest). Normally, small amounts of acid are occasionally allowed to come into the esophagus, but when this occurs on a frequent basis, or if the acid stays in the esophagus for a prolonged period of time, this is abnormal. Many people describe heartburn as a feeling of a burning discomfort in the chest often in the mid-chest behind the breastbone. Others note a sense of indigestion or a bitter or sour taste in the back of the mouth or throat. Other symptoms that can be caused by reflux include chronic hoarse voice or sore throat, difficulty swallowing, wheezing or even asthma.

What Causes GERD?  What is a Hiatal Hernia?

Normally, a muscular valve-like structure at the junction of the esophagus and stomach known as the lower esophageal sphincter (LES) serves to keep acid in the stomach by maintaining a barrier via its muscular contraction. In GERD, the sphincter relaxes too frequently and the underlying pressure of the valve (ability to stay continuously closed when one in not eating) is weak. This then allows flow of gastric acid and gastric juices into the esophagus. Often patients have a hiatal hernia associated with reflux. A hiatal hernia occurs when there is a weakening in the diaphragm, which separates the lungs from the abdomen. The reason this occurs is not known but can be worsened by obesity, heavy lifting, straining to pass stools or bending over. This opening then allows a portion of the stomach to herniate, or move up, into the chest cavity and further enable stomach contents and acid to flow upward. The hiatal hernia also reduces the normal ability of the esophagus to clear acid back down into the stomach. Hiatal hernias are not hereditary but are very common occurring in nearly sixty percent of people by age sixty. Although patients often attribute their reflux and indigestion symptoms to "my hiatal hernia", these hernias are often blamed for far more problems than they "deserve."

Other factors that can aggravate reflux are caused by further reduction of the lower esophageal sphincter (LES) pressure. Certain diet and lifestyle factors can play a role, such as chocolate, peppermint, spearmint, caffeine, alcoholic beverages and smoking. Obesity or pregnancy can put pressure on the stomach, forcing contents up into the esophagus. Some medications (discussed in treatment section) can weaken the sphincter-valve.

Diagnosis of GERD

In a patient with typical heartburn and reflux symptoms, the diagnosis can be made accurately by the medical history. When further evaluation is recommended, testing can be performed most thoroughly with endoscopy (please see separate article on Endoscopy-EGD). Endoscopy allows for accurate examination of the upper gastrointestinal tract to determine several important factors:

1. The degree of acid induced inflammation.

2. Evaluate the anatomy to rule out hiatal hernia or other abnormalities.

3. The ability to obtain biopsy tissue specimens for microscopic examination, if needed.

4. Ability to evaluate and treat other possible complications (see section on Complications). X-ray studies with an upper GI or Barium Swallow are sometimes performed and can help evaluate for the presence of hiatal hernias.

Twenty-four hour ambulatory pH monitoring can be very useful to objectively quantify the amount of acid exposure into the esophagus. This test is performed by placing, through the nose, a thin catheter that has an electrode on the tip of it to measure acid. The patient keeps this in place for 24 hours while performing usual daily activities (including eating). The tube is connected to a small computer that is worn on a belt. The computer measures and calculates the level of acid exposure during the 24 hour time period.

Complications of GERD

1. Esophagitis: Occasional acid exposure from the esophagus may be sensed as heartburn, but does not necessarily cause tissue damage. The damage or inflammation is called esophagitis. This is concept is analogous to placing one’s hand in warm water and feeling the heat, but the hand is not injured. This is like heartburn without esophagitis (damage or inflammation). With more prolonged exposure, however, then an injury (burn) can visibly occur. During endoscopy, esophagitis appears as an inflamed reddened area usually involving the lower portion of the esophagus and may contain ulcers (sores).

2. Bleeding: Bleeding can occur from this area which can make a patient anemic (low blood count).

3. Swallowing Difficulty and Stricture: Over time, as the inflammation heals, scar tissue may form causing a narrowing or stricture which can lead to problems with swallowing (food sticking). This can be stretched to smooth out the narrowed area at the time of endoscopy.

4. Ear, Throat, and Breathing (Asthma): Refluxed acid can reach the top of the esophagus and spill over into the trachea (respiratory passages) resulting in reflex constriction of the airways and wheezing or asthma. Irritation of the vocal cords or opening of the inner ear can cause chronic hoarse voice, sore throat, and ear and sinus infections. This process is heightened at night when laying flat in bed. At these times, gravity acts equally on the chest and abdomen, compared to an upright or sitting posture, which favors stomach contents staying down.

5. Barrett’s Esophagus: Barrett’s esophagus is a potentially precancerous condition that can occur as a result of reflux in some patients. The cells that normally line the esophagus are called squamous and are not "made to handle" acid exposure. As a response to long-standing reflux, these cells may undergo a change to columnar cells, which are the type of cells that are found in the stomach or intestine. Although this type of defense mechanism may seem beneficial, occasionally as this process occurs, these cells can transform into precancerous or even cancerous cells instead. It is for this reason that patients with long-standing reflux may need endoscopy to see if these changes are occurring and might then require more aggressive treatment. Unfortunately, there are no additional symptoms of precancerous Barrett’s esophagus except for those of the underlying reflux and heartburn. Barrett’s esophagus can develop in approximately ten percent of patients with chronic reflux. In patients who have Barrett’s esophagus, the risk of developing esophageal cancer is approximately one in 270.

Treatment of GERD

1. Life Style Modifications: The first step in treatment is aimed at lifestyle modifications. Eat smaller, more frequent meals to avoid overloading the stomach. Avoid eating within three hours of laying down for bed at night. Avoid excessive bending, lifting and tight belts. If overweight, weight loss can be very helpful. Avoid tobacco, alcohol, fatty foods, caffeine, chocolate, peppermint and spearmint. Elevate the head of the bed on 4-6" blocks so that gravity can help to keep stomach acid "down" in the chest rather that "up" into the esophagus.

2. Medications: Certain medications can provoke reflux, such as calcium channel blockers (Cardizem, Calan and others), nitroglycerin and others. Medications to treat GERD by neutralizing acid include antacids (Maalox, Mylanta, Gelusil, Rolaids, Tums and others). These can be taken as needed, when heartburn is felt. The main side effect is diarrhea. Alternagel is an alternative antacid that does not cause diarrhea but can be constipating. Drugs to inhibit acid secretion by the stomach include "H2 blockers" such as, Zantac, Tagamet, Axid and Pepcid and are now available over-the-counter and in a stronger prescription strength. If frequent use of these medications is needed (more than twice per week), treatment should be under your doctor’s supervision. Proton pump inhibitors (Prilosec, Prevacid, Protonix, Aciphex, Nexium) are a much more potent acid inhibitor and are available only by prescription except Prilosec OTC is now available without prescription. Medications known as "promotility agents" such as, Reglan (metoclopramide) can help to coordinate proper contractions (peristalsis) of the stomach and esophagus and stimulate the lower esophageal sphincter to maintain a tighter pressure.  

3. Surgery:  In patients whose problem is refractory to medical therapy, surgery can be performed to strengthen the lower esophageal sphincter muscle/barrier. The technique has been improved in recent years and is usually now done in a minimally-invasive fashion using laparoscopy.  Laparoscopy involves making several small incisions in the abdomen through which scopes are inserted and surgery is performed to wrap the top part of the stomach, fashioning a "new sphincter." 

4. Endoscopic therapy:  The latest technique involves treating the junction of the esophagus and stomach through the endoscope - no incisions! This can be accomplished by using coagulation (heat) method or suturing a tighter sphincter via the endoscope.  

Related Sites

GERD Information Resource Center, http://www.gerd.com
Pediatric/Adolescent Gastroesophageal Reflux Association (PAGER), http://www.reflux.org