Gastroesophageal Reflux Disease
(Hiatal Hernia and Heartburn)
Almost everyone has experienced heartburn. About 25 million American adults suffer daily from heartburn.
Gastroesophageal Reflux Disease (GERD) is a digestive disorder that affects the Lower Esophageal Sphincter (LES) - the muscle connecting the esophagus with the stomach. Many people, including pregnant women, suffer from heartburn or acid indigestion caused by GERD. Doctors believe that some people suffer from GERD due to a condition called Hiatal Hernia. In most cases, heartburn can be relieved through diet and lifestyle changes; however, some people may require medication or surgery.
What is Gastroesophageal Reflux?
Gastroesophageal refers to the stomach and esophagus. Reflux means to flow back or return. Therefore, Gastroesophageal Reflux is the return of the stomach's contents back up into the esophagus.
The esophagus carries food and liquid into the stomach. At the lower end of the esophagus where it enters the stomach, there is a strong muscular ring called the Lower Esophageal Sphincter (LES). The LES should remain tightly closed, except to allow food and liquid to pass into the stomach. In normal digestion, the LES opens to allow food to pass into the stomach and closes to prevent food and acidic stomach juices from flowing back into the esophagus. Gastroesophageal Reflux occurs when the LES is weak or relaxes inappropriately allowing the stomach's contents to flow up into the esophagus.
The severity of GERD depends on LES dysfunction as well as the type and amount of fluid brought up from the stomach, duration of acid refluxed into the esophagus and the neutralizing effect of saliva.
It is also common to find a Hiatal Hernia complicating GERD.
What is the role of Hiatal Hernia?
Some doctors believe a Hiatal Hernia may weaken the LES and cause reflux. Hiatal Hernia occurs when the upper part of the stomach moves up into the chest through a small opening in the diaphragm (Diaphragmatic Hiatus).
The diaphragm is the thin, flat muscle separating the stomach from the chest. Recent studies show that the opening in the diaphragm acts as an additional sphincter around the lower end of the esophagus. Studies also show that Hiatal Hernia results in retention of acid and other contents above this opening. These substances can reflux easily into the esophagus.
Coughing, vomiting, straining, or sudden physical exertion can cause increased pressure in the abdomen resulting in Hiatal Hernia. Obesity and pregnancy also contribute to this condition. Many otherwise healthy people age 50 and over have a small Hiatal Hernia. Although considered a condition of middle age, Hiatal Hernias affect people of all ages.
Hiatal Hernias usually do not require treatment. However, treatment may be necessary if the hernia is in danger of becoming strangulated (twisted in a way that cuts off blood supply, i.e., Paraesophageal Hernia) or is complicated by severe GERD or Esophagitis (inflammation of the esophagus). The doctor may perform surgery to reduce the size of the hernia or to prevent strangulation.
What other factors contribute to GERD?
Dietary and lifestyle choices may contribute to GERD.
For example, certain foods increase acid production and may weaken the LES causing reflux and heartburn.
- Chocolate
- Peppermint
- Coffee
- alcoholic beverages
Fatty foods increase the time food remains in the stomach.
Nicotine in cigarette smoke weaken or relax the LES.
Obesity places added pressure on the upper abdomen.
During pregnancy the LES weakens for unknown reasons.
What does Heartburn feel like?
Heartburn, also called acid indigestion, is the most common symptom of GERD and usually feels like a burning chest pain beginning behind the breastbone and moving upward to the neck and throat. Many people say it feels like food is coming back into the mouth leaving an acid or bitter taste.
The burning, pressure, or pain of heartburn can last as long as 2 hours and is often worse after eating. Lying down or bending over can also result in heartburn. Many people obtain relief by standing upright or by taking an antacid that clears acid out of the esophagus.
Heartburn pain can be mistaken for the pain associated with heart disease or a heart attack, but there are differences. Exercise may aggravate pain resulting from heart disease, and rest may relieve the pain. Heartburn pain is less likely to be associated with physical activity.
Frequent heartburn is the most common symptom. However, patients may also experience some of the following:
- sour or bitter taste
- bitter stomach fluid coming into the mouth, especially during sleep
- hoarseness
- repeatedly feeling a need to clear the throat
- difficulty swallowing food or liquid
- wheezing or coughing at night
- worsening of symptoms after eating, or when bending over or lying down.
How common is Heartburn?
More than 60 million American adults experience GERD and heartburn at least once a month, and about 25 million adults suffer daily from heartburn. Twenty-five percent of pregnant women experience daily heartburn, and more than 50 percent have occasional distress. Recent studies show that GERD in infants and children is more common than previously recognized and may produce recurrent vomiting, coughing and other respiratory problems, or failure to thrive.
What is the Treatment for GERD?
Doctors recommend lifestyle and dietary changes for most people with GERD. Treatment is aimed at reducing reflux and damage to the lining of the esophagus. Patients with GERD should follow these recommendations:
- Avoid foods and beverages that can weaken the LES. These include fatty foods, chocolate, spearmint, peppermint, milk, caffeine and alcohol-especially red wine.
- Avoid citrus fruits and juices, tomato products, pepper seasoning as these may irritate a damaged esophageal lining.
- Decrease size of portions of food at mealtime. This helps control symptoms.
- Avoid eating anything within three hours before bedtime. This lessen reflux by allowing the acid in the stomach to decrease and the stomach to empty partially.
- Antacids taken regularly can neutralize acid in the esophagus and stomach and stop heartburn. Many people find that nonprescription antacids provide temporary or partial relief. An antacid combined with a foaming agent such as alginic acid helps some people. These compounds are believed to form a foam barrier on top of the stomach that prevents acid reflux from occuring. Long-term use of antacids, however, can result in side effects, including diarrhea, altered calcium metabolism (a change in the way the body breaks down and uses calcium), and buildup of magnesium in the body. Too much magnesium can be serious for patients with kidney disease. If antacids are needed for more than 3 weeks, a doctor should be consulted.
- Avoid tight clothing or bending over after eating.
- Stop smoking. Nicotine in the blood weakens the LES.
- Review all medications with the physician. Certain drugs can weaken the LES, allowing acid irritation of the esophagus.
- Elevate the head of the bed or mattress 6 to 8 inches. This helps to keep acid in the stomach by gravity and minimizing reflux of stomach contents into the esophagus when sleeping. Extra pillows by themselves are not very helpful.
- In addition, being overweight often worsens symptoms. Many overweight people find relief when they lose weight. This may relieves upward pressure on the stomach and LES.
- For chronic reflux and heartburn, the doctor may prescribe medications to reduce acid in the stomach. These medicines include H2 blockers, Tagamet, Zantac, Pepcid and Axid. H2 blockers inhibit acid secretion in the stomach. Currently, four H2 blockers are available: cimetidine, famotidine, nizatidine, and ranitidine. Another type of drug, the Proton Pump (or Acid Pump) inhibitor omeprazole inhibits an enzyme (a protein in the acid-producing cells of the stomach) necessary for acid secretion. The acid pump inhibitor lansoprazole is currently under investigation as a new treatment for GERD. Certain potent newer drugs, such as Prilosec and Prevacid, can almost eliminate stomach acid entirely. These two drugs are most frequently used when GERD is severe. Other medications, such as Propulsid and Reglan (generic: metoclopramide) tighten the LES.
- Other approaches to therapy will increase the strength of the LES and quicken emptying of stomach contents with motility drugs that act on the upper gastrointestinal (GI) tract. These drugs include cisapride, bethanechol, and metoclopramide.
Tips to control Heartburn
- Avoid foods and beverages that affect LES pressure or irritate the esophagus lining, including fried and fatty foods, peppermint, chocolate, alcohol, coffee, citrus fruit and juices, and tomato products.
- Lose weight if overweight.
- Stop smoking.
- Elevate the head of the bed 6 inches.
- Avoid lying down 2 to 3 hours after eating.
- Take an antacid.
What if symptoms persist?
People with severe, chronic esophageal reflux or with symptoms not relieved by the treatment described above may need more complete diagnostic evaluation. Doctors use a variety of tests and procedures to examine a patient with chronic heartburn. First and foremost is the medical history.
An Upper GI Series may be performed during the early phase of testing. This test is a special x-ray that shows the esophagus, stomach, and duodenum (the upper part of the small intestine). For this x-ray, the patient swallows a liquid containing barium. This makes it possible to see the reflux and a Hiatal Hernia on the x-ray.While an upper GI series provides limited information about possible reflux, it is used to rule out other diagnoses, such as peptic ulcers.
Endoscopy is an important procedure for individuals with chronic GERD. It is done with the patient under sedation. By placing a small lighted tube with a tiny video camera on the end (Endoscope) into the esophagus, the doctor may see inflammation or irritation of the tissue lining the esophagus (Esophagitis). This exam is helpful in determining how severe the disease is, how much tissue damage there is, and if there are any complications. Certain conditions, such as narrowing or stricture in the esophagus, can usually be corrected during this procedure. If the findings of the endoscopy are abnormal or questionable and the physician suspects Barrett's esophagus, biopsy (removing a small sample of tissue) from the lining of the esophagus may be helpful to see if pre-cancerous changes have occurred.
The Bernstein test (dripping a mild acid through a tube placed in the mid-esophagus) is often performed as part of a complete evaluation. This test attempts to confirm that the symptoms result from acid in the esophagus. Esophageal manometric studies (pressure measurements of the esophagus) occasionally help identify critically low pressure in the LES or abnormalities in esophageal muscle contraction.
For patients in whom diagnosis is difficult, doctors may measure the acid levels inside the esophagus through pH testing. Testing pH monitors the acidity level of the esophagus and symptoms during meals, activity, and sleep. Newer techniques of long-term pH monitoring are improving diagnostic capability in this area.
Does GERD require surgery?
A small number of people with GERD may need surgery because of severe reflux and poor response to medical treatment. Fundoplication is a surgical procedure that increases pressure in the lower esophagus. It is usually done by laparoscopy. This is a new type of minimally invasive surgery, performed with a tiny incision at the naval and a few needle points in the upper abdomen. The patient usually returns home 1-2 days after surgery, with few problems. However, surgery should not be considered until all other measures have been tried. Surgery is often seriously considered for an otherwise healthy patient when the disease is severe, or the patient does not want to face the expense or regimen of long-term treatment with medications.
What are the complications of long-term GERD?
Sometimes severe or long-standing GERD results in serious complications. Constant irritation of the esophagus by stomach acid can lead to Esophagitis,inflammation, ulcers, and esophageal bleeding. Anemia or low blood count may develop. In addition, a narrowing or stricture of the esophagus may occur from chronic scarring making it difficult to swallow foods and liquids. Some people develop a condition known as Barrett's esophagus, which is severe damage to the skin-like lining of the esophagus. Barrett's esophagus may be a forerunner of esophageal cancer.
Conclusion
GERD is a common problem that requires medical attention when symptoms and tissue damage become troublesome. Although GERD can limit daily activities and productivity, it is rarely life-threatening.
Working together with the physician, a good medical program with an understanding of the causes and proper treatment can almost always be developed to successfully treat and relieve the patient with GERD.