As the name implies, gastroesophageal reflux disease means reflux of the contents of the stomach including hydrochloric acid and gastric enzymes into the esophagus. Occasional episodes of reflux are normal in healthy people but when this reflux occurs more often leading to inflammation of the esophagus, then it takes the form of a disease known as GERD. About 30% of the general population is affected by this disease.
Cause and Risk Factors for Gastroesophageal Reflux Disease (GERD)
The esophagus is normally contracted at its lower end with a smooth muscle called the sphincter. When there is abnormal relaxation of this sphincter, it causes reflux of acid from the stomach into the esophagus. The factors contributing to abnormal relaxation of the lower esophageal sphincter are:- Dietary and environmental factors: Alcohol, tea, coffee, chocolate, peppermint, and dietary fat
- Increased pressure inside the abdomen in pregnancy, obesity
- Defect in emptying of the stomach into the small bowel
- Hiatal hernia: sliding of a part of the stomach from the abdomen into the thorax
- Drugs: calcium channel blockers, sleeping pills, antidepressants
Clinical features of Gastroesophageal Reflux Disease (GERD)
Patients with GERD commonly complain of a burning sensation in the chest and waterbrash (salivation after acid enters into the mouth). These symptoms are provoked by lying down, bending, and straining. Some patients may also experience hoarseness of voice due to the gastric acid irritating the larynx, chronic cough, asthma, erosion of teeth enamel, and chest infections. Chronic GERD can lead to inflammation of the esophagus and if left untreated it can even cause cancer of the esophagus. In long-standing cases of GERD, patients may have difficulty swallowing food and water. Some health conditions associated with GERD include pharyngitis, chronic bronchitis, chronic sinusitis, fibrosis of the lung, and sleep apnea (pause in breathing while sleeping).Diagnosing Gastroesophageal Reflux Disease (GERD)
Young patients without severe symptoms such as difficulty swallowing, weight loss, and signs of an occult blood loss can be treated without investigations. Investigation is required if symptoms are atypical or any complication is suspected or the patient is over 50-55 years of age. In these patients, an endoscopy is done to rule out any disease that may be mimicking GERD and to identify any complications. Some health problems mimicking GERD include esophagitis (pill-induced or infection-induced), peptic ulcer disease, esophageal motility disorders, colicky pain due to gall stone, and dyspepsia. Elderly patients presenting with chest pain should be evaluated for coronary heart disease as heart diseases such as angina (decreased blood supply to the heart muscle) can also mimic GERD symptoms.24-hour pH monitoring may be advised by the physician if the diagnosis is not clear. In this procedure, a probe is placed inside the esophagus and the pH within the gastric lumen is recorded while the patient goes about his daily routine. If pH is found to be less than 4 for 6-7% of the recorded time, then the patient is diagnosed as having GERD. If a diagnosis can not be made with standard pH testing, then impedance testing is done, which is a technique to measure the amount and type of gastroesophageal reflux.
Management of Gastroesophageal Reflux Disease (GERD)
Management of GERD is done in a stepwise manner. Treatment of GERD is targeted at symptomatic relief, healing of esophagitis, and prevention of further complications.Change in lifestyle measures is recommended for GERD patients such as weight loss, avoidance of food that triggers symptoms, avoidance of acidic foods (e.g., tomato, citrus fruit), and avoiding taking meals late at night. Using multiple pillows while sleeping to raise the level of the head from the bed may also be beneficial for some.
If symptoms do not respond to lifestyle measures, then proton pump inhibitors (PPIs) such as Esomeprazole which decreases acid production are usually prescribed by physicians for the short term. However, in many cases, symptoms recur as soon as the drug intake is stopped. In such cases, PPI may be taken for longer durations to achieve symptom resolution.