Gastroesophageal Reflux Disease (GERD)

Definition

Gastroesophageal reflux disease (GERD) is a chronic digestive condition characterized by acid reflux where the gastric juice in the stomach regurgitates into the esophagus (food pipe). Occasionally, bile may also enter the food pipe. Approximately, 40% of adults are affected by GERD. Also known as heartburn, GERD is most commonly experienced as a burning feeling behind the breastbone and does not imply any heart-related disorder. More correctly though, heartburn is the most common symptom of GERD and not a disorder on its own.

Symptoms

The main symptom of GERD is a burning sensation in the chest (heartburn) which could at times spread as high up as the throat. The other signs are :

  • Bitter or sour taste in the mouth
  • Regurgitation of food or sour liquid
  • Dysphagia- difficulty in swallowing, particularly in esophageal strictures and Barrett’s esophagus
  • Frequent belching
  • Infants and children suffering from GERD may exhibit the following symptoms as well :
    – repeated vomiting
    – belching
    – coughing
    – respiratory problems such as wheezing
    – excessive salivation
    – inconsolable crying

GERD is diagnosed by- X-ray after a barium swallow, endoscopy, continuous monitoring of esophageal pH and esophageal manometry – a test for esophageal motility.

Causes

The muscles of the lower esophageal sphincter (LES) regulate entry of food into stomach. When these muscles relax, the ingested food enters the stomach. Thereafter, the LES constricts and closes the gastric opening. Weakening of these muscles makes them ineffective in closing down and the gastric juices in the stomach can regurgitate. The acids in the gastric juices corrode the lining of the esophagus leading to heartburn and to GERD, in chronic cases.

Fried and spicy foods, smoking, wearing tight clothes which constrict the abdomen are some common causes. Pregnancy hormones relax the LES and cause heartburn in the second and third trimester. It could also be a symptom of hiatal hernia or Zollinger-Ellison syndrome. Obesity and diabetes increase the risk for GERD. Untreated GERD can lead to complications such as esophageal ulcer, esophageal stricture, and Barrett’s esophagus.

Treatment

GERD can be prevented by simple measures such as eating smaller, low-fat meals and eating frequently, avoiding specific foods that trigger heartburn, maintaining a healthy weight and wearing comfortable clothes. There should be a gap of at least 3 hours between eating and sleeping. While lying down, the head should be slightly elevated.

Treatment options comprise of antacids, acid suppressing drugs and prokinetics. H-2 receptor blockers such as cimetidine, famotidine, nizatidine, ranitidine reduce acid production but cannot prevent GERD altogether. Blocking the acid production with medications like lansoprazole and omeprazole greatly facilitates esophageal healing. These drugs are proton pump blockers. Their intake may be supplemented with calcium tablets to reduce the osteoporotic, side-effects. Prokinetic drugs like metoclopramide help empty the stomach faster.

In complicated cases, surgical treatment is adopted. Nissen fundoplication is a standard surgery where the upper part of the stomach is wrapped around the LES by laparoscopic means. An incisionless approach which strengthens the LES is the transoral incisionless fundoplication (TIF). In this, a device is passed through the mouth, positioned at the LES, where ot folds the tissue and fastens it,thereby reconstructing the natural anatomy of the LES.

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