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In gastroesophageal
reflux (gastroesophageal reflux disease [GERD]), stomach acid and
enzymes flow backward from the stomach into the esophagus, causing
inflammation and pain in the esophagus.
The stomach lining protects the stomach from the effects of its own acid. Because the esophagus lacks a similar protective lining, stomach acid and enzymes that flow backward (reflux) into the esophagus routinely cause symptoms and in some cases damage.
Acid and enzymes reflux when the lower esophageal sphincter, the ring-shaped muscle that normally prevents the contents of the stomach from flowing back into the esophagus, is not functioning properly. When a person is standing or sitting, gravity helps to prevent the reflux of stomach contents into the esophagus, which explains why reflux can worsen when a person is lying down. Reflux is also more likely to occur soon after meals, when the volume and acidity of contents in the stomach are higher and the sphincter is less likely to work properly. Factors contributing to reflux include weight gain, fatty foods, chocolate, caffeinated and carbonated beverages, alcohol, tobacco smoking, and certain drugs. Types of drugs that interfere with lower esophageal sphincter function include those that have anticholinergic effects (such as many antihistamines and some antidepressants), calcium channel blockers, progesterone, and nitrates. Alcohol and coffee also contribute by stimulating acid production. Delayed emptying of the stomach (for example, due to diabetes or use of opioids) can also worsen reflux.
Symptoms and
Complications
Heartburn (a burning pain behind the breastbone) is the most obvious symptom of gastroesophageal reflux. Sometimes the pain even extends to the neck, throat, and face. Heartburn may be accompanied by regurgitation, in which the stomach contents reach the mouth.
Inflammation of the esophagus (esophagitis) may cause bleeding that is usually slight but can be massive. The blood may be vomited up or may pass through the digestive tract, resulting in the passage of dark, tarry stools (melena) or bright red blood, if the bleeding is heavy enough.
Esophageal ulcers, which are open sores on the lining of the esophagus, can result from repeated reflux. They can cause pain that is usually located behind the breastbone or just below it, similar to the location of heartburn.
Narrowing (stricture) of the esophagus from reflux makes swallowing solid foods increasingly more difficult. Narrowing of the airways can cause shortness of breath and wheezing. Other symptoms of gastroesophageal reflux include chest pain, sore throat, hoarseness, excessive salivation (water brash), a sensation of a lump in the throat (globus sensation), and inflammation of the sinuses (sinusitis).
With prolonged irritation of the lower part of the esophagus from repeated reflux, the cells lining the esophagus may change (resulting in a condition called Barrett's esophagus). Changes may occur even in the absence of symptoms. These abnormal cells are precancerous and progress to cancer in some people.
Diagnosis
The symptoms point to the diagnosis, and treatment can be started without detailed diagnostic testing. Specific testing is usually reserved for situations in which the diagnosis is not clear or treatment has not controlled symptoms. Examination of the esophagus using an endoscope (a flexible viewing tube), x-ray studies, pressure measurements (manometry) of the lower esophageal sphincter, and esophageal pH (acidity) tests are sometimes needed to help confirm the diagnosis and check for complications.
Endoscopy may confirm the diagnosis if the doctor finds that the person has esophagitis or Barrett's esophagus. Endoscopy also helps to exclude the presence of esophageal cancer. X-rays taken after a person drinks a barium solution (a substance that outlines the digestive tract) and then lies on an incline with the head lower than the feet may show reflux of the barium from the stomach into the esophagus. A doctor may press on the abdomen to increase the likelihood of reflux. The x-rays taken after the barium is swallowed also can reveal esophageal ulcers or a narrowed esophagus.
Pressure measurements at the lower esophageal sphincter indicate the strength of the sphincter and can distinguish a normal sphincter from a poorly functioning one. The information gained from this test helps the doctor decide whether surgery is an appropriate treatment.
Some doctors believe that the best test for gastroesophageal reflux is esophageal pH testing. In this test, a thin, flexible tube with a sensor probe on the tip is placed through the nose and into the lower esophagus. The other end of this tube is attached to a monitor that the person wears on his belt. The monitor records the acid levels in the esophagus, usually for 24 hours. Besides determining how much reflux is occurring, this test identifies the relationship between symptoms and reflux and is particularly helpful for people who have symptoms that are not typical of reflux. The esophageal pH test is needed for all people being considered for surgery to correct gastroesophageal reflux. A new device (using a small implanted pH electrode that transmits a signal) is available for people who cannot tolerate a tube in their nose.
Prevention and
Treatment
Several measures may be taken to relieve gastroesophageal reflux. Raising the head of the bed about 6 inches can prevent acid from flowing into the esophagus as a person sleeps. Causative foods and drugs should be avoided, as should smoking. A doctor may prescribe a drug (for example, bethanechol or metoclopramide) to make the lower sphincter close more tightly. Coffee, alcohol, acid-containing beverages such as orange juice, cola drinks, and vinegar-based salad dressings, and other substances that strongly stimulate the stomach to produce acid or that delay stomach emptying should be avoided as well.
Many of the drugs used to treat gastritis and peptic ulcers also help prevent and treat gastroesophageal reflux (see Peptic Disorders: Antacids). Antacids taken at bedtime, for example, are often helpful. Antacids can usually relieve the pain of esophageal ulcers by reducing the amount of acid that reaches the esophagus. However, proton pump inhibitors, the most powerful drugs for reducing acid production, are usually the most effective treatment for gastroesophageal reflux, because even a small amount of acid can cause significant symptoms. Healing requires drugs that reduce stomach acid over a 4- to 12-week period. The ulcers heal slowly, tend to recur, and, when chronic and severe, can leave a narrowed esophagus after healing.
Esophageal narrowing is treated with drugs and repeated dilation, which may be performed using balloons or progressively larger dilators (bougies). If dilation is successful, narrowing does not seriously limit what a person can eat.
Barrett's esophagus does not disappear when treatment relieves symptoms. Therefore, people with Barrett's esophagus are asked to undergo an endoscopic examination every 2 to 3 years to ensure that the condition is not progressing to cancer.
Surgery is an option for people whose symptoms are unresponsive to drugs or for people who have esophagitis that persists even after symptoms are relieved. In addition, surgery may be the preferred treatment for people who do not like the prospect of having to take drugs for many years. A minimally invasive procedure performed through a laparoscope is available. However, 20 to 30% of people who undergo this procedure experience side effects, most commonly difficulty swallowing and a feeling of bloating or abdominal discomfort after eating.
Last full review/revision October 2006 by Sidney Cohen, MD
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