Gastroesophageal Reflux
In gastroesophageal reflux (gastroesophageal reflux disease, or GERD), acid and enzymes produced by the stomach flow backward into the esophagus.
Reflux causes indigestion and heartburn. Occasional reflux, often the result of a dietary indiscretion, is usually bothersome but not serious. However, repeated reflux can result in inflammation of the esophagus (esophagitis), open sores (ulcers) in the lining of the esophagus, formation of scar tissue, and narrowing of the esophagus (strictures). After years, reflux can lead to esophageal cancer. Most of the time, reflux can be treated effectively with changes in lifestyle and with drugs.
About 1 out of 10 people has reflux every day, and about half of people have it at least once a month. Reflux affects old and young alike. It is more common among men.
The acid and enzymes produced by the stomach are designed to break down or digest food, but they can also break down some of the body's tissues. The stomach has a lining that protects it, but the esophagus does not. Thus, if stomach acid and enzymes flow backward into the esophagus, it can be damaged.
Normally, the ring-shaped muscle at the lower end of the esophagus (lower esophageal sphincter) remains contracted to prevent the contents of the stomach from flowing backward. The sphincter is triggered to relax when there is food in the esophagus, so that food can pass through to the stomach. After food passes into the stomach, the sphincter contracts again, closing off the esophagus.
A thin muscle called the diaphragm separates the chest from the abdomen. To get to the stomach, the esophagus passes through a small opening in the diaphragm called the hiatus. Like the lower esophageal sphincter, this opening also contracts and relaxes in response to food and may help prevent reflux.
Causes
Reflux occurs when the lower esophageal sphincter malfunctions. The sphincter may relax at the wrong time (when the stomach is full). Or the sphincter may be weak and unable to contract tightly enough. In either case, the stomach's contents can flow backward into the esophagus and can even reach the mouth.
Lying down soon after eating contributes to reflux. Thus, older people who go to sleep or take a nap very soon after eating often have reflux symptoms.
A hiatal hernia may contribute to reflux. In the most common type of hiatal hernia, the top part of the stomach sometimes slides up and bulges through the opening in the diaphragm (hiatus). This type is called a sliding hiatal hernia. A hiatal hernia may cause the lower esophageal sphincter to malfunction or refluxed material to remain in the esophagus longer (making damage more likely).
Reflux may be triggered or worsened by diet or lifestyle choices. Drinking alcohol or caffeinated beverages such as coffee stimulates acid production, making the symptoms of reflux worse. Being obese may make reflux worse because of what or how much is eaten. Also, the extra weight puts pressure on the stomach. Smoking and eating certain foods (such as chocolate and peppermint) tend to weaken the sphincter muscle. For some people, eating fatty foods and foods with a high acid content (such as citrus fruits) makes reflux symptoms worse.
Certain drugs (such as drugs with anticholinergic effects, some antidepressants, calcium channel blockers, and nitrates) tend to weaken the sphincter muscle. Some disorders, such as diabetes, and some drugs, such as opioids, delay the emptying of the stomach. Then, the stomach's contents increase, and more material is available for reflux.
Symptoms
The most obvious symptom of reflux is burning pain behind the breastbone (heartburn). Sometimes the pain extends to the neck, throat, and face. People with reflux may have a bitter, sour, or salty taste in the mouth, caused by regurgitated material from the stomach. The regurgitated material may stimulate saliva production. Often, symptoms occur after people eat or when they lie down.
Reflux does not always cause regurgitation or heartburn. In some people, reflux may cause squeezing chest pain similar to chest pain due to coronary artery disease (angina). Squeezing pain due to reflux, like heartburn, is usually felt behind the breastbone or just below it.
If reflux continues, swallowing solid foods may become more and more difficult. After eating, people may feel as if they have a lump in the throat. Swallowing becomes difficult when repeated irritation from the reflux causes scar tissue to form in the esophagus. The inflexible, tight scar tissue narrows the esophagus.
People who have difficulty swallowing may inhale (aspirate) food into the windpipe (trachea). Aspiration can result in lung disorders, including bronchitis and a form of pneumonia called aspiration pneumonia.
Sometimes blood is vomited up or appears in the stool. Blood in the stool usually appears dark and tarry. The blood appears because the inflamed esophagus may bleed. Bleeding is usually slight but can be massive.
Reflux may cause sore or bleeding gums, hoarseness, sore throat, inflamed sinuses (sinusitis), and earaches. These symptoms develop if continued reflux irritates the tissues of the mouth, throat, and nose.
When reflux repeatedly irritates the lower part of the esophagus for a long time, the cells lining the esophagus may change. This disorder is called Barrett's esophagus. This disorder may cause no other symptoms. However, the abnormal cells are precancerous (that is, they may develop into cancer). Having Barrett's esophagus greatly increases the risk of developing cancer called adenocarcinoma of the esophagus.
Diagnosis
People should see their doctor if reflux symptoms last longer than 2 weeks. In most people, reflux can be diagnosed based on symptoms, and treatment can be started without diagnostic tests. Tests are usually necessary only when the diagnosis is unclear or symptoms persist despite treatment.
When a test is needed, a doctor usually examines the esophagus with a flexible viewing tube (endoscope). This procedure, called endoscopy, is used to check for inflammation, Barrett's esophagus, and esophageal cancer. Occasionally, barium studies are done. X-rays are taken after a person consumes a barium solution or food coated with barium and lies down with the head lower than the feet. X-rays can show the reflux of barium from the stomach into the esophagus. A doctor may press on the person's abdomen to increase the likelihood of reflux. This test can also detect ulcers and narrowed areas in the esophagus.
Doctors may measure the strength of the lower esophageal sphincter. This test, called manometry, helps determine whether a sphincter is functioning normally and whether surgery is appropriate.
The pH (acidity) of the esophagus may be measured continuously, usually for 24 hours. In this test, a thin, flexible tube with a sensor probe on the tip is inserted through the nose and into the esophagus (near the lower esophageal sphincter). The other end of the tube is attached to a monitor on the person's belt. The monitor records the acid levels in the esophagus. Alternatively, a small probe is placed in the esophagus using a tube inserted through the mouth or nose. The probe is attached to the esophagus, and the tube is removed. The probe sends information about pH data to a small receiver worn by the person. The probe remains in place for almost 48 hours, then detaches, and passes through the digestive tract and out of the body. A pH test can determine how much reflux is occurring. It also helps doctors pinpoint when symptoms occur in relation to reflux. The esophageal pH test is done whenever surgery for reflux is being considered.
Treatment
For many people with gastroesophageal reflux, lifestyle changes may be the only treatment needed. Raising the head of the bed about 6 inches can prevent acid from flowing into the esophagus when a person is lying down. Using blocks under the head of the bed is more effective than extra pillows. Waiting for several hours after eating before lying down and eating smaller meals may lessen symptoms. Losing weight, if needed, can help. Foods (including fatty foods) and beverages (such as caffeinated beverages and alcohol) that make reflux worse should be eaten in limited amounts or eliminated. Smoking, which tends to weaken the sphincter muscle, should be stopped. Not wearing clothes that are tight around the middle of the body and avoiding unnecessary bending may help. If drugs are contributing to reflux, doctors may be able to substitute another drug or reduce the dose.
If symptoms persist, certain drugs are effective.
Doctors often recommend taking antacids at bedtime to relieve symptoms, such as heartburn and the pain due to ulcers in the esophagus. Antacids are most likely to be helpful when symptoms occur only occasionally. Antacids that are available without a prescription are often recommended. Antacids make stomach acid less acidic (that is, they neutralize the acid). These drugs do not cure reflux or help ulcers heal.
Histamine-2 (H2) blockers and proton pump inhibitors reduce acid production. H2 blockers include cimetidine, famotidine, nizatidine, and ranitidine. Some H2 blockers are available without a prescription. Proton pump inhibitors are usually the most effective treatment for gastroesophageal reflux, because they reduce acid production the most. Proton pump inhibitors are especially helpful when symptoms occur very frequently. Examples are esomeprazole, lansoprazole, omeprazole, pantoprazole, and rabeprazole. Omeprazole is available without a prescription. H2 blockers and proton pump inhibitors may quickly relieve most symptoms of reflux, but they must be given for 4 to 12 weeks for ulcers to heal completely. If symptoms recur, these drugs are started again. Some people have to take these drugs continuously.
Drugs with cholinergic effects (such as bethanechol or metoclopramide) can stimulate muscles in internal organs to contract. They may help the lower esophageal sphincter close more tightly and help the stomach empty its contents into the small intestine more quickly. However, these drugs have side effects that greatly limit their use.
If other treatments do not relieve symptoms or if inflammation persists, surgery may be done. Surgery may be preferable for people who do not want to take drugs for many years. Surgery may be done using a laparoscope in a minimally invasive procedure. This procedure is usually safe for older people. However, it causes problems in some people. The most common problems are difficulty swallowing, a sensation of bloating or abdominal discomfort after eating, and loss of the ability to belch or vomit.
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