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GASTROESOPHAGEAL REFLUX DISEASE

July 04, 2012

Added By :
Dr Shairi Abdullah


Gastroesophageal Reflux Disease or GERD is a common medical condition which develops when there is a reflux or backflow of gastric (stomach) contents into the esophagus (food tube) leading to troublesome symptoms or complications.
GERD can affect men and women of all ages and ethnicities as well as children and babies. In adults, the symptoms of GERD can include any or a combination of the following:  heartburn which is an uncomfortable and often burning sensation that arises behind the breastbone, regurgitation of liquid or food into the throat and mouth leading to a sour or bitter taste in the mouth, pain in the centre of the upper stomach, belching, bloating, nausea, hoarseness of voice, difficulty in swallowing, sensation of food getting stuck in the chest, chest pain, sore throat,  “lump“  sensation in the throat, persistent dry cough, bad breath and even asthma symptoms. Some of these symptoms can also be caused by other medical conditions and it is advisable to undergo an evaluation by your doctor.
GERD can cause symptoms severe enough to trouble the physical, social and emotional well-being of those affected. Sleep may be disturbed, there is a sense of frustration and work productivity may reduce. Sometimes GERD can lead to potentially harmful complications such as erosions ( injury to the superficial lining of esophagus ), ulcers, bleeding, anaemia and inability to swallow food and water due to narrowing of the esophagus ( stricture). Long standing GERD may occasionally cause an abnormal change in the cells lining the lower esophagus, called Barrett’s esophagus which in rare instances leads to cancer.
What causes GERD ? In most patients it is due to relaxation of the lower esophageal sphincter (LES) which is a valve that opens to allow food and liquids to pass into the stomach and closes to prevent food and stomach acid from flowing back into the esophagus. This relaxation of the LES happens normally a few times each day in people without GERD. However in GERD, this occurs more frequently or inappropriately. The esophagus lining is different from stomach lining  and isn't able to cope as well as with stomach acid. Thus, the esophagus is more prone to acid injury which leads to the symptoms and complications of GERD.
A condition called hiatal hernia may contribute to GERD – this occurs when the upper part of the stomach is above the diaphragm, which is the muscle wall that separates the stomach from the chest. The diaphragm helps the LES to prevent stomach acid from coming up into the esophagus. When a hiatal hernia is present, it is easier for acid to reflux into the esophagus. Abnormal contractions of the esophagus or delayed emptying of the stomach can worsen GERD. Other factors that may contribute to GERD include alcohol use, smoking, being overweight, pregnancy, some  medications and foods such as citrus and tomato based foods, spicy foods, fried and fatty foods, chocolates, garlic, onion, mints as well as caffeine containing and carbonated drinks .   
How do we diagnose GERD ? The history given by you is important and helps to establish the diagnosis in most cases. A procedure called upper endoscopy using a gastroscope is useful in certain situations. A gastroscope is a long thin flexible tube with a camera in one end which is introduced through the mouth and is used by the gastroenterologist to carefully examine the esophagus, stomach and part of the small bowel. Upper endoscopy can diagnose complications, treat bleeding or strictures and determine the presence of a hiatal hernia. Sometimes, the gastroenterologist may suggest a procedure known as Bravo® capsule pH monitoring to identify if you have increased amounts of acid reflux and if it is causing your symptoms. The capsule which is about the size of a vitamin pill is attached to the wall of your esophagus during upper endoscopy and passes out in the stools after a few days. The capsule measures pH (acidity) levels in the esophagus and transmits readings by radio telecommunications to a small receiver.
How is GERD treated in adults? GERD is often caused by a variety of factors and the treatment includes lifestyle and dietary changes as well as medications and sometimes, surgery. Avoidance or reduction in intake of certain foods and drinks as mentioned previously can be helpful. Measures you can take that may reduce reflux are – wait at least  2-3 hours after a meal before going to bed, avoid heavy  meals before bed time, use blocks to elevate the head end of the bed by 4-6 inches when sleeping, don’t wear very tight clothes or belts around the waist, stop smoking and maintain a healthy weight. Chewing gum (try mint free) increases saliva production which helps to neutralize acid.
Medications play an important role in GERD treatment. Antacids neutralize acid in the stomach so that there is no acid reflux but their action is brief. Alginate containing foam barriers form a protective layer in the stomach and help prevent reflux of stomach contents. Pro-motility drugs (eg: metoclopramide, itopride) act by increasing the pressure in the lower esophageal sphincter, strengthen contractions and speed up emptying of the stomach. They can be used to enhance the effect of other treatments. H2 blockers (eg: ranitidine, cimetidine) act by blocking the action of the chemical histamine 2 which is one of the important producers of stomach acid. Proton pump inhibitors or PPIs (eg: pantoprazole, rabeprazole, omeprazole, esomeprazole, lansoprazole) act by blocking acid production in the stomach by binding to molecules called proton pumps -  they have a more complete action and last longer than H2 blockers.  PPIs are also used when some of the complications of GERD exist such as erosions, ulcers, strictures and Barrett’s esophagus. If you have Barrett’s esophagus, discuss with your gastroenterologist regarding follow up and treatment. If you are pregnant or breastfeeding, talk to your doctor regarding suitable medicines.
Anti-reflux surgery is useful in some patients with GERD or hiatal hernia. The role for endoscopic anti-reflux treatment is limited at present. It is advisable to discuss with a doctor experienced in the management of GERD regarding which treatment would be appropriate for you.
DR ANIL K RADHAKRISHNAN
MBBS (MANGALORE), MMED (MALAYA), MRCP (UK), FRCP (GLASGOW), FELLOWSHIP IN GASTROENTEROLOGY (MELBOURNE AND KUALA LUMPUR)
CONSULTANT GASTROENTEROLOGIST, HEPATOLOGIST AND PHYSICIAN
KPJ KLANG SPECIALIST HOSPITAL