By Dr. Claudia Barghash
Dr. Claudia Barghash is a gastroenterologist at Digestive Healthcare Center in Hillsborough and Somerville. She completed her internal medicine residency at Staten Island University Hospital, and gastroenterology fellowship at SUNY Downstate Medical Center, NY. She has a special interest in digestive diseases in women, and pelvic floor disorders. She lives in Somerset County with her husband and three children.
Gastroesophageal reflux disease (GERD) occurs when the stomach contents reflux or back up into the esophagus or the mouth.
People with GERD experience symptoms that include heartburn, regurgitation, difficulty or pain with swallowing, occasionally hoarseness, sore throat and cough.
The esophagus is a tube-like structure, made of tissue and muscle layers that expand and contract to propel food to the stomach. At the lower end of the esophagus, there is a circular ring of muscles called the lower esophageal sphincter (LES). After swallowing, the LES relaxes to allow food into the stomach and then contracts to prevent back-up of food and acid into the esophagus. However, sometimes the LES is weak and becomes relaxed, allowing liquids in the stomach to wash back into the esophagus and causing symptoms. Causes include:
Acid reflux becomes GERD when it causes symptoms or injury to the esophagus.
The diaphragm is a large, flat muscle at the base of the lungs that contracts and relaxes as a person breathes in and out. The esophagus passes through an opening in the diaphragm before it joins with the stomach.
Normally, the diaphragm contracts which improves the strength of the LES, especially during bending and coughing. If there is a weakening of the diaphragm muscles at the hiatus, the stomach might be able to partially slip through the diaphragm into the chest, forming a sliding hiatus hernia. The presence of a hiatus hernia makes acid reflux more likely but is not the only reason for GERD. Obesity and pregnancy are also contributing factors, but the exact cause is unknown.
Symptoms of GERD
The most common symptom is heartburn, felt as a burning sensation in the center of the chest that sometimes spreads to the throat. Other symptoms include non-cardiac chest pain, difficulty swallowing, painful swallowing, hoarseness, sore throat, chronic cough, a sense of a lump in the throat, recurrent lung infections and waking up with a choking sensation.
Diagnosis of GERD
GERD is diagnosed based on symptoms and response to treatment. It is important to rule out potentially life-threatening problems that mimic reflux, such as heart disease.
An upper endoscopy is used to evaluate the esophagus. A small, flexible tube is passed into the esophagus, stomach and small intestine. Damage to the lining in these areas can be evaluated and a biopsy can be taken.
pH Bravo Study
A sensor is endoscopically inserted into the distal esophagus. It is left for 48 hours, and during this time the patient keeps a diary of symptoms. The sensor downloads information into a small monitor worn outside the body and gives information about the acid exposure of the esophagus during the 48 hours. The sensor simply passes on its own.
This test involves a tube that measures the muscle contractions of the esophagus. This test is usually done in patients who have unexplained chest pain, and patients who are getting ready for surgery for reflux disease.
Treatment of GERD
Lifestyle changes such as weight loss, raising the head of the bed six inches, smoking cessation, avoiding late meals and acid reflux-inducing foods (excessive caffeine, chocolate, alcohol, peppermint, and fatty foods) are general measures that help patients with mild reflux disease.
Antacids are commonly used for short-term relief of acid reflex (e.g., TUMS, Maalox and Mylanta) They are not very effective for GERD.
Examples of these medications include Zantac, Pepcid and Tagamet. They reduce the production of acid in the stomach, but are less effective than proton pump inhibitors.
Proton Pump Inhibitors
These are the best acid-reduction medications in the market. They are used for eight weeks, and sometimes three months. However, if symptoms return, long-term treatment is recommended.
Proton pump inhibitors are generally safe. There are several studies in recent years that linked them to osteoporosis, cardiac disease, renal disease, and dementia. These studies had limitations in their quality, and further studies are needed for confirmation.
Nevertheless, the lowest dose for good control of symptoms should be the target of treatment.
This is reserved for severe cases which do not resolve with noninvasive treatment. Although the outcome of surgery is usually good, complications can occur. In addition, many patients still need to take medications for GERD after surgery.