GERD is a very common disease where acid reflux and heartburn are the key symptoms. It affects a lot of people. Diagnosis is relatively straightforward. It can be treated with lifestyle changes, antacids, medication or surgery. However, if left untreated, the frequent exposure of esophagus to stomach acid can have some dangerous potential effects, including cancer.
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Acid reflux and heartburn are symptoms of several conditions, but are strongly associated with gastroesophageal reflux disease (GERD). GERD is the most common gastroenterological disorder in the US, where about 20% of Americans struggle with weekly symptoms. The disease itself isn’t serious, but it can have some unpleasant complications if left unchecked.
GERD is defined as: “a condition which develops when the reflux of stomach contents causes troublesome symptoms and/or complications”.
From this definition, it can be split up into two categories. GERD can either stay in the esophagus, that is, the pipe that connects your mouth to your stomach, or it can leave the esophagus and affect other parts of your body. These have their own associated symptoms, but both typically present with acid reflux and heartburn.
The esophogastric junction is where the esophagus joins the stomach. It’s composed of three parts: the lower esophageal sphincter (LES), a part of the diaphragm, and a flap valve. Together, these work to stop reflux. GERD occurs where there’s a problem in the esophagus, the stomach, or their junction.
For instance, the sphincter maintains a certain level of pressure. If pressure inside the abdomen overloads the sphincter, it can open, and allow the contents of the stomach to shoot up and out, like ketchup from a squeezy bottle. This can also happen if the stomach takes too long to empty food out into the small intestine: pressure rises, and the sphincter is overwhelmed.
Another potential cause is relaxations of the sphincter. These are normal, and are part of why you belch. However, if a few other parts of the system are dysfunctional, these can allow acid to enter the esophagus unabated. The right crus or “leg” of the diaphragm is wrapped about the lower part of the esophagus. This essentially is a secondary sphincter, further controlling what comes and goes from the esophagus. When the original sphincter relaxes, so does the diaphragm.
The flap valve is some tissue where the esophagus joins the stomach. It’s at an angle, like an almost shut door. When we swallow, the esophogastric junction moves. This opens the flap, allowing food to fall into the stomach. After the food is in the stomach, the muscles in the sphincter close, and the pressure shuts the flap. However, over time, the ligaments in the junction weaken and the stomach’s shape changes, and the angle where the esophagus joins the stomach widens, like the mouth of a funnel. This leaves the sphincter as the only barrier to prevent reflux. When the flap valve stops working, acid reflux is much more likely. The sphincter, as well as the secondary one made by the diaphragm wrapping around the lower esophagus are both much weaker if the flap valve fails.
The esophagus protects itself from stomach acid in three ways:
If there’s a problem with the esophagus, the body can’t properly deal with the acid, resulting in GERD.
In short, GERD is caused if there’s problems with the stomach, the esophagus, or with the junction between them.
There are a few factors that make it more likely for somebody to have GERD:
Other risk factors include having a connective tissue disorder or IBS. This means that a person who has IBS is about twice as likely as the general population to develop GERD, and vice versa. The effects of taking certain medicines like beta-blockers, Ibuprofen and anticholinergics also can result in GERD as a side effect.
There is no evidence that chocolate, coffee, spicy food, soft drinks like Coke, fruit juice or mint will make symptoms worse or can cause GERD, so it won’t help to cut them out of your diet.
You can also get GERD if you’re pregnant, because the lower esophageal sphincter is affected by hormones that are produced more during pregnancy.
So what are acid reflux and heartburn? Heartburn can feel like a deep burning sensation in your lower chest, that travels up. It has nothing to do with your heart, and is the feeling of acid travelling up your esophagus. With acid reflux, you may taste a sour or bitter liquid at the back of your mouth. This may mix with the saliva in your mouth. If you suffer from heartburn or regurgitations more than once a week, you should talk to your PCP about it. Another indicator is difficulty swallowing or painful swallowing. It’s important to tell someone if you suffer from this because, especially in the context of GERD, as it could be the first sign of a very serious complication, called Barrett’s Esophagus.
Extra-esophageal reflux disease is a closely related condition to GERD. It’s as of yet unclear whether they’re a separate illness, or merely an uncommon presentation.
There are some symptoms that GERD shares with other conditions. These are less common than acid reflux and heartburn, but are nonetheless important to mention:
These could be signs of GERD but are also related to conditions like gastritis (inflammation of the stomach), gastroparesis and peptic ulcer disease.
Complications that can arise from GERD include
However, in some cases, GERD may be asymptomatic, especially in older people.
Heartburn and heart attack are different, but can feel similar. Sometimes, even doctors have trouble telling them apart. A key difference is that a heart attack will come on suddenly, start in the upper chest and move outwards, and that you’ll have trouble breathing. This varies from patient to patient.
The patient can be given a drug that will stop the secretion of stomach acid. Nowadays, that drug is a proton-pump inhibitor, or PPI. If the severeness of symptoms is reduced by 50% or more, it’s likely that the patient has GERD. However, it also works for other stomach illnesses, like peptic ulcer disease, and there’s a placebo effect. It’s still useful, though, because if there are no complications, and there’s a positive result, extra tests aren’t necessary. However, in cases where things are slightly more complicated, other diagnostic methods are necessary.
This test involves a sensor being inserted into the patient, either a wireless capsule, or by way of a catheter. The sensor can then record the drop in pH (that is, increase in acidity) each time there’s a reflux event. There are pros and cons for each method, but the key is that they both test whether there’s an association with reflux events and symptoms. If there’s a positive connection, then a diagnosis can be made.
Endoscopies are troublesome here: on one hand, if there’s evidence of Barret’s esophagus or or inflammation of the esophagus, then a diagnosis of GERD is all but certain. However, a healthy esophagus doesn’t mean that a patient does not have GERD. An endoscopy can be most powerfully used to rule out alternatives, like an infection or a pill injury.
Manometry isn’t useful for GERD diagnosis per se, but can be useful to rule out other esophageal disorders. For instance, achalasia is when the lower esophageal sphincter fails to open when you swallow. It can present with regurgitation and heartburn, which means that a patient could be misdiagnosed with GERD when they actually have something else entirely.
The most closely related disorder is EERD, or extra-esophageal reflux disease. It’s debatable as to whether it’s an entirely separate condition, but a hallmark of it, alongside its host of respiratory effects, is that people who suffer from it don’t experience heartburn.
The only lifestyle changes with any clinical weight behind them are weight loss, sleeping with your head elevated, and not eating close to bedtime. One reason why some people are woken up by heartburn or acid reflux is that they’ve eaten too late.
There is no evidence that other changes, including eliminating trigger foods from the diet, and stopping smoking or drinking alcohol will treat GERD.
The most common medical treatment is acid inhibition drugs, like PPIs. For patients with non-erosive disease, histamine-2-receptor antagonists (H2As) can also be helpful. However, PPIs are king here. They’re very safe, however, over the long term, having reduced levels of stomach acid can result in vitamin and mineral deficiencies, such as iron, B12 and magnesium. There’s also a greater chance of fractures, as well as diarrhea caused by bacterial infections.
We offer a variety of PPIs, including Esomeprazole (Nexium), Omeprazole (Prilosefc), Llansoprazole (Prevacid) and Rabeprazole (AcipHex). Of these, only AcipHex requires a prescription for use. If you have trouble swallowing pills, then Rabeprazole could be the right choice, since it is smaller than other PPIs.
If you’re taking a PPI, it’s important to be aware that they limit the efficacy of anti-fungal drugs, and can increase the concentration in the blood of cilostazol. Esomeprazole and Omeprazole can also make anti-coagulants, like Warfarin, and benzodiazapines like Valium have stronger effects, but can also stop Plavix from functioning. It is a very bad idea to take drugs that interact with one another, without the express permission of your PCP. The reason why is that it can be detrimental to your health.
We offer one H2A, Ranitidine, also known as Zantac. It has proven efficacy during pregnancy, and would be a good choice to start on if lifestyle changes and antacids aren’t effective.
Sucralfate (Carafate) is another common drug used to fight GERD. It produces a paste that helps keep stomach acidity stable, and protects the lining of the stomach and the esophagus. It’s safe for use during pregnancy, but since it has a lot of aluminum in it, it’s unsuitable for people who have kidney failure.
Surgery is typically an option for patients who do not want to stay on drugs for life, or for whom medication isn’t working. Larparoscopic anti-reflux surgery, also called Nissen fundoplication, is a low-invasive treatment. In it, the angle of the flap valve is restored to its original state. There are some variants on the procedure, where the lower esophageal sphincter is tightened.
It’s a very effective treatment for GERD. When compared with PPI treatment over the course of 5 years, the group taking PPIs had more acid reflux.
Another surgical treatment is Linx reflux management, where a ring of magnetic-core titanium beads is placed around the bottom of the esophagus. It makes the sphincter stronger. It’s effective, but hasn’t seen large-scale study.
It is safe to take PPIs during pregnancy, except for Omeprazole, which can cause birth defects. If you’re pregnant, PPIs should be a last resort, once lifestyle changes, antacids and H2As prove ineffective.
Take antacid and rest with your head raised. While there’s a possibility that you have GERD, you should seek medical advice if you’re experiencing heartburn or acid reflux on a weekly basis.
No. According to a 2006 study, Esomeprazole, also known as Nexium, is more effective than other PPIs in healing severe GERD. When it comes to more mild cases, however, they’re all about the same. Some PPIs are more effective in conjunction with other drugs, like prokinetics. However, it’s a very bad idea to mix drugs unless your doctor has said that it’s okay.
There is strong evidence that GERD and stress are associated with one another, and high stress correlates with more intense reflux episodes. However, whether there’s an A to B cause is less clear. Living with GERD can mean that previously enjoyable things like sleep and mealtime are disrupted, and that can be stressful.
Indigestion, or dyspepsia, is related to heartburn but they are not the same thing. Heartburn is a symptom of indigestion, along with feelings of bloatedness or nausea.
Fortunately, not. Non-erosive GERD will not change into an erosive form.
If after eight weeks, your heartburn isn’t receding, then you should talk to your doctor about alternatives. While it’s not cleared by the FDA, evidence suggests that Baclofen, a GABA drug, can be helpful.
Probably not. It’s true that some foods, especially spicy meals and acidic drinks, like fruit juice, cola or coffee can give you a heartburn-like sensation, but unless you have heartburn on a weekly basis or more, you don’t have to worry: over the counter antacids can be an effective remedy.
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